Digital resilience of clinical nurses: a concept analysis

Background

A rapid but profound shift, driven by digital technologies integration, is occurring within healthcare environments, which presents nurses with opportunities, challenges, and difficulties. To meet the digital challenges, the digital resilience of clinical nurses plays an important role.

Purpose

This paper aims to conduct a comprehensive analysis of the concept of digital resilience of clinical nurses, including explaining its antecedents and consequences, constructing cases to make it more concrete and explicit, and finally extracting the key points of each section in order to construct a model for digital resilience of clinical nurses.

Methods

Walker & Avant’s classical conceptual analysis was used to examine the attributes, antecedents, and consequences of digital resilience of clinical nurses.

Results

The digital resilience of clinical nurses is the positive power driven by intrinsic force when confronted with digital advancements in clinical environments, and its realistic performance is expressed as sustained dynamic feedback which consists of acquired behaviours. Digital resilience among clinical nurses empowers them to navigate the challenges of ongoing digital updates in healthcare environments.

Conclusions

This study has reviewed the core attributes and conceptual examples of digital resilience via the Walker & Avant’s classical conceptual analysis methodology. The prospective model of digital resilience facilitates understandings of how nurses effectively navigate the sustained pressures arising from continual digital advancements within healthcare. The model should be further tested across diverse nursing communities to facilitate the development of tailored interventions. Such interventions, grounded in acquired behaviour performances and the activation of positive intrinsic power/force, are fundamental to nurses’ digital resilience. Ongoing adjustments in response to sustained dynamic feedback remain equally critical.

As pointed out in the document grafted by world health organization (WHO) [1], we are witnessing healthcare is continually transformed or even reshaped by digital technology, which conducts itself and shapes global health through artificial intelligence appreciably in a significant way that has never been seen before [2,3,4]. Enormous ideas and research methods originated in information science are constantly being integrated into nursing practice, which opened up a brand-new path for nurses to improve their working routine and principles that could be recognized as obsolescent previously [5, 6]; Rony & Kayesh et al. [7]. With the emergence of expert systems for clinical decision support, the nurse scheduling model, being acknowledged as the beginning of artificial intelligence utility in nursing [8]. Since then, updated digital healthcare tools assisted by informatic technology have become the focus of innovation and development, and related research has begun to soar in healthcare [9].

As an emerging transformative force, nurses have seized opportunities that digital technologies have brought. Nurses proactively utilised artificial intelligence-guided technologies, granting stratified tendencies in nursing routines. Robots can gradually learn and implement primary care tasks (e.g., taking vital signs, administrating medications, and collecting demographic information) throughout continuing care [7, 10], which can provide more time to nurses to take care of patients, to offer accurate and efficient care, ultimately promising to improve patient well-being [11,12,13]. Nonetheless, we cannot afford to ignore the shocks and challenges that coincided with the opportunities. Software failures or incorrect data entry in digital health systems (e.g., digital prescribing systems or digital health record systems) carry the risk of medical errors, which would have an incalculable impact on care based on true occasions and records, as well as legal challenges [14]. As principal users of electronic health records (EHRs) and information systems, nurses were dissatisfied and concerned about the EHR systems they use, which were widely perceived as not being user-friendly for nurses due to their lack of nursing terminology and poor usability [3, 15, 16]. The mandatory and widespread implementation of digital technology have increased the pressure and workload on nurses to learn to utilize it [17, 18]. Nurses are dealing with stress in the tidal waves of deeper integration of digital technologies and nursing practice.

Nurses’ efforts to cope with stress are indispensable in sustaining their own physical and mental balance to navigate multifaceted risks, in brief, obtaining and maintaining resilience is essential. In 1973, Holling first proposed the current idea of “resilience” in ecology, and subsequent studies have continuously enriched the connotation and characteristics of resilience [19,20,21]. As a concept discussed in multiple disciplines, the description and characterization of resilience varies among researchers from different disciplines [22]. Research in the medical healthcare field defined resilience as “the ability to bounce back from adversity”, “the process of adapting well in the face of stress and adversity, involving personal qualities and strengths”, or “the capacity to maintain one’s normal functioning under stressful situations” [23,24,25]. Given the importance of nurses’ resilience in managing risk and adapting to challenges, previous researches have developed programs to enhance resilience among nurses. These programs encompassed a spectrum of methods, such as mindfulness and relaxation, psychoeducation, emotion regulation, cognitive strategies, problem-solving, and so on [24, 26, 27].

Among them, intervention programs based on the web or digital technologies have caught our attention. Unlike antecedent intervention tools or devices, digital technologies gave nurses’ resilience opportunities to transform into a new form, namely, digital resilience (yet undefined in the context of clinical nurses). While digital resilience phenomena had been discussed and tested to varying extents in current healthcare-related research, interventions for digital resilience phenomena have been developed based on the general concept of resilience, with varying outcomes. The influence of digital technologies on nurses is often overlooked. Whether digital resilience occurs within nurses’ interactions with digital technologies has also been rarely discussed by researchers. Meanwhile, there was few robust description of attributes of nurses’ digital resilience and how it would impact clinical nurses we had found in the present studies. Therefore, this study intends to make a concept analysis for digital resilience of clinical nurses in the first place. We then used Walker & Avant’s classical conceptual analysis to explore the core attributes of digital resilience, identify its antecedents and consequences, provide model cases and related cases, discuss the practical significance of digital resilience of clinical nurses to illustrate this increasingly important but poorly understood concept.

Study design

Concept analysis is an effective method of parsing terminology that decomposes theory into the essential components, namely, the concepts, to rationally understand and easily measure them [28, 29]. Walker & Avant’s classical conceptual analysis provides the ideas and methodology for this study. As one of the most commonly used concept analysis methods by researchers in the field of nursing, Walker & Avant summarise and simplify Wilson’s concept analysis process by proposing an eight-step process of analysis, including: (a) select a concept: digital resilience of clinical nurses was selected in this paper; (b) determine the aims or purposes of analysis: the aim of this paper was to conceptualize this concept and explore the key relevance of it; (c) identify all uses of the concept: universal definitions of digital and resilience were found in the dictionary; (d) determine the defining attributes: characteristics that are the most frequently associated with this concept, which referred to attributes, were identified; (e) identify model cases: an typical example of this concept that encompasses the defining attributes was developed to enhance the understanding; (f) identify other cases: one additional case were developed, aiming to differentiate similar phenomena from digital resilience of clinical nurses well; (g) identify antecedents and consequences: incidents that occurred prior to this concept and the sequent consequences of this concept’s emergence; (h) define empirical referents: empirical measures of digital resilience of clinical nurses were reviewed based on literature.

Literature search strategy

To better unde rstand the scope of the applied concepts, we needed to explore and review literature outside the nursing field [29]. A comprehensive and exhaustive literature search was implemented on 15 November 2023 using databases such as PubMed, WOS, CINAHL, Cochrane Library, Embase, ProQuest, Scopus, SinoMed database, CNKI, and Wangfang data. The searching strings like “Psychological resilience OR Psychological resiliency OR Psychologic Adaptation* OR Physiological Adaptation* OR Adaptive Plasticity OR Coping Behavior* OR Coping Strateg* OR Adaptive Behavior* OR Social Adjustment*” have been applied. The entry terms labelled in the MeSH subject headings of the above-mentioned terms were used together to search for relevant literature. The search terms could be used individually or jointly through Boolean logic. In order to encompass the most updated literature on technologies applied in the nursing practice environments, minimizing potential bias in results, the publication date of the included literature is limited to 2019 to 2024. The researcher used the key phrase “digital resilience” on 13 December 2023 in a literature search in PubMed and Web of Science for a supplement without date filtering. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) search strategy guidelines were followed by the search process, which we plotted in Fig. 1.

Flowchart of selection process

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Article selection and analysis

An experienced mentor and trained current graduate student are engaged in a literature screening process based on Walker & Avant’s classical conceptual analysis. Before screening the literature, the researcher developed a search plan and inclusion/exclusion criteria. The inclusion/exclusion criteria were as follows.

• Inclusion criteria: (a) Having a focus on digital resilience; (b) Consisting of the contents of one of the following items at least: the definition, the attributes, the antecedents, and the consequences; (c) Written in English or Chinese; (d) Being available in full text with abstract.

• Exclusion criteria: (a) Conference reports or abstracts; (b) Subject of digital resilience that shows beyond individual aspects (hospital, community, institution, society).

First, we methodically extracted the basic information of each document, including the year, title, author, subject of the study, and the definition of digital resilience in the article. Subsequently, we used thematic analysis, which is the most commonly used method in qualitative research, to identify and interpret the content and to describe the attributes, antecedents, and consequences of digital resilience by reading and iterating through the articles in an attempt to facilitate their complete conceptual framework and complete it eventually. The results are shown in Supplementary Table 1.

Use of the concept

Recognising the usage of the concept is necessary which is in a bid to prevent limiting ourselves to a facet of the concept and failing to understand the essence of the concept [29]. “Digital” is described in the Merriam-Webster dictionary as “utilising devices constructed or working by the methods or principles of electronics characterized by electronic and especially computerised technology” Merriam-Webster [30]. The concept of “Digital” is not only a term used to describe the use of electronic devices but also a term used to describe the use of electronic devices, which operates on the principles of electronics “Electronic” [31], in the context of the concept. An electronic device is defined as a device that operates on the principles of electronics, which involves the manipulation of electrons and other electrically charged particles. “Resilience” is described in the Merriam-Webster dictionary as “the ability of a strained body to regain its size and shape” or “the ability to recover or adapt easily from misfortune or change” Merriam-Webster [32]. From the literature, we can conclude that the concept of resilience is mostly focused on the positive or desired restoration or process of people or things after changes, impacts, or trauma. The term resilience was first proposed in ecological research to interpret ability of a system to withstand disturbances without changing its properties [19]. At the individual level, “Resilience” is an individual trait that refers to ability to recover from adversity [33], hereditary individual skills for regulating emotions [34]. From a process perspective, resilience is also an individual’s response to illness, expressed through energy, rhythm, and movement [35], or the process of performing better than expected in adverse circumstances [36]. The Resilience Framework for Nursing and Healthcare was developed and reconstructed resilience from a “survival trait” into a measurable, intervenable, and sustainable professional competency system [37].

After reading the title and abstract, 8420 results were removed according to the inclusive/exclusive criteria. The researchers conducted a detailed full-text reading of the included literature, then excluded 77 studies, and finally, a total of 21 records and findings relevant to this study were included.

Attributes are the most essential ingredients of concepts and enable them to be distinguishable from the parallel concepts [29]. After a comprehensive review of the literature included in this study, we present the attributes, antecedents, and consequences as shown in Supplementary Table 1 which we have distilled four core attributes that form a complete and indivisible solid structure. The attributes of digital resilience in nurses include acquired behaviours, positive power, intrinsic force, and sustained dynamic feedback.

Acquired behaviours

Acquired behaviours are practices in which nurses are immersed in practice environments with digital technologies in the face of shocks and adversities, taking actions anchored in active learning and deepening understanding, culminating in resilience. Acquired behaviours have three evident stages of performance, including understanding and absorbing shocks, responding and taking actions, and performing digital resilience, which can be divided into a perception level and an action level, with the latter being the action level. The three phases are either chronologically sequential or intermittently in nurses with digital resilience [38].

Confronted with digital dilemmas and shocks, understanding and absorbing shocks is the beginning and essential condition of acquired behaviours. Nurses with digital resilience will show a clear, active perception and acceptance of shocks at this stage. The digital resilience framework [39] describes this as understanding, whereby individuals recognise when they are at risk online and judge where they are. Upon digital shock, nurses utilize their prior experience and knowledge to explore the components and characteristics of the digital shock, reflect on its relationship and interactions with the digital environment, and anticipate how it will grow and its impact. The purpose of understanding risk is to better cope with changing environments [38]. Nurses with digital resilience do not hold a reluctant attitude to the adversities and shocks of digital change and digital transformation but rather apply the critical thinking required by the process to recognise the complexity and unfamiliarity of the digital environment, accepting it with an open mind, then get prepared for future actions [12, 36, 40].

Secondly, Responding and taking action are the dominant components of acquired behaviour. The response is varied, but all involve nurses deploying resources to buffer risks and quieten perturbations. The resilience assessment grip developed by Hollnagel regards monitoring, attending, learning, and responding as the four potentials of resilience, and digital resilience similarly requires learning and responding [41]. Learn refers to the ability of nurses to learn from their own experiences and, in this way, adapt to future choices [25]. In addition, as Bandura describes in his social learning theory, learning also represents the active acquisition of digital knowledge [42,43,44]. Nurses with digital resilience, after holding knowledge and understanding of information technologies, gather resources from internal and external sources to ask for help when they encounter a digital shock [10]. Successful experience in dealing with risks in the past can give standard solutions, digital knowledge, and trained skills gained that learned in the digital environment can lead to the emergence of targeted methods. At the same time, those nurses can use digitally relevant technologies critically, in other words, digital competence [45, 46], and nurses can decide where to get support and how to use a blend of experience, knowledge, and skills so that they achieve the optimal solution to a problem.

Lastly, performing digital resilience refers to an individual’s ability to recover from online adversity by receiving modest support. Sun et al. [25] argue in their study that digital resilience helps an individual to return to a pre-risk state or to reach a more advanced state. Boh et al. [38] insist that an individual, in the face of a digital shock, can establish digital resilience by redeploying and modifying resources and changing behaviours or practices to move towards a new state. Tim and Floetgen [40] also reported in their study that a new normal is a better way to move forward rather than return to the same state as in the past. Consequently, nurses with digital resilience have successfully dealt with adversities, they review the impact and lessons learned from the shock and develop a different or superior state of stability than the state before the risk, enabling them to be ready for the next shock and risk.

Positive power

Positive power refers to the fact that digital resilience encourages nurses to take measures that are favourable to their own situation, achieve their recovery goals.

Digital resilience, although possessing unique characteristics, is in essence a new form of resilience in the digital environment [36, 47, 48]. Individual entities can use digital technologies to enhance resilience and increase the likelihood of desired outcomes [38], which means that digital resilience will eventually help nurses achieve outcomes in their favour. The positive power of nurses’ digital resilience varies in different groups. For example, Zeng suggests that digital resilience acts as a bridge between individuals and work organisations, and increased personal digital resilience is accompanied by increased innovation, thus optimised personal performance [49]. When it comes to nurses, the potential of nurses to successfully apply digital technology to solve nursing problems, leading to positive clinical outcomes, can be realised by the positive power of digital resilience. Digital resilience built within a healthy support network empowers individuals to deal with negative digital experiences of failure and emotional risk [50]. It is argued that helping individuals access support systems is one of the core functions of digital resilience and that digital resilience encourages individuals to access help from multiple systems and groups rather than having to face digital threats and distress alone [36]. Furthermore, the positive power of digital resilience, while improving nurses inwardly, can also help nurses to actively move beyond their self-imposed limitations to seek out and build support networks to dilute helplessness in the face of adversity and access effective interventions.

Intrinsic force

Intrinsic force is the essential driving force and foundational roots behind individuals’ digital resilience. This study considers nurses’ intrinsic force related to adaptive self-efficacy and learning capacity.

It has been suggested that the adaptive capacity of a system is the mechanism by which resilience is built. Dalziell suggests that resilience is a functional relationship between the interaction of vulnerability and adaptive capacity within a system, resilience arises in systems with adaptive capacity, and resilience links resources to outcomes [51].

Self-efficacy is one of the most critical internal forces in the generation and development of digital resilience [36]. According to Bandura, self-efficacy is the degree to which a person believes they can perform a task successfully in a given situation so that self-efficacy is considered to be a powerful anti-stress resource [25, 50]. The precondition of being equipped with digital resilience is that nurses can acquire knowledge and experience related to digital technologies, which requires learning capability, as mentioned in acquired behaviours. The rapid advancement of digital techniques asks nurses to constantly update their knowledge, keep learning, and accumulate digital skills or experiences in their work. Behrendt argued in their paper that online resilience intervention programmes improve self-efficacy and, thus, resilience, reducing stress symptoms [52]. Digital education interventions can enhance individual self-efficacy. Individuals with high levels of self-efficacy can better understand and cope with risks and shocks in digital environments, which can better advocate for themselves [36, 53].

Sustained dynamic feedback

Digital resilience is continuous feedback, which is dynamic and changing on the present status. Dynamic requires nurses to engage in digital risk and to adapt to the specific environment to help nurses continuously adjust to changing external environments and overcome internal instability [54]. A randomised controlled trial based on an online resilience project suggested that individuals’ levels of resilience may vary according to fluctuations in the internal and external challenges they encounter [55]. Digital Resilience Working Group [39] suggests that digital resilience is a dynamic personality resource that grows through digital activation, such as engaging with risk and facing challenges. It is applied to varying degrees in different specific situations rather than being a static linear process. Meanwhile, Sun argues that digital resilience is a changeable capacity that arises from the interaction between the individual and the environment and fluctuates to varying degrees in response to changes in time and environment [25].

The dynamic and changing traits of digital resilience are confirmed by continuous feedback. The constant feedback reflects that digital resilience helps nurses successfully navigate the risks of the digital environment as long as they are exposed to the shocks, positive effects remain internalised into nurses’ self-confident personalities [33]. Continuous feedback provides real-time information on the cognitive level, allowing for adjustments to be made to an individual’s performance at any time, which aligns with the trait’s dynamic nature. Continuous feedback can continue to strengthen the power of digital resilience as well. The study by Hammond et al. suggests that digital resilience is a cyclical learning process, and continually experiencing risk enhances the protective factors of resilience [47].

Sustained dynamic feedback is the description of the overall resilience process in a temporal dimension, with a focus on the emergence of digital resilience of clinical nurses alongside digital adversities, which continues to exert its influence as them fluctuates.

Antecedents are events that exist or occur before the concept’s appearance and are prerequisites for the concept. Consequences are events that occur because of the emergence of a concept. They are the direct result of the conceptual event [28, 29]. Based on the digital nursing quality management framework [56], this study explains the antecedents and consequences of digital resilience from a human-related, technology-related, and organisation-related perspective.

Digital technology-related antecedents

The rapid development of digital transformation has led to nurses being surrounded by digital resources in their workplace, with artificial intelligence and robotics being the most prominent [3, 5, 16, 57]. Artificial intelligence technologies have affected how people think and pushed the boundaries of their perceptions and how healthcare professionals work and live [58]. Digital technology, integrated into the art of resilience programmes that provide patients with spiritual encouragement, becomes a care pathway facilitator in a clinical microcosm full of rapid uncertainty, not only guiding nurses towards a better acceptance of digital technology in conjunction with the nature of nursing care, but also benefiting nurses involved in the whole care process. [59]. For example, activity-assisted robots controlled by networks have been tested and implemented in several hospital intensive care units over the past few years, reducing nurses’ fatigue. At Yale New Haven Hospital, the Rothman index, calculated from electronic medical record data, is used to identify a patient’s high-risk status. Algorithms are being integrated into the nursing process, and the experience of using algorithmic tools is crucial to nurses [57].

Owing to the gradual but expeditious filling of the healthcare sector with digital resources, nurses are both actively (passively occasionally) involved in adapting and driving the digitalisation process, therefore, making nurses be exposed to the shocks and risks that we can foresee in this context. Expectedly, nudged by the application of massive digital technologies, nurses have the autonomous power to transform into a more resilient state, in other words, nurses who are better equipped to navigate the digital environment and deal with the rapidly changing nature of their work and patients. That is the key, digital resilience.

Human-related antecedents

As one of the most significant end-product users of digital health technologies, the changes that occur in the nurses as they use those technologies cannot be ignored [60].

Mutual dialogue among nurses and technologies

Nurses’ engagement in engineering, deploying digital resources and feedback on implementing digital technologies, and mutual dialogue between nurses and technologies, in brief words, are imperative in countering digital risks and building digital resilience. Meanwhile, technologies shape nurses’ behaviours, perspectives, and attitudes. As digital technologies continue to spread in all aspects of the healthcare setting, the value of nurses in the clinical, financial, and operational processes of digital technology adoption is recognised. By working with nursing teams, Microsoft has identified areas where artificial intelligence can provide added value to patients and healthcare [57]. Since the uncertainties of the early warning system vital signs tool for patient safety, experienced nurses using advanced thinking (e.g., critical thinking, clinical reasoning, etc.) have made timely, accurate, and rational decisions that have improved the quality of care and improved patient outcomes [12, 61]. Therefore, the interplay between the two allows nurses to develop a foundational competence base to resist risk and vulnerability.

Digital literacy and character trait within nurses

Digital literacy, which refers to an individual’s ability to access digital technologies and adequately understand digital information and tools, focuses on interpreting the skill level [62]. Digital literacy is fundamentally linked to the distinction that digital resilience is structurally transformative, i.e., the understanding, utility, and dissemination of digital resources and technologies and the resulting shifts in attitudes, beliefs, and cognition [25, 62, 63]. Digital skills from nurses serve as a stepping stone for developing digital resilience across the divide between skills and cognition. Digital resilience is acquired in the digital environment, which is progressive from digital literacy to digital resilience, and getting access to digital literacy needs experience online practice rather than avoidance [25, 36, 38, 64].

Personality traits have a definite and persistent impact on behaviour, which is no different in the digital age [65]. Positive dispositions have navigated nurses amid digital threats. Nurses insist on their critical thinking with the assistance of AI healthcare technology and continuing to provide appropriate quality and personalised care to their patients, even under threats that they would be unemployed caused by intelligent, caring robots as well as remote healthcare technologies maim nurses’ touches for patients, of which essence is generally acknowledged as human touch [4]. Nurses are confident they will not lose their irreplaceable merit [10, 12]. Having high-level self-efficacy is an essential manifestation of positive traits. Nurses with high levels of self-efficacy showed more interest and confidence in addressing robotics and related skills of technologies like programming in healthcare [66].

Hence, digital literacy and nurses’ traits serve as guiding hands in facing digital challenges, with digital literacy demonstrating the extent of grasping digital technologies and personal traits predicting whether a digital resilience outcome is produced eventually.

Organisation-related antecedents

Digital transformation within hospitals is accelerating. During the COVID-19 pandemic, the public health network, with hospitals as the primary nodes, suffered incomparable disruptions in their operational order at varying extents of shocks [67]. The previous offline collective consultation models in hospitals were replaced by remote online models (e.g., online appointment registration, online doctor-patient and nurse-patient interactions, etc.) [67, 68]. The accumulation of patient information in electronic health record systems has left healthcare professionals with more burdensome health-recording labour than ever before, fuelling hospital information management to tap into AI to automate clinical information capture and recording, optimising the potential time to clinical decision-making by leveraging AI due to its agile responses [3, 16, 69, 70]. The use of AI to establish standardised language and technology frameworks for nursing is also an undeniable part of organizational digital transformation, enabling a wide range of empirical nursing techniques and processes to be standardised, which further regularised how nursing is practised [11, 16]. Ultimately, integrating care with digital technology achieves the ultimate goal of making care more straightforward and convenient [2].

From a practical perspective, the digital transformation of organisations and the internal dialogue are co-occurring and are fuelling each other. Organisation’s ongoing deepening of digital operational ways of working shapes the practice environment for nurses from the outside, and interaction between nurses and technologies activates nurses’ intrinsic force from the inside. Finally, nurses’ character traits, such as self-efficacy, sustain that positive force from within, i.e., digital resilience.

Consequences occur due to a concept and directly result from the concept [28]. The consequences of nurses’ digital resilience can likewise be explained at three levels: digital technology-related, human-related, and organisation-related. This study argues for differences in the consequences of digital resilience in nurses. It is important to register that despite digital resilience as a positive force, there are individual variations in the robustness of digital resilience due to stimuli antecedents posed to nurses that differ in intensity, duration, or how attributes act. These variations manifest themselves in various extents of the final effect of resilience. Nurses’ recovery was positively correlated with the strength of digital resilience.

Digital technology-related consequences

While digital resilience transforms nurses as a power that can be realised in practice, digital technology is also changing one of its antecedents.

Nurses who use digital technology continually question the problems with digital technologies using critical thinking. Issues with digital technologies, such as the racial bias of the implanted algorithms, uncertainty about safety, and ambiguity about legal liability, can cause poor clinical outcomes. Nurses with digital resilience can provide feedback on technical issues during work. The data generated by the nurse’s careful observation and engagement with the patient compensates for the neglect of biological complexity by algorithms supporting digital techniques, thus completing the upgrading and refinement of digital technologies [2, 14, 60, 71]. At the same time, the human touch from nurses ensured that the digital technology was implemented without creating a crisis of trust between the nurse-patient-digital technology due to the potential loss of patient privacy and human care [72].

Human-related consequences

Unlike digital technologies or machines that execute algorithmic instructions, nurses, as human beings, are complex. The consequences of digital resilience on clinical nurses depend on the extent to which nurses are digitally resilient.

Nurses with a high level of digital resilience can cope well with digital risks. Digital resilience not only positively improves nurses but also empowers nurses with digital thinking. Digital thinking means that nurses use digital skills and information literacy to seek solutions to nursing problems and consider digital principles as guiding views of clinical work, which improve the quality of care while contributing to the development of the individual nurse [15].

Nonetheless, nurses with low levels of digital resilience cannot cope with the threats and challenges of digital transformation. Nurses with insufficient skills will not be able to use digital technologies correctly, leading to increased rates of errors and safety risks. Nurses with poor skills will not be able to use digital technologies correctly, causing an increased incidence of mistakes and creating new safety risks [15]. Nurses who are unable to master the digital technologies and tools within the workplace proficiently, fail to adapt to the requirements of a digitalised work environment, and are incapable of cultivating a high level of digital resilience will ultimately compromise the quality of care provided to patients, potentially resulting in varying degrees of adverse outcomes for them. Lack of solid digital resilience and negative experiences with digital technology can develop new occupational stresses in the digital age, which, if sustained over time, can result in headaches, burnout symptoms, reduced job satisfaction, and so on [11, 73].

Organisation-related consequences

Nurses with digital resilience show a pioneering role in digitalisation in healthcare organisations. The widespread utility of digital health technologies improves care delivery and access to nursing care [25]. AI technology reporting frameworks and guidelines reviewed by nurse leaders play an important role in standardising nursing care for the integration of digital technologies into nursing [1, 57, 60, 74], while digital nursing quality management systems built with the participation of nurses with digital resilience will create the possibility of reducing the burden of nursing care in hospitals settings, improving management efficiencies, and shifting from previously empirical to intelligent management of nursing care [56, 75]. The iterative updating of digital technology aligns with the nurses’ spirit of innovation. Nurses with digital resilience can embrace innovation based on the essential human touch of nursing, contributing to advancing digital health in healthcare organisations [4].

The antecedents and consequences of digital resilience highlight its strong links to the four fundamental philosophical concepts of nursing, from which, as analysed above, we can conclude. In addition, antecedents and consequences of digital resilience and its many attributes are not in a linear correspondence or a containment-containment relationship, but instead, they can be interconnected across boundaries and closely intertwined.

Walker & Avant insist that researchers must examine definitions and attributes together with borderline cases, related cases, and contrary cases despite providing model cases [29]. Here, we provide fictional both model case and contrary case to clarify and illustrate the attributes, antecedents and consequences of digital resilience for better understanding.

Model case

Model case shows all the attributes of the concept, and it is an absolute case that fits perfectly with the definition and attributes of which researchers can be confident.

Alison is an experienced young nurse. The hospital where she works is a local central hospital where digital health and care is a specialty, with online applets enabling two-way interaction between medical staff and patients (digital technology-related antecedents). During the COVID-19 pandemic, she spent long hours, as a frontline caregiver, every day providing safe care measures to patients while facing the risk of infection. At the same time, the hospital implemented digital quality management to cope with the impact of the COVID-19 pandemic. Nurses were required to fill in a large number of online examinations records every day, as well as frequently attending open Internet courses to learn about the prevention of infectious diseases and the latest healthcare techniques (mutual dialogue among nurses and technology). She felt exhausted due to constant overload and fearfulness for being infected with coronavirus. She knew that such negative feelings could seriously influence her state of health and work, so she decided to change all that. She believed that she had a strong learning ability, that she could master the prevention of infections during an epidemic, that she was skilled in the use of new medical and nursing equipment, and that she could adapt to and perform well during a temporary change in her life and work (intrinsic force; self-efficacy). Encouraged by her colleagues, she joined the hospital’s coronavirus prevention and control team, responsible for controlling coronavirus in her department. She attended a series of mental health courses and lectures on digital technology, which enabled her to learn proper psychological counselling methods and improve her digital literacy. Since then, she has taken a proactive approach to risk, being able to scientifically analyse its elements and characteristics (understand and absorb shocks), learn the right management strategies, and apply them to her work. She used the latest nursing equipment to provide the best care for patients daily and completed work records and inspection reports (respond and take action). Finally, she gradually adapted to her current work situation and gained experience dealing with major infectious diseases and caring for critically ill patients (perform resilience; positive power). After the COVID-19 pandemic, she continued to learn about digital information technology. She actively participated in the hospital’s digital management transformation, translating her work experience and ideas into recommendations for departmental improvements (sustained dynamic feedback).

Contrary case

On the contrary, the cases do not match the attributes of the concepts we studied, and readers can easily distinguish between concepts by contrary case.

Kim is a trainee nurse at Central Hospital and hopes to become qualified, but the reality is disappointing. She was confused by the hospital’s information system and digital nursing technologies but had to accept and use them, which made her feel bored and resistant. The COVID-19 pandemic not only seriously disrupted the hospital’s workflow but also had a very severe impact on Kim’s mental and working conditions. During this period, Kim was involved in treating different patients daily. Still, she was overwhelmed by the constant updating of digital technologies and felt frustrated and disempowered by the lack of informatic learning in her work. She felt that her work had become more demanding due to the intervention of digital technologies and, therefore, was more resistant to achieving at work. She also did not do well in her nursing training exams and gradually developed a fear of work and information technology. Eventually, she displayed irritability, scepticism, and lower self-confidence. She gradually alienated herself from her colleagues, always had an avoidant attitude at work, and was reluctant to interact with patients. She kept thinking that she should not suffer from such pain and even resisted work. As a last resort, she applied for resignation from the personnel department.

The final step in the concept analysis is to identify empirical referents to support or validate the conclusions of our study [29]. Current measurements of digital resilience are primarily in terms of general resilience. Digital resilience is a subtype of general resilience in the digital age, and they are essentially the same. There are 19 commonly used resilience scales, all requiring further validation. Still, the Connor-Davidson Resilience Scale, the Resilience Scale for Adults, and the Brief Resilience Scale have better psychological ratings when applied broadly [76, 77]. A study aims to develop the Nursing Digital Applied Skills Scale (NDASS) to test the psychometric properties of digital literacy. However, the study did not extend digital technology application skills to digital resilience, even though the study group was nurses [15]. Hitherto, we have not found an accurate and tailored assessment tool for digital resilience in the clinical nurse community that measure it or determine its existence, convert the measurement or evaluation into an operational rating system.

Our analyses of digital resilience attributes, antecedents, consequences, and case studies above showed us digital resilience focusing on clinical nurses. The digital resilience of clinical nurses is the positive power driven by intrinsic force when confronted with digital impact in digital environments, and its realistic performance is expressed as sustained dynamic feedback that consists of acquired behaviours. Based on this initial concept, a preliminary conceptual model that covers the attributes, antecedents, and consequences of digital resilience and the interaction relationships of these factors was drawn up for us. As shown in the Fig. 2.

The conceptual model of digital resilience of clinical nurses

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This study identified four core attributes, antecedents, consequences of digital resilience of clinical nurses, provide cases to strengthening understanding, establish a conceptual model eventually. There are differences between the digital resilience attributes of clinical nurses, so it is feasible to identify and distinguish their attributes. understanding and absorbing shocks, responding and taking actions, and performing digital resilience are the key stages of acquired behaviours. During these stages, clinical nurses with digital resilience demonstrate a non-confrontational attitude towards the arrival of digital technologies and the changes it brings, while quickly grabbing and using digital technologies and even teaching solutions to colleagues who in digital adversities [12, 36]. These are resilience phenomenon that can be observed. Positive power and intrinsic force emphasized the differences from different perspectives. Firstly, positive power focuses on the desirable changes brought about by its process and ultimately well outcomes, while intrinsic force highlights that it is rooted in nurse themselves [10, 38]. Secondly, positive power breaks the constraints of nurses’ social contact, enabling nurses to build support networks to navigate challenges [36], whereas intrinsic force elevates the nurses’ threshold for digital adversities, thereby enhancing their self-efficacy in resolving such adversities. Sustained dynamic feedback is the description of the overall resilience process in a temporal dimension, with a focus on the emergence of digital resilience of clinical nurses alongside digital adversities, which continues to exert its influence as them fluctuates.

The antecedents and consequences of digital resilience are discussed at the three-dimensional levels of digital technology-related, people-related, and organisational-related. Firstly, the ongoing and comprehensive integration of digital technologies into healthcare practices is the primary catalyst for nurses’ positive adaptation and digital resilience, driving digital transformation [48, 57, 78]. Secondly, the structural adjustments in organizational frameworks resulting from digital change continuously influence the perceptions and behaviours of nurses at every level of the organization [60]. Finally, nurses’ intrinsic digital literacy and character traits are crucial in developing and sustaining digital resilience. Digital resilience empowers nurses with digital thinking and cultivates their ability to utilise digital technologies to solve practical problems. Nurses with digital resilience can also draw upon their autonomy under critical thinking, compensating for the potential risks associated with the lack of human touch and procedural errors in digital technologies [61]. Overall, nursing quality and the well-being of patients are ultimately reinforced owing to the positive interaction between nurses and digital technologies at every level within healthcare settings and the optimisation of organisational structures and operational practice.

The challenges and adversities brought about by digital technologies are input into the nurses’ own digital resilience circular system, which filters them and outputs the consequences and changes. Due to varying levels of digital resilience, nurses experience different changes after being impacted. This linear process is similar to the stress and coping model and adaption model [79]. Resilience is a functional relationship between a system’s adaptability and its inherent vulnerability, which changes under stress. This is consistent with the changes brought about by digital resilience [51, 80]. Roy’s adaptation model emphasises [81] the process and outcome of harmoniously integrating oneself and environmental factors as a whole system when coping with stress. This is consistent with abstract process that digital resilience enables nurses of absorbing and integrating environmental support factors and one’s own support network actions [79].

Developing projects to cultivate and enhance digital resilience of clinical nurses is fundamental to form the nurse-technology positive ecosystem in healthcare surroundings. However, due to the lack of a precise definition of digital resilience, these intervention projects and implementation paths are often overlooked. Our research provides certain recommendations for future related research. Firstly, it is worthwhile to choose and affirm the intrinsic force of personal digital resilience [82]. Awakening clinical nurses’ self-learning potential abilities and re-recognising the value of digital technologies plays an irreplaceable role in intervention training programmes. Secondly, the antecedents and consequences of digital resilience imply policymakers on creating a holistic integrated training environment for nurses. We believe that digital resilience is the product between an individual and their environment [25]. The digital resilience online/offline training based on the existing continuing education credit system plays a fundamental role. Crucial is leadership support for fostering nurses’ adherence, thereby preventing their attrition due to clinical workload pressures [83]. Due consideration must be accorded to the impact of socio-cultural factors across diverse regions on clinical nurses. The development of digital resilience inherently implicates expressions of occupational stress and distress, rendering the culture in facilitating nurses’ articulation of affective states and needs [84] – a dimension warranting systematic integration within conceptual frameworks in the future.

Developing digital resilience is essential for clinical nurses to cope with digital challenges via understanding a deeper meaning of the combination process of nurses and digital resilience.

Presently, digital resilience is more commonly discussed in information science and management. Still, less empirical research has been conducted in nursing, where the concept of digital resilience is often substituted or conflated with general resilience. Although the nature of digital resilience can be explained by general resilience, the characteristics of digital resilience should not be ignored by researchers. Further exploration of the concept and attributes of digital resilience could help better understand how nurses, a community known for its adaptability [4], absorb and internalise risk and transmit information outward in their systems in the face of danger.

Secondly, the variables in the dynamic and sustained process of digital resilience influence the outcome, yet the dynamic and sustained process has rarely been discussed. Previous researchers have focused only on whether resilience occurs and the factors that affect it and then, in turn, designed interventions to enhance resilience outcomes [24, 27]. However, the process of recovery is uncertain and highly susceptible to change. There is a need to separate the process and explore factors leading to different consequences, respectively, by which nurses’ digital resilience can be promoted.

Finally, there is a need for more quantitative research to develop more accurate and nuanced assessment measures of digital resilience, as well as more research on qualitative processes to explain how digital information and skills is exchanged and linked with resilience between nurses, technologies at the cognitive and practical levels.

Our study clarifies the concept of digital resilience of clinical nurses. We offer practical assistance for further interpretation of digital resilience of clinical nurses and the development of relevant quantitative measurement tools or qualitative research frameworks.

It is frank but evitable that we need to acknowledge the limitations of this study in analysing. Firstly, the newer iterations of digital technology keep moving forward with the concepts established, which are still crumbling down in the future [29]. Secondly, the text study only searched specific Chinese and English databases and included only Chinese and English written journal literature, which may lead to bias. Also, we included policy documents only when necessary to explain the concepts but excluded blogs, tweets, etc., which may affect the richness of the concepts. In our inclusion and exclusion criteria, we believe that literature focusing on “digital resilience” should be included. However, this may compromise, to certain extent, the diversity of the literature screening causing circular argument bias [85]. Future research may adjust the screening criteria of review to ensure a wide range of perspectives.

The concept analysis of this study follows Walker & Avant’s classical conceptual analysis methods to deliver a comprehensive account of digital resilience of clinical nurses. We describe the digital resilience of clinical nurses as the positive power driven by intrinsic force when confronted with digital impact in digital environments, and its realistic performance is expressed as sustained dynamic feedback which consists of acquired behaviours, offering attributes, antecedents, and potential consequences. Our study will help policymakers and hospital administrators develop effective intervention programmes to enhance digital resilience for nurses, for example, conducting continuing education training courses on digital resilience, establish a departmental digital resilience guidance group, or create a digital resilience art therapy environment [59].

Digital technologies have brought clinical nurses unavoidable digital challenges, problems, and adversities to various extent. Yet digital resilience allows nurses to neutralize digital adversities. Behind the digital resilience of clinical resilience, combining nursing practice advancement and digital co-connection/transformation to actualize not only intelligent precise care but also more humanized and self-liberated nursing wellbeing principles, which is still remains as one of the most exciting and promising research perspectives. Therefore, nursing researchers shall take furthermore steps to plot the digital resilience theoretical model and keep accordance with the agelong practice focusing on nursing world. At last, enduring spirit of nursing “Human Touch” should continue to give meaning to psychological and behavioural studies of nurses.

No datasets were generated or analysed during the current study.

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This work was partially supported by the National Nature Science Foundation of China [grant number 72274087], and the Management Project of Gansu Provincial Hospital [grant number 23GSSYC-2].

1. Yusheng Mo and Hongyan Zhang are co-first authors and have contributed to this work equally.

Authors and Affiliations

1. Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou City, Gansu Province, China

   Yusheng Mo, Shixia Lei & Lin Han

2. Department of Nursing, Gansu Provincial Hospital, Lanzhou City, Gansu Province, China

   Hongyan Zhang, Xinrui Bai & Lin Han

Contributions

Y.M: First Author. Conceptualization, Methodology, Writing - Original Draft preparation, editing, reviewing, final manuscript preparation. H.Z: First Author. Conceptualization, writing - review, editing, funding acquisition. X.B: Reviewing, editing, supervision. S.L: Reviewing, editing, supervision. L.H: Corresponding Author. Reviewing, editing, supervision, funding acquisition. Y.M and H.Z are co-first authors and contributed to this work equally.

Corresponding author

Correspondence to Lin Han.

Ethic approval and consent to participate

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Not applicable.

Competing interests

The authors declare no competing interests.

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