Journal of Psychiatric and Mental Health Nursing, 2015, 22, 326–332
Nursing students’ post-traumatic growth, emotional intelligence and psychological resilience Y. L I 1
c a n d i d a t e , F. C A O 2
& J. LIU1
PhD-student, Professor, School of Nursing, Shandong University, and Nurse, Qianfo Hospital, Shandong University, Jinan, Shandong, China
Keywords: childhood adversities,
emotional intelligence, nursing, post-traumatic growth, psychological
resilience, students Correspondence: F. Cao School of Nursing Shandong University No.44 Wenhua Xi Road Jinan Shandong 250012 China E-mail: [email protected]
Accepted for publication: 10 November 2014 doi: 10.1111/jpm.12192
• • •
Nursing students in the present sample who have experienced childhood adversity have a certain level of post-traumatic growth. If introduced into nursing curricula, emotional intelligence interventions may increase emotional coping resources and enhance social skills for nurses, which may benefit their long-term occupational health. As researchers consider personal resilience a strategy for responding to workplace adversity in nurses, resilience building should be incorporated into nursing education. This is a preliminary study that may guide future investigations of the curvilinear relationship rather than linear relationship between post-traumatic growth and positive factors in the special sample of nursing students.
Abstract Resilience, emotional intelligence and post-traumatic growth may benefit nursing students’ careers and personal well-being in clinical work. Developing both their emotional intelligence and resilience may assist their individual post-traumatic growth and enhance their ability to cope with clinical stress. To investigate the relationships among post-traumatic growth, emotional intelligence and psychological resilience in vocational school nursing students who have experienced childhood adversities, a cross-sectional research design with anonymous questionnaires was conducted and self-report data were analysed. The Childhood Adversities Checklist (Chinese version), Posttraumatic Growth Inventory, Emotional Intelligence Scale and the 10-item Connor–Davidson Resilience Scale were used. Survey data were collected from 202 Chinese vocational school nursing students during 2011. Post-traumatic growth was associated with emotional intelligence and psychological resilience. Results indicated a curvilinear relationship between emotional intelligence and posttraumatic growth, and between psychological resilience and post-traumatic growth. Moderate-level emotional intelligence and psychological resilience were most associated with the greatest levels of growth. The results imply that moderate resilience and emotional intelligence can help nursing students cope with adversity in their future clinical work. This study first provided preliminary data suggesting the curvilinear relationship rather than linear relationship between post-traumatic growth and positive factors in the sample of nursing students.
Introduction Substantial literature suggests that child maltreatment and traumatic stressors have long-term consequences for adult 326
health outcomes, such as psychiatric illness, depression and post-traumatic stress disorder (PTSD) (Chapman et al. 2004, Widom et al. 2007, LeardMann et al. 2010). However, increasingly more studies have confirmed that © 2014 John Wiley & Sons Ltd
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some positive outcomes, including post-traumatic growth (PTG), may emerge from negative experiences. ‘PTG is the experience of positive change that occurs as a result of the struggle with highly challenging life crises’ (Tedeschi & Calhoun 2004). Childhood adversity (CA) is common among healthcare workers. The study by Maunder et al. suggested that the prevalence of CA is 33%, and healthcare workers who experienced CA also reported a greater number of distressing life events and additional psychological distress and impairment (Maunder et al. 2010). However, few studies have identified the positive outcomes (such as PTG or resilience) of nurses with CA. Healthcare workers face many stressors that are specific to their profession, such as exposure to workplace violence (Duncan et al. 2001) and personal side effects that the work environment imposes on care (McGillis-Hall & Kiesners 2005). Identifying the determinants of nurses’ growth or vulnerability to life stress may lead to better personal health and, in turn, enhance nurse–patient relations and quality of care. Similarly, because nursing students are the professional nurses of the future, it is important that any CA they have experienced be adequately addressed, as it may influence their long-term occupational health and well-being and subsequently their patient care. Researchers have suggested that PTG is associated with both negative and positive factors, with several studies noting that PTG relates more to well-being, such as increased personal resources following trauma (Park & Fenster 2004) and more positive mood (Carver & Antoni 2004), and less to distress. Emotional intelligence (EI) and psychological resilience may be the other positive factors potentially associated with PTG. Salovey et al. (2003) defined EI as ‘the ability to perceive emotion, integrate emotion to facilitate thought, understand emotions, and to regulate emotions to promote personal growth’. While Petrides et al. (2007) considered EI a personality trait, some researchers (Mayer et al. 2000) believed that EI encompasses four abilities: (1) identifying emotions in oneself and others, (2) using emotion to facilitate thought necessary to communicate feelings, (3) understanding emotions and their meaning through relationships, and (4) managing and regulating emotions. Emotional intelligence may predict stress responses and adaptive coping strategies in a variety of applied settings (Matthews et al. 2006); it enables and enhances empathy and responding to others’ feelings, self-regulation and the development of coping skills in conflict situations (Schutte et al. 2001, Salovey et al. 2004). Furthermore, Bar-On (2010) stated that EI is an indispensable part of positive psychology, which is the scientific study of the strengths and virtues that enable individuals and communities to © 2014 John Wiley & Sons Ltd
thrive, and several empirical findings support this notion (Horowitz 1991, Calhoun & Tedeschi 1998, Cadell et al. 2003). Additionally, positive psychological responses in the aftermath of trauma (e.g. PTG), have recently attracted more attention from trauma researchers. Therefore, EI may have some correlation with PTG as a part of positive psychology. To our knowledge, few studies have focused on the nuanced relationship between EI and PTG in nursing students who have experienced CA. Resilience associated with trauma and positive adaptation to adversity is another controversial area within PTG studies. Increasingly more research suggests that most adults who were exposed to a potentially traumatic event will quickly recover from any adverse effects (Shalev 2002), and some display only moderate or no disruptions in their normal ability to function. Resilience can be used to represent an individual’s successful adaptation to trauma (Wang et al. 2010), suggesting that resilient people have the ability to adjust and cope successfully in the face of adversity, exhibiting a stable trajectory of healthy functioning across time and the capacity for positive emotions after having experienced stressful life events (Bonanno et al. 2001). Therefore, both PTG and resilience refer to constructs that result in positive adaptation after a traumatic event. Carver (1998) and Tedeschi & Calhoun (1996) assumed that for PTG to occur, a person must display resilience and return to healthy functioning before moving towards more effective functioning. However, a literature review indicates that the researchers failed to make a distinction between individuals who were low, moderate or high in resilience, and how these different levels of resilience related to PTG. In the current study, we specifically focused on the relationship between resilience and PTG in nursing students who experienced high-level CA. Our aim was to explore the relationship among PTG, EI and resilience, positing that the relationship could be more nuanced than previously believed, and potentially resulting in a linear or curvilinear (inverted-U) relationship among PTG, EI and resilience.
Methods A cross-sectional research study with anonymous questionnaires was conducted using a convenience sample of 260 nursing students from a vocational school in the Shandong province of China. The self-report data were collected throughout 2011. Students were informed of the purpose of the study and were told that their participation was voluntary. Ethics committee approval was obtained from our affiliated university in China, and informed consent was obtained from all participants. Students anonymously 327
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completed the questionnaires in the classroom with no time limits. Two hundred sixteen out of the 260 students completed the questionnaire. For this study, we analysed only the data of participants who self-reported any ‘most distressing’ event on at least one scale of the Childhood Adversities Checklist (Chinese version) and who had completed all measures used in this study. Fourteen of them had incomplete information on part of the measures, leaving an analytic sample of 202 (93.5%) persons. Participants were all female, aged between 18 and 22 (M = 19.4, SD = .8), and nearly half were from the rural areas (41.6%).
Measures Childhood Adversities Checklist (Chinese version) This checklist consists of 36 items with four main categories (Li et al. 2011). The first category, ‘family adversity’, includes three subcategories: parents’ divorce or separation, increased arguments between parents, and a family member’s illness/accident or death. The second category, ‘community adversity’, includes neighbours’ substance abuse, neighbours’ sentence to prison and neighbours having a mental disorder. The third category, ‘school adversity’, includes failure on an entrance examination, problems with a teacher and being abused by a teacher. The fourth category, ‘personal adversity’, includes events such as having a severe illness or accident, being a victim of crime, being abused by a parent or other family members, being forced to repeat a school year, or witnessing a serious traffic/fire accident. Its reliability and validity (α = .68) and split-half reliability (.61) in the Chinese population have been well documented in our other study (Li et al. 2011). Participants were asked to choose the most traumatic/stressful event in their early life (before 16 years old) from any of the Childhood Adversities Checklist categories. Posttraumatic Growth Inventory (PTGI) The PTGI was used to assess PTG in the participants. The reliability and validity of the Chinese version of PTGI have been verified (Gao et al. 2010) and used among individuals who experienced the Sichuan Earthquake (Yu et al. 2010). The adapted Chinese version of PTGI has 19 items and three subscales: personal strength, new possibilities and relating to others (α = .94 for the full scale; α = .70–.89 for the subscales; Table 2). Item responses ranged from 0 (did not experience) to 5 (experienced to a very great degree), and items were summed for a total score (Tedeschi & Calhoun 1996). Each participant was assigned a score equal to the mean of his or her scores on all items, with higher scores indicating greater levels of growth. 328
10-Item Connor–Davidson Resilience Scale (CD-RISC) This scale was extracted from the original 25-item CD-RISC (Connor & Davidson 2003), a commonly used self-rated instrument for measuring resilience with good internal consistency (α = .85) and excellent structure validity for goodness of fit. Each item is rated on a 5-point scale from 0 (not true at all) to 4 (true nearly all the time). The Chinese version of the 10-item CD-RISC (Wang et al. 2010) was adapted by a two-stage process of translation and back-translation. Its reliability and validity (α = .91) and test–retest reliability (r = .90) in the Chinese population have been well documented. In the present study, Pearson correlations between all items ranged from r = .31 (P < .001) to r = .57 (P < .001); thus, we used an overall summated score with high internal consistency (α = .87; Table 2). Emotional Intelligence Scale (Chinese version) (EIS) The original EIS has four interpretable factors (emotional perception, emotional expression, emotional management of self and others) and was developed by Schutte et al. (1998). It assesses EI based on self-report responses to 33 items using a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). The original EIS has demonstrated high internal consistency (α = .87–.90) and good 2-week test–retest reliability (r = .78; Schutte et al. 1998). When administered to Chinese students in a college, the Chinese version of this questionnaire showed acceptable psychometric properties with Cronbach’s alpha of .85 (Huang et al. 2008). In our study, the coefficient reliabilities were as follows: emotional perception (α = .75), emotional management of others (α = .69), emotional selfmanagement (α = .62) and emotional expression (α = .69); the overall score, which has a high internal consistency (α = .88), was used (Table 2).
Data analysis We used SPSS 16.0 for Windows for analysis (Chicago, IL, USA). Descriptive statistics were calculated for demographic variables. Independent-samples t-test was used to examine the differences between rural students and city students in PTG. To explore the relationships among PTGI, CD-RISC and EIS scores, Pearson’s product-moment correlations were calculated. Then, two models – linear and quadratic – were used to estimate the relationships between the variables. We did this to assess whether the observed relationships (Table 2) were approximately linear. We examined each bivariate relationship in a separate regression model with PTG as the dependent variable. A P-value of .05 or below was accepted as statistically significant. © 2014 John Wiley & Sons Ltd
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Relationships among PTG, EI and CD-RISC
Descriptive analyses Post-traumatic growth was not found to differ by region (rural area vs. city), P > .05, and was not significantly associated with age (r = .14, ns). The types of CA were family adversity (99.5%, n = 201), community adversity (28.2%, n = 57), school adversity (87.1%, n = 176) and personal adversity (45.1%, n = 91). The mean number of CAs was 5.02 (SE = 2.62) among those who had experienced any CAs. Among the study sample, 8.9% reported having experienced only one type of CA and 14.6% reported having experienced all types of CAs (Table 1). The mean score of the PTGI was 38.84 (SD = 16.63), for EI it was 120.06 (SD = 13.58), and for CD-RISC it was 23.96 (SD = 6.56; Table 2).
Table 1 The ratio and descriptive statistic for four categories of CAs
I. Childhood adversities Family adversity Community adversity School adversity Personal adversity Any of above adversities Total number of CAs II. Number of CAs 1 2 3 4
Ratio of CAs
Descriptive statistic (number of CAs)
201 57 176 91 202
99.5 28.2 87.1 45.1 93.5
2.59 .42 1.81 .71
1.26 .79 1.34 .98
18 75 79 30
8.9 37.1 39.1 14.6
CAs, childhood adversities.
First, the general intercorrelations among the total EIS, EIS dimensions, CD-RISC, and total PTGI and PTGI dimensions showed that total PTGI scores were significantly related to total EIS (r = .221, P < .01) and total CD-RISC (r = .227, P < .01; Table 2) scores, whereas the total PTGI and its dimensions were not significantly related to emotional expression, separately. Second, we used the Lowess procedure to assess whether the observed relationships (Table 2) were approximately linear. Figure 1 shows the scatter plots for the relationships of EIS and CD-RISC with PTGI. The dotted lines show the linear fits generated by Stata’s Lowess procedure; the solid curves are the quadratic regression fits to the data. The linear models account for 4.2% and 4.4% of the variance in PTGI scores due to CD-RISC and EIS, respectively, whereas the quadratic model accounts for 13.8% and 7.7%. We therefore conclude that the relationships between CD-RISC scores and PTGI, and between EIS scores and PTGI, are curvilinear, with shapes roughly approximated by a quadratic function. Table 3 presents the findings for linear and quadratic fits of PTGI scores regressed separately on CD-RICS and EIS scores. Both linear and quadratic components of CD-RICS and EIS significantly predicted PTGI, with quadratic relationships providing significantly better fits than simple linear relationships. A final regression model was tested including all predictors with linear and/or curvilinear relationships with PTG, and both CD-RICS and EIS scores remained statistically significant when included in the full model, accounting for 15.8% (adjusted R2) of the variance in PTGI scores.
Table 2 Correlation between study variables, and the mean, SD and Cronbach’s alpha
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Total EIS Emotional perception Emotional management of others Emotional self-management Emotional expression Total CD-RISC Total PTGI Personal strength New possibilities Relating to others
120.06 44.87 34.80 23.33 17.07 23.96 38.84 20.89 6.47 11.63
13.58 5.49 4.81 3.27 2.57 6.56 16.63 8.26 4.39 5.56
– .9251 .8741 .7801 .6631 .4071 .2211 .2571 .087 .2051
– .7171 .6851 .4961 .4541 .2601 .2911 .1622 .2131
.88 .75 .69 .62 .69 .87 .94 .89 .70 .79
– – −.5441 .3431 .4591 .1652 .1712 .049 .1951
– .3431 .2331 .2571 .3121 .101 .2191
– .3311 .005 .039 −.071 .013
– .2271 .2401 .1742 .1522
– .9541 .8291 .8951
– .7071 .7851
n = 202. Cronbach’s alphas are located on the diagonal in parentheses. 1 Correlation is significant at the .01 level (two-tailed). 2 Correlation is significant at the .05 level (two-tailed). EIS, Emotional Intelligence Scale; CD-RISC, Connor–Davidson Resilience Scale; PTGI, Posttraumatic Growth Inventory.
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Table 3 Comparison of linear and quadratic fits of PTGI regressed separately on CD-RISC and EIS scores 95% Confidence interval for B β
Adjusted R2 (model)
Linear Quadratic term
Linear Quadratic term
Predictor CD-RISC Step 1: Step 2: EIS Step 1: Step 2:
EIS, Emotional Intelligence Scale; CD-RISC, Connor–Davidson Resilience Scale; PTGI, Posttraumatic Growth Inventory.
Figure 1 Scatter plots of Posttraumatic Growth Inventory (PTGI) total scores vs. Connor–Davidson Resilience Scale (CD-RISC) total score, and PTGI total scores vs. Emotional intelligence (EI) total score Notes: Dotted lines show linear fits; solid curves are quadratic regression fits.
Discussion This study explored the relationship among EI, resilience and PTG of nursing students who had CAs, and the nature 330
of these relationships. A novel finding was that there were quadratic (inverted-U) relationships among PTG, EI and psychological resilience. Nursing students with low or high EI or resilience reported lower levels of growth than did those with intermediate EI or resilience levels. This finding may help account for the mixed results reported in previous research regarding the relationship between PTG/benefitfinding, EI and resilience. These curvilinear relationships among PTG, EI and resilience suggest that an optimal level of EI or resilience (e.g. nursing students with scores in the midrange of EIS and CD-RISC) may foster the development of PTG, whereas low-level EI or resilience may be insufficient to stimulate growth. Furthermore, an overwhelming level of EI or resilience (e.g. nursing students with scores well above the average scores on the EIS or CD-RISC) may impede the development of growth following traumatic events. Potentially, nursing students with low-level EI may be less able to respond to others’ feelings and to fulfil self-regulation, and may lack empathy, perspective-taking and the development of coping skills in conflict situations (Bar-On 2010), all of which are important to well-being (e.g. PTG). Therefore, they may have fewer opportunities for growth. Conversely, students with high-level EI may cope with greater adversity and suffer less from confronting crises. However, PTG only occurs if the trauma has been sufficiently upsetting to drive the survivor to (positive) meaning-making of the negative event (Levine et al. 2009). Overall, nursing students with moderate-level EI may experience the greatest growth when coping with trauma as they can both cope with different traumas and have the potential to achieve growth. Although studies asserted that individual characteristics (such as EI) predispose one to engage in constructive cognitive processing for promoting growth, the nature of the relationship between the two concepts remained unknown. Our results concur with Westphal & Bonanno’s (2007) study showing that people with high resilience would not engage in cognitive processing to the extent necessary for PTG to occur. Thus, students with high-level resilience have less growth. For people to engage in a meaning-making © 2014 John Wiley & Sons Ltd
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process, they need to experience a ‘psychologically seismic’ event that severely shakes or threatens their schematic structures that have guided their understanding, decision making and meaningfulness (Tedeschi & Calhoun 1995, 1996, Levine et al. 2009). Without such an experience, the person will not engage in the necessary rumination necessary to experience growth. However, resilience may make a person less likely to perceive threats to the self or world views (Levine et al. 2009). Therefore, resilient outcomes may provide little need or opportunity for PTG (Westphal & Bonanno 2007). Furthermore, Tedeschi & Calhoun (1995) assumed that a moderate score for resilience would result in the greatest PTG compared with those scoring high or low. We also found evidence that students with moderate resilience experience the most PTG. Theoretical assumptions made about the relationship between PTG and resilience suggest that either resilience is a necessary precondition for PTG to occur (Tedeschi & Calhoun 1995) or resilient people will not engage in any meaning-making process as they do not undergo any significant struggle (Westphal & Bonanno 2007). However, the more nuanced relationship has not been extensively studied so far. This study is the first to report a relationship between resilience and PTG in a Chinese convenience sample. In our study, approximately 93.5% of nursing students had experienced at least one instance of CA. Community surveys and prospective samples have shown that a range of CAs are robust predictors of the onset, recurrence and maintenance of a range of mental disorders in adulthood (Edwards et al. 2003, Pesonen et al. 2007, Widom et al. 2007). Furthermore, nursing students with CAs may have also suffered negative effects in their mental health or social function. However, we found that nursing students who experienced CAs also had a certain level of positive psychological outcomes, such as PTG. As there were more female nursing students than male nursing students in the vocational school of China, this study only examined the relationships for female students. Other studies have examined gender differences and found that women tend to have greater personal growth after traumatic experiences (Tedeschi & Calhoun 1996, Polatinsky & Esprey 2000, Büchi et al. 2007). These growth and change are potentially because women tend to contemplate and brood constructively, recalling their strengths, relying on their social networks and using therapy more often than men do (Vishnevsky et al. 2010). Women are also more likely to develop PTSD as they perceive situations as more threatening than men do (Tolin & Foa 2006). Potentially, the female participants had greater opportunity to face their distress and emotions; ‘work through’ problems, feelings and beliefs connected to the trauma; and subsequently experienced PTG. © 2014 John Wiley & Sons Ltd
Although our study is unique both in its sample and in its examination of the relationship of PTG to positive factors, there are several limitations. Foremost, the study’s generalizability may be limited, as it draws on data from a convenience sample of female nursing students who largely represent a select group of young and highly educated individuals. Although the students in the present sample reported experiencing a broad range of CAs, future investigations of these questions should employ a more representative sample of young adults. Further, the use of selfreport, retrospective recall measures also raises questions about the accuracy of the descriptions of the most traumatic events and reactions experienced at the time of these events, and the cross-sectional design prevents the examination of the trajectory of growth over time. Besides, fewer numbers, with low and high EI or resilience, or extreme values (e.g. EI total score > 160), which we have not considered in the present study, may be exerting an influence on the results. However, this study has both theoretical and practical implications. It adds to the current literature on the relationship among PTG, EI and resilience by showing that growth can be related to EI and resilience in a nonlinear way. Specifically, students with low- or high-level EI and resilience were associated with lower growth, whereas moderate EI and resilience was associated with higher growth. Our fundamental finding is that there were quadratic (inverted-U) relationships between PTG and EI and psychological resilience in nursing students. Overall, it is essential for nursing students to have EI and resilience, and EI can be cultivated in vocational schooling. Previous research (Görgens-Ekermans & Brand 2012) has shown that EI assists with the formation of successful human relationships in the workplace. If introduced into the nursing curricula, EI developmental interventions may increase emotional coping resources and enhance social skills, which may in turn benefit the long-term occupational health of nurses. An EI development curriculum would include reflective learning experiences that focus on developing the self and dialogic relationships, and developing empathy and practising listening skills, both in the classroom and in practice (Freshwater & Stickley 2004). Further, nursing educators could address the role of EI in facilitating personal development and motivate students to enhance their EI. Researchers (Jackson et al. 2007) also considered personal resilience as a strategy for responding to workplace adversity in nurses. Therefore, resilience building should be incorporated into nursing education, and professional support could be encouraged through mentorship programmes outside nurses’ immediate working environments. Future studies are needed to work discovering the optimal rate of resilience and EI on current measures. 331
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© 2014 John Wiley & Sons Ltd