RESEARCH AND DEVELOPMENT
Resilience and its relationship with spiritual
wellbeing among patients with heart failure
Ali Razaghpoor1
Hossein Rafiei2
Fateme Taqavi2
Seyedeh Mahnaz
Hashemi2
Correspondence to:
Hossein Rafiei;
Hosseinr21@gmail.com
How to cite this article:
Razaghpoor A, Rafiei H,
Taqavi F et al. Resilience and
its relationship with spiritual
wellbeing among patients with
heart failure. British Journal
of Cardiac Nursing. 2021.
https://doi.org/10.12968/
bjca.2020.0109
1
Abstract
Background/Aims The importance of resilience among patients with chronic diseases
has been demonstrated, but rarely among patients with heart failure. This study examines
resilience and its relationship with spiritual wellbeing among this patient group.
Methods This descriptive study was carried out with 130 patients with heart failure
in Iran. The tools used were a 29-item resilience scale and the Paloutzian and Ellison
Spiritual Wellbeing scale.
Results The average resilience score was 107±19.5. Among the demographic variables,
age, education, duration of disease and the presence of other concomitant diseases
were significantly correlated with the patients’ total resilience scores (P<0.05). The
average spiritual wellbeing score was 83.12, with results showing a significant and direct
relationship between resilience and spiritual wellbeing (P=0.001, r=0.386).
Conclusions: Levels of resilience have a strong relationship with spiritual wellbeing
among patients with heart failure. Therefore, building resilience should be incorporated
into holistic care of these patients.
Key words: Heart failure; Holistic nursing; Resilience; Spirituality
Submitted: 28 July 2020; Accepted following double-blind peer review: 01 December 2020
Introduction
Chronic diseases are a significant burden to both patients and healthcare systems. One
of the most common chronic conditions if heart failure (Evans et al, 2016; Lesyuk et al,
2018). Heart failure is a global health issue that affects millions of people worldwide,
with studies showing that this number is increasing (Savarese and Lund, 2017; Benjamin
et al, 2019). Although data on the prevalence of heart disease in Iran is very limited,
Ahmadi et al (2014) found it to be at 8% of the population, which is relatively high
compared to other countries.
The role of resilience in the wellbeing of patients with heart failure has been the topic
of several studies over the past two decades. Shin et al (2009) defined a resilient person
as ‘one who has a positive attitude towards restoration, the power to reconstruct and
control his/her disease (personal dimension), and support from a supportive system with
supportive persons (interpersonal dimension)’. In patients with cardiovascular conditions,
resilience can play a significant role in increasing adaptability to the diseases, allowing
them to live a more fulfilled life despite their diagnosis (Besharat and Ramesh, 2019).
On the other hand, patients with low resilience were more likely to experience depression
after reaching an acute stage of their disease (Kirchberger et al, 2019). Similarly, Rezai
et al (2019) reported that more resilient patients with heart failure experienced higher
levels of psychological wellbeing (Rezai et al, 2019). Improving resilience among
patients with cardiac conditions, such as heart failure, can result in improved mental and
physical wellbeing (Liu et al, 2018). Therefore, a comprehensive understanding of this
© 2021 MA Healthcare Ltd
issue and the factors that influence it could help health professionals to provide holistic
care to these patients.
In the past decade, spiritual wellbeing has been emphasised by the World Health
Organization as an aspect of overall wellbeing (Tabei et al, 2016). Spiritual wellbeing
provides a harmonious and integrated connection between one’s inner forces, and leads
to stability in life, a sense of peace and close connection with one’s self, God, community
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 RESEARCH AND DEVELOPMENT

and/or environment (Siavoshi et al, 2018). The importance of spiritual wellbeing and its
impact on different aspects of the lives of patients with chronic conditions has received
much attention by health researchers (Tabei et al, 2016). Studies have shown that issues such
as stress, anxiety, depression, hope, self-esteem, quality of life, and adjustment to illness
have more positive outcomes among patients with better spiritual wellbeing (Mohebbifar
et al, 2015; Ghanbari Afra and Zaheri, 2017; Niyazmand et al, 2018; Senmar et al, 2020a).
Considering the impact of spiritual wellbeing on different aspects of patients’ lives, the
authors of the present study aimed to investigate whether there is a relationship between
resilience among patients with heart failure and their spiritual wellbeing. A literature review
suggested that this is the first study to examine this specifically. The research questions
this article will investigate are:
■ What is the general level of resilience among patients with heart failure?
■ What are the demographic variables associated with resilience among patients with
heart failure?
■ What is the relationship between resilience and spiritual wellbeing among this
patient group?

Methods
This descriptive, analytical study was carried out in Qazvin, Iran. Data collection was
performed over a period of 6 months from July 2019 to January 2020. Half of the
patients involved were recruited from BooAli Sina Hospital, while the other half were
from Razi Hospital. Almost all patients with heart failure in Qazvin are treated at one
of these healthcare centres.
Patients met the inclusion criteria if they had been diagnosed with heart failure by a
specialist cardiologist at least 6 months before, were able to complete the questionnaire and
were willing to participate in the study. Patients who were in class IV of heart failure, based
on the New York Heart Association classification system, were excluded from the study.
The wards participants were recruited from in the two hospitals included cardiac internal
wards and coronary care units for both male and female patients. The researchers visited
these wards to collect the data and obtain informed consent from the patients. Permission
was also obtained from the authorities at the Qazvin University of Medical Sciences, as
well as the managers of the hospitals, before the study began.

Tools used for data collection

Data was collected using two questionnaires that were distributed to the participants on the
ward. After collection, the researchers reviewed the completed questionnaires and checked
with the participant if there were any incomplete or ambiguous answers.
The first questionnaire comprised a demographic variables check list which was designed
by the researchers and included items about participants’ age, sex, marital status, duration
of disease, severity of disease and the presence of other concomitant diseases. The second
questionnaire was a 29-item resilience scale that was designed in Iran by Gheshlagh et al
(2018). This scale uses five subscales to examine respondents’ resilience levels:
■ Active compatibility (10 items)
■ Self-management (7 items)
■ Logical empowerment (7 items)
■ Adherence to treatment (3 items)
■ Spirituality (2 items).
Each item is scored using a 5-point Likert scale, with a score of 5 indicating complete
agreement and a score of 1 indicating complete disagreement. Total scores ranged from 29
to 145 on this questionnaire. The scores for each of these sub-scales are then added up. A
© 2021 MA Healthcare Ltd

total score of 77 or lower indicates low levels of resilience, 78 to 107 indicates moderate
resilience and a score of 108 or higher indicates high resilience.
To measure spiritual wellbeing, the Paloutzian and Ellison Spiritual Wellbeing Scale
(Bufford et al, 1991) was used. This scale consists of 20 items in total, which are split into
two sub-scales (existential and religious) of 10 questions. Each question presents a statement,
to which respondents indicate their level of agreement from 1 (completely disagree) to 6

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 RESEARCH AND DEVELOPMENT

(completely agree). Higher scores, out of a total possible score of 120, indicate a higher
level of spiritual wellbeing. This scale has previously been translated into Farsi to be used
among patients with cancer in Iran, and was found to have a favourable level of validity and
reliability for this group (Seyedfatemi et al, 2006).

Ethical considerations
Approval was obtained from the Qazvin University of Medical Sciences (IR.QUMS.
REC.1397.245) to conduct this study and the researchers provided three reports to the
university during the process. Informed consent was sought from all participants and their
individual responses were kept confidential. It was emphasised to the participants that
their participation in the study was voluntary and that their refusal to take part would not
affect their care in any way.

Data analysis
Data were analysed using the SPSS version 16. First, the normal distribution of the
variables was confirmed using a Kolmogorov-Smitnov test. Parametric tests were then
used for further analysis. A Pearson correlation test was used to investigate the relationship
between the average resilience score and the average spiritual wellbeing score. This test
was also used to examine the relationship between the average scores in both resilience
and spiritual wellbeing with the participants’ ages. An independent t-test was used to
compare the mean total resilience and spiritual wellbeing scores with bivariate qualitative
demographic variables, including sex, education and the presence of other concomitant
diseases. One-way analysis of variance was used to compare the average resilience and
spiritual wellbeing scores with multivariate qualitative demographic variables, including
duration of disease. A P value of less than 0.05 was taken as significant.

Results
Demographic variables
In total, 130 patients participated in the study, of whom 73 (56.2%) were women. The
mean age of the subjects was 64.2±12.3 years. Most of the participants (n=107) did not
have a diploma level of qualification. In terms of the duration of heart failure, 14 patients
had been diagnosed less than 1 year before the study period, 22 had lived with the disease
for 1–2 years, 30 had lived with the disease for 2–3 years, and the rest had lived with the
disease for more than 3 years. Out of these 130 patients, 80 of them reported having other
concomitant diseases besides heart failure.

Resilience scores
The average score on the resilience scale was 107±19.5. The average scores on the subscales
of active compatibility, self-management, logical empowerment, adherence to treatment
and spirituality were 66.38, 64.06, 68.04, 75.83 and 74.42 respectively. Of the 29 items
on the scale, the highest mean score was related to the item ‘I adhere to the therapeutic
recommendations of doctors and nurses’, while ‘I try to manage my stresses’ had the
lowest mean score. Table 1 shows the relationship between the domains of resilience and
the demographic variables.

Spiritual wellbeing scores

Participants’ average score on the spiritual wellbeing scale was 83.12 out of 120. The
average scores of existential and religious dimensions were 43.26 and 39.86 respectively.
None of the demographic variables were significantly correlated with the patients’ level
of spiritual wellbeing (Table 2).
© 2021 MA Healthcare Ltd

The relationship between resilience and spiritual wellbeing

A significant relationship was demonstrated between the average score for resilience and
the average score for spiritual wellbeing (P=0.001, r=0.386). The results also showed a
significant relationship between resilience and the existential (r=0.476, P=0.001) and
religious (P=0.001, r=0.272) dimensions of spiritual wellbeing (Table 3).

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 RESEARCH AND DEVELOPMENT

Table 1. Relationship between domains of resilience and the demographic variables. r=correlation
coefficient
Demographic Active Self- Logical Adherence Spirituality Total
characteristic compatibility management empowerment to treatment Resilience

Age (years) r=-0.331, r=-0.366, r=-0.304, r=-0.169, r=-0.152, r=-0.330,

P<0.001 P<0.001 P<0.001 P=0.05 P=0.08 P<0.001

Sex Male 64.5 P= 64.6 P= 66.6 P= 74.5 P= 71.4 P= 106.1 P=

0.40 0.70 0.37 0.42 0.06 0.40
Female 67.5 63.5 69.1 76.8 76.7 108.8

Level of Under 64.1 P= 61.1 P= 66.1 P= 74.9 P= 73.3 P= 105.1 P=

education diploma 0.01 0.003 0.02 0.24 0.32 0.01

Diploma 76.9 77.7 76.7 80.1 77.1 118.8

and
higher

Comorbidity Yes 62.4 P= 59.5 P= 65.5 P= 75.4 P= 73.4 P= 103.9 P=

0.004 0.002 0.04 0.73 0.41 0.006
No 72.6 71.2 72.1 76.5 76.1 113.4

Illness Less 66.4 P= 58.4 P= 67.3 P= 76.7 P= 76.7 P= 106.1 P=

duration than 0.001 0.001 0.01 0.86 0.41 0.003
1 year
114.9
1–3 74.1 73.1 73.2 74.1 76.7
years
101.7
More 60.1 57.5 63.7 75.1 72.1
than
3 years

Discussion
Heart failure can affect many different aspects of a patient’s life, but the responses to the
questionnaires used in this study showed that participants had a moderate level of resilience.
Resilience levels were more likely to be higher in younger and more educated patients, as well
as those who had no other concomitant diseases. The results also showed that resilience levels
were significantly higher among participants who reported a high level of spiritual wellbeing.
Resilience plays a vital role in allowing individuals with chronic conditions to have a
good quality of life (Liu et al, 2018). The authors found one study that was similar to the
present research in their literature review. This study was conducted in Germany, where
researchers examined resilience among 186 patients with chronic heart failure and, in
contrast with the present study, found low levels of resilience (Lossnitzer et al, 2014). There
are two potential reasons for the differences between the two studies. The first relates to
the different tools used to assess resilience; the scale used in the present study is specific
to patients with cardiovascular diseases, whereas the scale used by Lossnitzer et al (2014)
was not specific to this patient group. The second reason was that the Lossnitzer et al
(2014) study only included patients with both heart failure and depression, which likely
affected their resilience scores.
Given the significant impact of resilience on patients with chronic conditions, it is
necessary for healthcare providers to consider and incorporate resilience training into
effective interventions for such patients. Such interventions include cognitive behavioural
therapy, individual and group therapy, and mindfulness‐based therapy, all of which have
© 2021 MA Healthcare Ltd

been shown to improve resilience levels in both healthy individuals and patients with
chronic conditions (Bekki et al, 2013; Helmreich et al, 2017; Joyce et al, 2018; Ludolph
et al, 2019). However, further research into the effectiveness of these interventions for
patients with heart failure is still needed.
The present study indicated that younger participants generally had higher levels of
resilience. Kashi et al (2019) produced similar results in a study involving patients with

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Table 2. Relationship between spiritual wellbeing and the demographic variables. r=correlation
coefficient
Existential Total spiritual
wellbeing Religious wellbeing wellbeing

Age r=-0.103, P=0.245 r=0.036, P=0.688 r=-0.032, P=0.719

Sex Male 39.1 P=0.17 42.2 P=0.14 81.3 P=0.146

Female 40.4 44.1 84.5

Level of education Under diploma 39.4 P=0.27 43.2 P=0.95 82.7 P=0.60

Diploma or 41.6 43.1 84.7

higher

Comorbidity Yes 39.5 P=0.41 43.8 P=0.20 83.3 P=0.77

No 40.4 42.2 82.7

Illness duration Less than 1 42.2 P=0.03 47.0 P=0.04 89.2 P=0.01
year

1–3 years 38.5 39.1 77.7

More than 3 41.9 44.2 86.1

years

Table 3. Relationship between resilience and its domains with the demographic variables
Active Self- Logical Adherence
compatibility management empowerment to treatment Spirituality

Existential r=0.497, P<0.001 r=0.397, P<0.001 r=0.461, P<0.001 r=0.381, P<0.001 r=0.392,
wellbeing P<0.001

Religious r=0.258, P=0.003 r=0.154, P<0.080 r=0.278, P=0.001 r=0.420, P<0.001 r=0.341,
wellbeing P<0.001

Total spiritual r=0.388, P<0.001 r=0.282 P=0.001 r=0.381, P<0.001 r=0.418, P<0.001 r=0.381,
well being P<0.001

ischaemic heart disease, as did Lee et al (2020) in a study of patients with coronary artery
disease. They suggested that, as individuals get older, various physical problems and
diseases can accompany heart problems, which can negatively impact resilience levels. It
can also be more difficult for elderly patients to manage lifestyle changes and adherence
to medications, which can also affect their resilience (Lee et al, 2020). Further research
into the link between resilience and age in patients with heart failure specifically is needed
to expand on these findings.
The finding that higher levels of education were linked to resilience has a precedent in
research by Nouri-Saeed et al (2015), who found similar results among patients with heart
disease. It has been stipulated that educating and empowering patients can have positive
effects on their resilience levels, and this is easier to do with patients with higher levels of
© 2021 MA Healthcare Ltd

education (Seyedoshohadaee et al, 2018; Lee et al, 2020).

Duration of disease and the presence of comorbidities was also found to affect the
resilience levels of participants, which aligns with previous studies of cohorts with heart
conditions (Nouri-Saeed et al, 2015; Lee et al, 2020). Comorbidities can be associated with
various complex problems for patients, which can easily affect their sense of resilience.
However, the present study also found that patients who had been diagnosed with heart

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 RESEARCH AND DEVELOPMENT

failure for less than a year had lower levels of resilience than those diagnosed for 1–3 years,
with resilience levels dropping again after 3 years. This relationship may thus be complex
and requires further study among this patient group.
Spiritual wellbeing as a dimension of health has been investigated in several studies
involving individuals with chronic health conditions (Rafiei et al, 2018; Senmar et al, 2020a,
b) but, to the authors’ knowledge, this was the first study to investigate the relationship
between spiritual wellbeing and resilience in patients with heart failure. A few similar studies
exist involving patients with other conditions, which produced similar results. For example,
Gultekin et al (2019) found a relationship between spiritual wellbeing and resilience among
127 patients who had undergone a liver transplant. Jones et al (2016) also found higher
levels of spiritual wellbeing in patients with spinal chord injuries who had higher levels of
resilience. Meanwhile, various studies have demonstrated the positive relationship between
spiritual wellbeing and self-efficacy among patients with chronic conditions (Chabok et al,
2017; Hasanshahi et al, 2018; Mikaeili and Samadifard, 2018; Rahmanian et al, 2018), as
well as decreased stress, anxiety and depression (Aghaeipour Amshal et al, 2016; Ahoei
et al, 2017; Rafiei et al, 2019). The strong relationship found between spiritual wellbeing
and resilience in the present study emphasises the need for both of these aspects to be taken
into consideration for holistic care of patients with chronic heart conditions.

Limitations
Patients who were at class IV of heart failure were not included in the present study, so it
is not possible to generalise the findings to very ill patients. All participants in this study
were Muslim, as the concept of spirituality in Muslim countries is very much integrated
into the concept of religion, which may make the findings inapplicable to individuals from
other religions or cultures.

Conclusions
Resilience is highly important for patients with heart failure. This study indicated that
there is a need for interventional programmes that aim to improve resilience, as this may
have a strong impact on patients’ spiritual wellbeing. However, given the lack of studies
on resilience and spiritual wellbeing among patients with heart failure, the authors strongly
recommend that further studies be conducted, especially among patients from other cultures
and religious backgrounds.

Key points
■ Resilience is an important skill for patients with heart failure and interventions to
improve their wellbeing and outcomes should reflect this.
■ A strong relationship was found between levels of resilience and spiritual wellbeing
among patients with heart failure.
■ Resilience levels were found to be higher in younger and more educated patients, as
well as those with no other concomitant diseases. These associations require further
research in order to be applied to practice.

Reflective questions
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■ Why is resilience important for the wellbeing of patients with heart failure?
■ How might spiritual wellbeing promote resilience in this patient group?
■ Suggest some reasons why younger and more educated patients have higher levels
of resilience.

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Author details
1Social
Determinants of Health Research Center, Research Institute for Prevention of Non-
Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
2Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran

Acknowledgment
The present study is the result of a student research project approved by the Qazvin University
of Medical Sciences. The researchers are grateful to the university’s research authorities
and would also like to thank the patients who participated in the study.

Conflicts of interest
The authors declare that there are no conflicts of interest.

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