Nursing home nurses’ experiences of psychological resilience development in dementia care: A qualitative descriptive study

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Understanding the mechanisms of resilience development is crucial for designing effective support interventions and improving the quality of dementia care in institutional settings. Methods A qualitative descriptive study informed by Interpretative Phenomenological Analysis (IPA) principles was conducted. Semi-structured interviews were conducted with 24 nurses from nursing homes in Guangzhou and Jinan, China between January and June 2025. Maximum variation sampling ensured diversity across gender, age, educational background, work experience, and institution type. Data were analysed using IPA combined with the Qualitative Analysis Guide of Leuven (QUAGOL). Transformative Learning Theory (TLT) provided the theoretical framework. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines were followed. Results Nurses’ psychological resilience development followed a transformative learning pathway comprising three interrelated phases. In the first phase, nurses encountered triggering dilemma experiences including professional value concealment, emotional boundary tensions, and therapeutic expectation conflicts. During the second phase of adaptive reconstruction, nurses engaged in professional identity questioning and rebuilding, practical wisdom accumulation, and caring innovation. The third phase of resilience wisdom generation encompassed existential meaning re-examination, reciprocal relationship discovery, and cultural context negotiation. Nurses who actively engaged in critical reflection developed resilience more effectively, while those lacking reflective support experienced more prolonged struggles with adaptation. Conclusions Nursing home nurses develop psychological resilience through transformative learning involving cognitive restructuring, professional identity reconstruction, and meaning-making. Support strategies should target each transformation phase. Chinese cultural context, particularly the interplay between person-centred principles and family-centred traditions, significantly shapes resilience development pathways. Interventions should foster critical reflection, provide mentorship opportunities, and create organizational cultures that value emotional labour in dementia care. Dementia care Nursing home Psychological resilience Transformative learning Qualitative research China Person-centred care Figures Figure 1 Introduction Person(s) living with dementia (PLWD) represent one of the most significant global health challenges of the 21st century, with approximately 55 million people currently affected worldwide, projected to reach 139 million by 2050 [1]. In China, over 16 million individuals are affected by dementia, making it the country with the largest dementia population globally [2]. The majority of PLWD eventually require long-term institutional care as the disease progresses [3]. Person-centred care (PCC) is recognized as the gold standard in dementia care, emphasizing the preservation of personhood, individual preferences, and the maintenance of meaningful relationships [4,5]. PLWD have the right to receive person-centred, coordinated, and quality care throughout their illness trajectory [6]. However, providing PCC in institutional settings presents considerable challenges, particularly when PLWD exhibit behavioral and psychological symptoms of dementia (BPSD), which occur in up to 90% of cases [7]. These symptoms include agitation, aggression, wandering, and resistance to care, creating significant psychological burden for nursing staff [8]. When PLWD do not agree with provided care or resist caregiving activities, this can lead to distressing situations for all parties involved [9,10]. Research indicates that nursing staff often experience moral distress when they feel unable to provide care that aligns with their professional values [11,12]. Background Nursing homes have become essential settings for dementia care as family caregiving capacity diminishes in the context of demographic aging and changing family structures [13]. Nurses working in these settings face unique challenges distinct from those encountered in acute care environments. The progressive and irreversible nature of dementia means that nurses must continuously adapt their care approaches as residents’ cognitive and functional abilities decline [14]. Recent research has highlighted that approximately half of PLWD receiving professional care experience involuntary treatment—care provided without consent or to which the person resists [15]. This reality creates profound ethical tensions for nurses who wish to provide dignified, person-centred care while also ensuring resident safety [16]. Psychological resilience refers to the dynamic process of positively adapting to significant adversity, trauma, or stress [17]. Unlike conceptualizations that treat resilience as a static personality trait, contemporary frameworks emphasize its developmental, contextual, and process-oriented nature [18]. In nursing contexts, resilience has been conceptualized as the ability to recover from workplace challenges while maintaining professional effectiveness and personal wellbeing [19]. Research has identified several factors associated with nurse resilience, including self-efficacy, social support, mindfulness, and meaning-making [20,21]. However, most existing studies have employed quantitative approaches that capture resilience as an outcome rather than illuminating the developmental processes [22]. Moral distress occurs when nurses know the ethically appropriate action but feel constrained from taking it, often due to institutional barriers or resource limitations [23]. In dementia care settings, moral distress is particularly prevalent given the complex ethical terrain nurses must navigate, including conflicts between autonomy and safety, tension between institutional policies and individual needs, and family expectations that conflict with professional judgment [24,25]. Transformative Learning Theory (TLT), developed by Jack Mezirow, provides a comprehensive framework for understanding how adults fundamentally change their frames of reference through critical reflection on assumptions [26]. The theory proposes that transformation typically begins with a disorienting dilemma—an experience that challenges existing beliefs [27]. TLT has been successfully applied in nursing education and professional development contexts [28,29], offering utility for understanding how challenging experiences can catalyze positive growth rather than simply causing harm [30]. The Chinese nursing home sector has expanded rapidly in response to demographic aging and changing family structures [13]. Traditional Confucian values, particularly filial piety , have historically placed responsibility for elder care on adult children. However, urbanization, declining birth rates, and increased female workforce participation have eroded family caregiving capacity [31,32]. Chinese nursing homes face challenges including inadequate staffing ratios, limited dementia-specific training, and medical-model orientations that may not align with person-centred care principles [33]. The tension between Western-derived person-centred principles emphasizing individual autonomy and Chinese family-centred decision-making traditions creates unique ethical terrain for nurses [34,35]. Studies from Western contexts have examined nurses’ experiences with dementia care ethical dilemmas [12] and involuntary treatment [16], but research examining resilience development in Chinese cultural contexts remains limited. Study aim This study aimed to explore nursing home nurses’ experiences of psychological resilience development in dementia care, using Transformative Learning Theory as a theoretical lens. The research questions were: What experiences do nurses perceive as challenging or dilemma-inducing in their dementia care work? How do nurses adapt and reconstruct their professional practice through these challenging experiences? What wisdom, meaning, or transformed perspectives do nurses derive from their experiences? Methods Design A qualitative descriptive approach was adopted based on naturalistic inquiry to gain a rich description of nursing home nurses’ experiences of resilience development [36]. The study was informed by Interpretative Phenomenological Analysis (IPA) principles, which emphasize detailed examination of participants’ lived experiences and the meanings they attach to these experiences [37]. While traditional IPA studies typically employ smaller samples (6–10 participants) for deep idiographic analysis, we adopted IPA as an analytic lens rather than a strict phenomenological methodology. This methodological adaptation was justified for three reasons: (1) the need to capture regional variations across two geographically and culturally distinct Chinese cities; (2) the importance of representing diverse nursing backgrounds including varying education levels, experience, and institutional contexts; and (3) alignment with recent methodological guidance suggesting that IPA principles can be applied flexibly when the research aims require broader sampling while maintaining interpretive depth [38]. This approach allowed for in-depth exploration while accommodating the larger sample size necessary for capturing diverse perspectives across the Chinese nursing home context. Data analysis was guided by the Qualitative Analysis Guide of Leuven (QUAGOL), a method inspired by the constant comparative approach of Grounded Theory [39]. QUAGOL provides systematic procedures for moving from raw data to conceptual themes while maintaining close connection to participants’ own words and meanings [40]. Transformative Learning Theory provided the theoretical framework for understanding how challenging experiences might catalyze perspective transformation [26]. While TLT encompasses ten phases of transformation, we focused analytically on three core phases most relevant to resilience development: disorienting dilemmas (phase 1), critical reflection on assumptions (phases 2–7 consolidated), and perspective transformation with action (phases 8–10 consolidated). This selective application was informed by the recognition that in naturalistic workplace learning contexts, the intermediate phases often occur simultaneously or iteratively rather than sequentially, and our focus on the experiential dimensions of resilience development necessitated attention to these consolidated phases [27,30]. To ensure rigour, we followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [41]. Setting Participants were recruited from nursing homes in two major Chinese cities: Guangzhou (Guangdong Province, Southern China) and Jinan (Shandong Province, Northern China). This dual-site approach captured regional variations in dementia care practices and cultural traditions. Both public and private facilities were included to capture variation in organizational contexts. Selection criteria for participating institutions included: (1) operational for at least 3 years; (2) dementia residents comprising at least 30% of total residents; (3) bed capacity of at least 100; and (4) institutional approval for research participation. Four nursing homes meeting these criteria (two in each city, one public and one private in each location) agreed to participate. Sampling Maximum variation sampling was employed to create a diverse sample capturing the breadth of nursing experiences [42]. Sampling dimensions included gender, age, educational background, total nursing experience, dementia care training status, and institution type. Inclusion criteria required participants to be: (1) registered nurses currently working in a participating nursing home for at least 6 months; (2) directly involved in providing care to residents with dementia; (3) able to articulate their experiences in sufficient depth; and (4) willing to participate voluntarily. Exclusion criteria were: (1) solely administrative roles without direct care responsibilities; (2) on extended leave during the study period; and (3) unwillingness to have interviews audio-recorded. Sample size was determined by data saturation [43]. Data collection and preliminary analysis proceeded iteratively, with regular team discussions to assess theme development and saturation status. Data collection Research team and reflexivity Interviews were conducted by two researchers with extensive qualitative research training. The primary interviewer was a nurse supervisor with 5 years of clinical experience in geriatric care. The secondary interviewer was a junior nurse with 3 years of experience. Neither interviewer had prior relationships with any participants. Reflexive journals were maintained throughout the research process, documenting assumptions, emotional responses, and evolving interpretations. Interview procedures Interviews were conducted in private meeting rooms at each nursing home. Before each interview, written informed consent was obtained, including permission for audio recording. The semi-structured interview guide was developed based on TLT’s core phases and refined through expert review and pilot testing [26,27]. Two pilot interviews were conducted to assess question clarity; minor refinements were made based on pilot feedback. The semi-structured interview guide was developed based on TLT’s core phases and refined through expert review and pilot testing [26,27]. Two pilot interviews were conducted to assess question clarity; minor refinements were made based on pilot feedback. The interview guide is presented in Table 1 . Table 1 Interview guide Dimension Main Questions Probe Questions Opening Please describe your overall experience caring for dementia residents. How did you come to work in dementia care? What drew you to this work? What were your initial expectations? Triggering dilemmas What difficulties or challenges have impressed you deeply while caring for dementia residents? What exactly happened? What caused this situation? What were your feelings at the time? Adaptive reconstruction How did you cope with and adjust to these difficulties? What strategies did you adopt? How effective were they? How did your understanding change over time? Support and resources What support and help did you receive in coping with these difficulties? What support did colleagues, supervisors, or family provide? What was most helpful? Resilience wisdom What impact have these experiences had on your personal growth and professional development? What new understanding do you have about the meaning of care? What wisdom have you gained? Closing Is there anything else you would like to share? What advice would you give to newly hired nurses? Note: Probe questions were flexibly adjusted based on participants’ responses. Interviews lasted 45–90 minutes and were audio-recorded. Data collection occurred between January and June 2025. Data saturation was reached after the 21st interview; three additional interviews confirmed saturation. Supplementary data sources Researchers conducted 3-month periods of on-site observation at each site prior to and during the interview phase, focusing on care routines, staff interactions, and institutional practices. Relevant institutional documents were also reviewed, including training materials and care protocols. While interview data formed the primary basis for thematic analysis, observational and documentary data contributed to the researchers’ interpretive framework and strengthened confirmability [44]. Data analysis Data analysis employed IPA principles [37] combined with QUAGOL procedures [39], proceeding through preparatory and actual coding phases. During the preparatory phase, interview recordings were transcribed verbatim within 24 hours and verified for accuracy. Four researchers independently read each transcript multiple times to achieve immersion. Initial annotation involved descriptive comments, linguistic comments, and conceptual comments. Team meetings were held after every 3-4 interviews to compare themes and reach consensus. The actual coding phase began once preliminary themes were established. A hierarchical coding framework was developed, informed by TLT phases while remaining open to inductively emerging themes. The primary researcher systematically coded all transcripts using NVivo 12.0 software. Coding verification involved team discussions to ensure consistency. Two researchers independently developed storylines, which were then compared and integrated. The full research team reviewed findings at multiple stages until consensus was reached. Rigour and trustworthiness Trustworthiness was established according to Lincoln and Guba’s criteria [44]. Credibility was enhanced through triangulation (combining interviews, observations, and document analysis), member checking (summarizing key points at interview conclusion and returning findings to five participants for review), peer debriefing (discussing findings with five experienced dementia care nurses), and prolonged engagement (3 months of on-site observation at each site). Dependability was ensured through a detailed audit trail and researcher triangulation (four team members independently analyzing data). Confirmability was supported through thick description and reflexive journaling. Transferability was facilitated through detailed description of the research setting, participant characteristics, and study procedures. Ethical considerations This study received ethical approval from the Ethics Committee of the 960th Hospital of the PLA Joint Logistic Support Force in Jinan, China. All procedures followed the Declaration of Helsinki. Written informed consent was obtained from each participant. Participants were informed of their right to withdraw at any time. Contact information for counseling services was provided to all participants. Audio recordings were stored on encrypted devices, and transcripts were anonymized. Results Participant characteristics Twenty-four nurses participated from nursing homes in Guangzhou (n=14) and Jinan (n=10). Table 2 presents participant characteristics. The majority were female (n=21, 87.5%) with ages ranging from 24 to 56 years (mean 38.2±8.6). Educational backgrounds included diploma (n=3), associate degree (n=8), bachelor’s degree (n=11), and master’s degree (n=2). Nursing home experience ranged from 1 to 18 years (mean 7.3±4.2), and dementia care experience ranged from 0.5 to 12 years (mean 5.6±3.8). Most participants (n=15) had received specialized dementia care training. Interview duration ranged from 45 to 90 minutes (mean 62.8±12.4). Table 2 Characteristics of participants (n=24) Characteristic n (%) or Mean±SD Gender Female 21 (87.5%) Male 3 (12.5%) Age (years) 38.2±8.6 (range: 24-56) 20-29 5 (20.8%) 30-39 9 (37.5%) ≥40 10 (41.7%) Education Diploma 3 (12.5%) Associate degree 8 (33.3%) Bachelor’s degree 11 (45.8%) Master’s degree 2 (8.3%) Nursing home experience (years) 7.3±4.2 (range: 1-18) Dementia care experience (years) 5.6±3.8 (range: 0.5-12) Received dementia training Yes 15 (62.5%) No 9 (37.5%) Institution type Public 14 (58.3%) Private 10 (41.7%) Overview of findings Analysis generated 427 initial codes organized into three main themes and nine subthemes following the TLT framework. Figure 1 presents a conceptual model illustrating nurses’ psychological resilience development through three interconnected phases: triggering dilemma experiences, adaptive reconstruction processes, and resilience wisdom generation. The themes and subthemes, along with their correspondence to Transformative Learning Theory, are presented in Table 3 . Table 3 Themes and subthemes with correspondence to Transformative Learning Theory TLT Phase Theme Subtheme Disorienting dilemma Triggering dilemma experiences Professional value concealment/emergence Emotional investment vs. boundary tension Therapeutic expectations vs. reality Critical reflection Adaptive reconstruction processes Professional identity questioning/rebuilding Practical wisdom accumulation/integration Caring wisdom integration/innovation Perspective transformation Resilience wisdom generation Existential meaning re-examination Reciprocal relationship value discovery Cultural context professional reshaping Theme 1: Triggering dilemma experiences Consistent with TLT’s concept of disorienting dilemmas, participants described experiences that profoundly challenged their existing assumptions about nursing, dementia, and their professional role. Professional value concealment and emergence The majority of participants reported that their professional contributions were systematically ignored or devalued by families and society. This invisibility of nursing work created a painful sense that their expertise went unrecognized. “Families come to visit maybe once a week. They see one small thing out of place and immediately complain. But they don’t see the hours we spend bathing her, turning her to prevent bedsores, coaxing her to eat when she refuses. All that daily care is invisible to them.” (N6, female, 34, 3 years experience) However, many participants also described meaningful moments when they were able to make residents’ personhood visible—to recognize the individual identity that remained despite cognitive decline. These moments of “seeing” and “being seen” emerged as powerfully restorative. “Grandma Wang has severe dementia. She barely communicates. But I learned she was a teacher before retirement. One morning, while combing her hair, I softly called her ‘Teacher Wang.’ Her eyes suddenly lit up. She grasped my hand tightly and murmured, ‘Someone remembers me.’” (N12, female, 37, 5 years experience) Several participants described similar experiences of making residents’ hidden identities visible through small but meaningful interactions. “When I first started, I saw only the disease. But gradually I learned to see the person. Mr. Chen was a calligrapher. His hands shake now, but when I put a brush in his hand, something changes in his eyes. He may not remember writing, but his hands remember.” (N1, female, 45, 8 years experience) “Society thinks we are just ‘elderly sitters.’ They don’t understand the complexity of what we do—the constant assessment, the therapeutic communication, the crisis prevention. When a resident with dementia becomes calm because I remembered her favorite song from fifty years ago, that’s not luck. That’s professional skill.” (N5, female, 39, 6 years experience) Emotional investment and professional boundary tension Most participants reported ongoing tension between the deep emotional bonds they developed with residents and professional boundaries they had been taught to maintain. The intimate, extended nature of nursing home care naturally fostered attachment that felt more like family than professional relationship. “After caring for them so long, they really do become like family. I know Grandpa Li’s habits better than his own children do. There’s genuine love there.” (N3, male, 28, 2 years experience) Yet this emotional investment created vulnerability. The unpredictable nature of dementia meant that the same resident who smiled at a nurse one day might fail to recognize her the next. “But then suddenly, he doesn’t recognize me. Or worse, he becomes hostile. That sense of being pushed away is particularly strong. Over time, I learned I had to find balance—to care deeply, but also to maintain some distance to protect myself.” (N3, continued) This emotional vulnerability was echoed by other participants who struggled to maintain professional boundaries while providing compassionate care. “I cried when Grandma Liu passed away. My supervisor said I was too emotionally involved. But how can you care for someone for three years and not feel something? I think the real question is how to hold both—the professional and the personal—without losing yourself.” (N11, female, 33, 4 years experience) “In nursing school, they teach you about professional boundaries. But no one tells you what to do when a resident calls you ‘daughter’ and holds your hand like you’re her only connection to the world. Those moments are both beautiful and heartbreaking.” (N14, female, 27, 2 years experience) Therapeutic expectations versus reality limitations Many participants described profound conflict between their therapeutic expectations and the irreversible nature of dementia. Traditional nursing education had prepared them to expect that good care would lead to patient improvement. “In the beginning, I kept thinking there must be something more I could do. Maybe if I tried a different approach, I could stop the decline. But no matter what I did, the trajectory was always the same—always downward.” (N9, female, 36, 4 years experience) This collision between therapeutic hope and disease reality created a crisis of professional identity. For some, this struggle was resolved through reconceptualization of meaningful care. “It took a long time, but eventually I understood. The process itself—maintaining dignity, reducing distress, preserving moments of connection—is meaningful. Every day they feel loved and safe, that’s a victory, even if they forget it tomorrow.” (N9, continued) Other participants described similar journeys of redefining what successful care means in the context of progressive cognitive decline. “I used to measure success by whether residents improved. Now I measure it differently—did she smile today? Did he eat without distress? Did I help her feel safe during a confusing moment? These small victories are actually huge.” (N13, female, 44, 7 years experience) “My biggest struggle was accepting that I cannot fix dementia. In hospital nursing, you work toward discharge, toward recovery. Here, the goal is different—it’s about quality of life, about presence, about making each moment count even when they won’t remember it.” (N17, female, 38, 5 years experience) Theme 2: Adaptive reconstruction processes The second theme captures how nurses engaged in critical reflection and active reconstruction in response to triggering dilemmas. Professional identity questioning and rebuilding Most participants described experiences of professional identity crisis triggered by the perceived inadequacy of their training for dementia care realities. The biomedical model emphasized in their education proved insufficient for the relational and emotional dimensions of dementia care. “In nursing school, we learned about IV skills, wound care, medication administration. But here in the nursing home, what matters is how to respond to residents’ emotional fluctuations, how to complete care when they’re uncooperative. I felt lost, like everything I knew was useless.” (N7, female, 42, 9 years experience) Through practice experience, nurses developed what might be termed a “biographical approach” to care—recognizing that effective dementia care required knowing residents as whole persons with histories and continuing identities. “An experienced care worker taught me that Grandpa Zhang was a teacher before retirement. One afternoon when he was agitated, we simply gave him a briefcase and said it was time for work. He immediately calmed down. I realized that understanding life stories may be more important than mastering techniques.” (N20, female, 56, 10 years experience) Practical wisdom accumulation and integration Experienced participants described developing tacit knowledge that could not be articulated in procedural terms but proved essential for effective care. “This kind of knowing isn’t learned from books. Grandma Wang can’t speak anymore, but she has her own language. A slight frown might mean discomfort. Wandering eyes might mean she needs the toilet. I can’t explain how I know these things; I just do.” (N4, female, 52, 12 years experience) Less experienced participants recognized the value of this practical wisdom and sought to learn from senior colleagues, though tacit knowledge proved difficult to transmit through formal teaching. “The older nurses know things that aren’t in any textbook. They made it look easy, but when I asked how they did it, they couldn’t really explain. ‘You’ll learn,’ they said. And eventually, I did—through doing, through making mistakes, through paying attention.” (N8, female, 29, 1 year experience) This process of developing intuitive understanding through accumulated experience was described by multiple participants as essential yet difficult to formalize. “After years of experience, I can sense when something is wrong before the resident shows obvious symptoms. It’s like reading a book without words. A change in breathing, a different look in their eyes, subtle restlessness—these tell me stories that medical charts cannot capture.” (N16, female, 48, 11 years experience) “Every resident with dementia is unique. What works for one person might agitate another. I’ve learned to be a detective—observing, experimenting, remembering what works. This knowledge lives in my hands and my heart, not just my head.” (N18, female, 35, 4 years experience) Caring wisdom integration and innovation Many participants described developing “indigenous innovations”—novel approaches to care that integrated formal knowledge, practical wisdom, and creative problem-solving. “Standard approaches often don’t work with dementia. For one resident who was very agitated every evening, we developed our own reminiscence therapy approach. We found music she loved, displayed photos of her family, created familiar rituals. It worked better than any medication.” (N2, female, 46, 8 years experience) Theme 3: Resilience wisdom generation The third theme captures the outcomes of transformation—the new perspectives, meanings, and ways of being that emerged from nurses’ journeys through challenging experiences. Existential meaning re-examination Many participants described developing transcendent care philosophies—new understandings of meaning and purpose that extended beyond conventional professional frameworks. “Caring for dementia residents completely changed how I view life. Watching residents who had lost memory, lost cognitive function—and yet remained somehow present, somehow worthy of love and care—I began to question everything. Who are we, really, if not our memories and achievements?” (N19, female, 41, 6 years experience) This philosophical deepening had practical implications. Nurses who developed transcendent perspectives described experiencing greater peace in their work. “Once I understood that the person is still there—not the same, but still there—everything became easier. I stopped grieving for who they used to be and started appreciating who they are now.” (N23, female, 47, 9 years experience) Several participants described how this work prompted profound personal reflection on life, aging, and human connection. “This work has made me think about my own aging, my own mortality. I’ve become more present in my own life, more appreciative of small moments. My residents have taught me that identity goes deeper than memory—there’s something essential that remains.” (N21, female, 50, 15 years experience) “Before this work, I defined myself by what I could do, what I could achieve. Now I understand that human worth isn’t about productivity. When I hold the hand of a resident who cannot speak, who cannot remember my name, I feel a connection that transcends words. That has changed how I see everything.” (N22, male, 32, 3 years experience) Reciprocal relationship value discovery Many participants recognized the bidirectional nature of caring relationships—discovering that care was not merely something they provided but something they also received. “At first, I thought I was just giving. But over time, I realized that wasn’t true. These residents teach me patience, acceptance, presence. They remind me what really matters in life.” (N8, female, 29, 1 year experience) “Grandpa Chen can’t remember my name. But he remembers that someone cares for him. And in his forgetting, he’s taught me to find meaning in each moment rather than expecting continuity.” (N15, female, 31, 3 years experience) This sense of mutual benefit and reciprocal learning was a recurring theme across participants with varying levels of experience. “I came into this work thinking I would help them. I didn’t expect them to help me. But they have—they’ve taught me to slow down, to be present, to find joy in simple things. When Grandma Zhou laughs at something only she understands, her joy is contagious. That’s a gift she gives me every day.” (N24, female, 26, 1.5 years experience) Professional reshaping within cultural context Many participants described negotiating the tension between Western-derived person-centred care principles and Chinese cultural traditions, particularly regarding family involvement and truth-telling. “In Western models, respecting patient autonomy is paramount. But in Chinese care environments, family is often the decision-making center. Some families ask us not to tell the elderly person they have dementia. In Chinese culture, it’s understood as protection—shielding the elder from distressing information.” (N10, female, 45, 10 years experience) Navigating this complexity required nuanced judgment about when and how to apply different ethical frameworks. “I’ve learned that there’s no universal right answer. What works for one family might be wrong for another. My job is to figure out what serves this particular person, in this particular situation, within this particular cultural context.” (N10, continued) Discussion This study explored how nursing home nurses in China develop psychological resilience through their experiences caring for residents with dementia. Using Transformative Learning Theory as a guiding framework, we identified a three-phase developmental pathway: triggering dilemma experiences, adaptive reconstruction processes, and resilience wisdom generation. Our findings suggest that resilience in this context is not merely a capacity to endure adversity but a dynamic process of transformation through which nurses develop new perspectives, competencies, and sources of meaning. Transformative pathway to resilience Our results align with Mezirow’s theory that transformative learning begins with disorienting dilemmas—experiences that challenge existing frames of reference [26,27]. The triggering experiences identified in this study—professional value concealment, emotional boundary tension, and therapeutic expectation-reality conflict—functioned as classic disorienting dilemmas, presenting fundamental challenges to nurses’ assumptions about their professional role. Notably, these dilemmas correspond to Mezirow’s first phase of transformation, wherein individuals encounter experiences that their existing meaning perspectives cannot adequately address. Similar to findings from Moermans and colleagues regarding involuntary treatment in dementia care [16], our participants experienced cognitive dissonance when their professional values conflicted with care realities. The adaptive reconstruction phase reflected the critical reflection processes central to TLT, encompassing what Mezirow described as self-examination (phase 2), critical assessment of assumptions (phase 3), recognition that others share similar transformations (phase 4), exploration of new roles and relationships (phase 5), planning courses of action (phase 6), and acquiring knowledge and skills for implementing plans (phase 7) [26]. In our data, these phases manifested as an integrated process rather than discrete sequential steps, with nurses simultaneously questioning their professional identities, seeking guidance from experienced colleagues, and experimenting with new care approaches. Our finding that nurses rebuilt their professional identities around biographical and relational approaches rather than biomedical frameworks represents a fundamental paradigm shift [34], echoing nursing education research demonstrating that reflection facilitates professional development [28,45]. The final phase represents what Mezirow termed perspective transformation, corresponding to phases 8–10: provisional trying of new roles, building competence and self-confidence in new roles, and reintegration into life on the basis of new perspectives [26]. Participants who reached this phase described experiencing their work through entirely new lenses—no longer focusing on what residents had lost but on what remained, no longer seeking cure but valuing care processes themselves. This reintegration was not merely cognitive but embodied, as nurses described a fundamental shift in how they experienced their daily work and relationships with residents. Professional identity reconstruction A key finding was nurses’ transition from biomedical to person-centred paradigms as a central component of resilience development. Traditional nursing education emphasizes technical competencies and cure-oriented outcomes [13,33]—frames that proved inadequate for dementia care complexity. Our participants developed new professional identities centred on residents’ life stories rather than disease processes, aligning with theoretical work on person-centred dementia care [46]. The development of tacit knowledge parallels Benner’s novice-to-expert progression [47]. However, in dementia care, expertise development involves fundamentally reconceptualizing what nursing expertise means, consistent with Polanyi’s concept of tacit knowledge [48]. Our findings also resonate with research on moral distress in long-term care [11,23,24]. Rather than simply experiencing these as sources of distress, participants who developed resilience learned to navigate tensions through perspective transformation and practical wisdom. Cultural dimensions of resilience Chinese cultural context significantly shaped resilience development pathways. The tension between Western person-centred principles emphasizing individual autonomy and Chinese family-centred decision-making traditions created unique ethical challenges [34,35]. Participants developed hybrid approaches honoring both perspectives—respecting family involvement while maintaining focus on resident wellbeing. Beyond the autonomy-family tension, other cultural dimensions influenced resilience development. The concept of “face” (mianzi) shaped how nurses navigated conflicts with families, often employing indirect communication strategies to preserve relational harmony while advocating for residents. Collectivist values meant that nurses frequently drew upon peer support networks rather than individual coping strategies, and organizational harmony was prioritized alongside individual professional development. This cultural negotiation represents a sophisticated form of resilience resonating with Ungar’s concept of cultural resilience [18]. The influence of filial piety deserves particular attention, as this value profoundly shapes Chinese families’ decisions about elder care [49,50,51]. These findings have implications for transferability of resilience interventions developed in Western contexts; strategies emphasizing individual coping may be less appropriate in collectivist cultural contexts. Implications for practice Our findings suggest several strategies for supporting nurse resilience: First, structured debriefing opportunities should be created for processing challenging experiences. Regular case discussions or reflective practice groups could provide forums for nurses to examine experiences and develop new perspectives together. Second, mentorship programs pairing novice with experienced nurses may facilitate tacit knowledge transmission, as practical wisdom develops through extended experience and cannot easily be conveyed through formal teaching. Third, organizational cultures that value emotional labour and relational aspects of care should be cultivated. Organizations should communicate that relational care is as important as task completion. Fourth, training programs should incorporate biographical approaches and life story work, equipping nurses with skills for eliciting and incorporating life histories into care planning. Fifth, institutionalized reflective practice through case conferences should be established, framed as core professional activities rather than additional requirements. Implications for research Several directions for future research emerge. First, longitudinal studies could track resilience development over time, providing stronger evidence about developmental trajectories. Second, intervention studies could test whether programs based on transformative learning principles enhance resilience more effectively than conventional training. Third, comparative studies across cultural contexts could illuminate how resilience processes vary across different value systems. Fourth, research should examine organizational factors that facilitate or impede resilience development. Methodological considerations Several limitations should be acknowledged. First, the study was conducted in nursing homes in two Chinese cities, which may limit transferability to other regions or international contexts. However, thick descriptions of context, participant characteristics, and setting were provided. Similar themes regarding professional identity transformation and meaning-making have been identified in international studies [16,25,12], suggesting broader relevance. Second, our cross-sectional design captured retrospective accounts rather than prospective documentation. Participants’ narratives may have been influenced by memory reconstruction or post-hoc meaning-making. Longitudinal designs would provide stronger evidence about developmental processes. Third, we interviewed only nurses who had continued working in dementia care; those who left the field may have had different experiences. This potential survivor bias means our findings may overrepresent successful resilience development. Fourth, while TLT provided a useful organizing framework, other theoretical lenses might reveal additional dimensions. Future research could explore alternative frameworks such as post-traumatic growth theory or self-determination theory. Fifth, our sample size (n=24) exceeds that typical for pure IPA studies (typically 6–10 participants). However, we employed IPA as an analytic lens rather than strict methodology, prioritizing diversity while maintaining interpretive depth through detailed individual analysis and team-based verification. This approach aligns with recent guidance suggesting that IPA principles can be flexibly applied when research aims require broader sampling, provided that idiographic commitment is maintained through careful attention to individual cases before moving to cross-case patterns [38]. Our team-based analysis process, involving independent coding by four researchers with regular consensus meetings, ensured that individual participant experiences were not lost in the pursuit of broader themes. Conclusions This study illuminates how nursing home nurses develop psychological resilience through dementia care experiences, following a transformative learning pathway from disorienting dilemmas through critical reflection to perspective transformation. Our findings reveal that resilience in this context is not merely endurance but transformation—a process of questioning existing frameworks, experimenting with new approaches, and developing new perspectives on professional identity and care meaning. The three-phase model we identified—triggering dilemma experiences, adaptive reconstruction processes, and resilience wisdom generation—provides a framework for understanding resilience development as an ongoing process requiring active engagement. Support strategies should target each phase: helping nurses recognize and process triggering dilemmas, facilitating critical reflection during adaptive reconstruction, and supporting integration of new perspectives during wisdom generation. Chinese cultural context shapes resilience development in distinctive ways, particularly regarding negotiation between person-centred principles and family-centred traditions. Culturally adapted support strategies should recognize family involvement, address filial piety dynamics, and equip nurses with skills for ethical negotiation across value systems. Future research should examine the effectiveness of transformation-informed resilience interventions, explore organizational factors that facilitate or impede resilience development, and compare resilience processes across cultural contexts. As dementia care needs continue to grow globally, understanding and supporting nurse resilience becomes increasingly critical for ensuring quality care for persons living with dementia. Abbreviations BPSD Behavioral and psychological symptoms of dementia COREQ Consolidated criteria for reporting qualitative research IPA Interpretative Phenomenological Analysis PCC Person-centred care PLWD Person(s) living with dementia QUAGOL Qualitative Analysis Guide of Leuven TLT Transformative Learning Theory Declarations Acknowledgements The authors would like to thank all the nurses who participated in this study and shared their valuable experiences. We also thank the nursing home administrators who facilitated this research. Authors’ contributions Study design was performed by Bing Han under the supervision of Yan Shao; data collection by Bing Han and Yan Shao; data analysis by Bing Han with methodological guidance from Yan Shao; and manuscript preparation by Bing Han with critical revision and final approval by Yan Shao. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Availability of data and materials The datasets generated and analysed during the current study are not publicly available due to ethical restrictions protecting participant confidentiality but are available from the corresponding author upon reasonable request. Trial registration Not applicable. This study is not a clinical trial. Ethics approval and consent to participate This study received ethical approval from the Ethics Committee of the 960th Hospital of the PLA Joint Logistic Support Force in Jinan, China. All procedures followed the Declaration of Helsinki. Written informed consent was obtained from each participant before interviews. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Author details 1 The 960th Hospital of the PLA Joint Logistic Support Force, Jinan, China References World Health Organization. Global status report on the public health response to dementia. Geneva: WHO; 2021. Jia L, Du Y, Chu L, et al. 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Dierckx de Casterlé B, De Vliegher K, Gastmans C, et al. Complex qualitative data analysis: lessons learned from QUAGOL. Qual Health Res. 2021;31(6):1083-1093. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-357. Palinkas LA, Horwitz SM, Green CA, et al. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm Policy Ment Health. 2015;42(5):533-544. Saunders B, Sim J, Kingstone T, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52(4):1893-1907. Lincoln YS, Guba EG. Naturalistic Inquiry. Beverly Hills, CA: Sage Publications; 1985. Andersen HE, Toubøl AG. Communities of reflection in nurse education programs: A qualitative multi-methods study. Nurse Educ Today. 2024;140:106293. Prins M, Willemse BM, Heijkants CH, Pot AM. Nursing home care for people with dementia: Update of the design of the Living Arrangements for people with Dementia (LAD)-study. J Adv Nurs. 2019;75(12):3792-3804. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley; 1984. Polanyi M. The Tacit Dimension. New York: Doubleday; 1966. Zhang L, Han Y, Ma Y, Xu Z, Fang Y. Eastern perspectives on roles, responsibilities and filial piety: a case study. Nurs Ethics. 2020;28(3):327-345. Chang YP. Decisional conflict among Chinese family caregivers regarding nursing home placement of older adults with dementia. J Aging Stud. 2012;26(2):121-129. Xiao C, Patrician PA, Montgomery AP, et al. Filial piety and older adult caregiving among Chinese and Chinese-American families in the United States: a concept analysis. BMC Nurs. 2024;23(1):115. Additional Declarations No competing interests reported. Supplementary Files AdditionalFile1COREQChecklist.xlsx Supplementary Information Additional file 1: COREQ (Consolidated Criteria for Reporting Qualitative Research) 32-item checklist. This checklist provides detailed information about the research team, study design, data collection, analysis, and reporting in accordance with established qualitative research reporting standards. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8543600","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":586547622,"identity":"2992a2fb-b8fb-43d9-a922-17667121be19","order_by":0,"name":"Bing Han","email":"","orcid":"","institution":"The 960th Hospital of the PLA Joint Logistic Support Force","correspondingAuthor":false,"prefix":"","firstName":"Bing","middleName":"","lastName":"Han","suffix":""},{"id":586547623,"identity":"33540509-68fc-4710-b5b1-438f330a6184","order_by":1,"name":"Yan Shao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwUlEQVRIiWNgGAWjYBACNvaGhAMSP2yY+dkbiNTCx3Pg4QPLnjR2yZ4DRGqRk0h8bFDBdpjfYEYCsQ5jSE6TuMFzWNpA8vHGGww1NtFEaDmWJjnDIt3YXDqt2ALIyW0gqIWxJ01agsc62XJ2jpkEY8NhIrQw83+T/sPGXL/h5hlitQA9YyDB5sxscIOHWC08DIkPJHvSmIG42CKBGL/Iz38Ai8rDG298qLEhrAUZGEgkkKIcooVUHaNgFIyCUTAyAADAhTu57L9oWQAAAABJRU5ErkJggg==","orcid":"","institution":"The 960th Hospital of the PLA Joint Logistic Support Force","correspondingAuthor":true,"prefix":"","firstName":"Yan","middleName":"","lastName":"Shao","suffix":""}],"badges":[],"createdAt":"2026-01-07 16:09:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8543600/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8543600/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-026-04657-1","type":"published","date":"2026-04-15T15:59:28+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":102021307,"identity":"1578123b-540d-4a43-af2d-c8f8ea6626c1","added_by":"auto","created_at":"2026-02-06 08:44:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":130163,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eConceptual model of nurses’ resilience development\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFigure 1. Nurses’ experiences of psychological resilience development in dementia care. The model illustrates three phases aligned with Transformative Learning Theory: (1) triggering dilemma experiences, (2) adaptive reconstruction processes, and (3) resilience wisdom generation.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8543600/v1/4619a82fe2622ab560753ba8.png"},{"id":107351021,"identity":"efba1f39-fc8d-45c5-a3a4-1842cb663a77","added_by":"auto","created_at":"2026-04-20 16:07:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":569946,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8543600/v1/575a4bbc-c48f-467f-80b8-67058edceca3.pdf"},{"id":102021308,"identity":"f5f89120-e0e0-4f4c-b670-181cf887b87e","added_by":"auto","created_at":"2026-02-06 08:44:16","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":8459,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary Information\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional file 1:\u003c/strong\u003e COREQ (Consolidated Criteria for Reporting Qualitative Research) 32-item checklist. This checklist provides detailed information about the research team, study design, data collection, analysis, and reporting in accordance with established qualitative research reporting standards.\u003c/p\u003e","description":"","filename":"AdditionalFile1COREQChecklist.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-8543600/v1/ff43356fd479803e58a59d50.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Nursing home nurses’ experiences of psychological resilience development in dementia care: A qualitative descriptive study","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePerson(s) living with dementia (PLWD) represent one of the most significant global health challenges of the 21st century, with approximately 55 million people currently affected worldwide, projected to reach 139 million by 2050 [1]. In China, over 16 million individuals are affected by dementia, making it the country with the largest dementia population globally [2]. The majority of PLWD eventually require long-term institutional care as the disease progresses [3]. Person-centred care (PCC) is recognized as the gold standard in dementia care, emphasizing the preservation of personhood, individual preferences, and the maintenance of meaningful relationships [4,5]. PLWD have the right to receive person-centred, coordinated, and quality care throughout their illness trajectory [6].\u003c/p\u003e\n\u003cp\u003eHowever, providing PCC in institutional settings presents considerable challenges, particularly when PLWD exhibit behavioral and psychological symptoms of dementia (BPSD), which occur in up to 90% of cases [7]. These symptoms include agitation, aggression, wandering, and resistance to care, creating significant psychological burden for nursing staff [8]. When PLWD do not agree with provided care or resist caregiving activities, this can lead to distressing situations for all parties involved [9,10]. Research indicates that nursing staff often experience moral distress when they feel unable to provide care that aligns with their professional values [11,12].\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eNursing homes have become essential settings for dementia care as family caregiving capacity diminishes in the context of demographic aging and changing family structures [13]. Nurses working in these settings face unique challenges distinct from those encountered in acute care environments. The progressive and irreversible nature of dementia means that nurses must continuously adapt their care approaches as residents’ cognitive and functional abilities decline [14]. Recent research has highlighted that approximately half of PLWD receiving professional care experience involuntary treatment—care provided without consent or to which the person resists [15]. This reality creates profound ethical tensions for nurses who wish to provide dignified, person-centred care while also ensuring resident safety [16].\u003c/p\u003e\n\u003cp\u003ePsychological resilience refers to the dynamic process of positively adapting to significant adversity, trauma, or stress [17]. Unlike conceptualizations that treat resilience as a static personality trait, contemporary frameworks emphasize its developmental, contextual, and process-oriented nature [18]. In nursing contexts, resilience has been conceptualized as the ability to recover from workplace challenges while maintaining professional effectiveness and personal wellbeing [19]. Research has identified several factors associated with nurse resilience, including self-efficacy, social support, mindfulness, and meaning-making [20,21]. However, most existing studies have employed quantitative approaches that capture resilience as an outcome rather than illuminating the developmental processes [22].\u003c/p\u003e\n\u003cp\u003eMoral distress occurs when nurses know the ethically appropriate action but feel constrained from taking it, often due to institutional barriers or resource limitations [23]. In dementia care settings, moral distress is particularly prevalent given the complex ethical terrain nurses must navigate, including conflicts between autonomy and safety, tension between institutional policies and individual needs, and family expectations that conflict with professional judgment [24,25].\u003c/p\u003e\n\u003cp\u003eTransformative Learning Theory (TLT), developed by Jack Mezirow, provides a comprehensive framework for understanding how adults fundamentally change their frames of reference through critical reflection on assumptions [26]. The theory proposes that transformation typically begins with a disorienting dilemma—an experience that challenges existing beliefs [27]. TLT has been successfully applied in nursing education and professional development contexts [28,29], offering utility for understanding how challenging experiences can catalyze positive growth rather than simply causing harm [30].\u003c/p\u003e\n\u003cp\u003eThe Chinese nursing home sector has expanded rapidly in response to demographic aging and changing family structures [13]. Traditional Confucian values, particularly filial piety , have historically placed responsibility for elder care on adult children. However, urbanization, declining birth rates, and increased female workforce participation have eroded family caregiving capacity [31,32]. Chinese nursing homes face challenges including inadequate staffing ratios, limited dementia-specific training, and medical-model orientations that may not align with person-centred care principles [33]. The tension between Western-derived person-centred principles emphasizing individual autonomy and Chinese family-centred decision-making traditions creates unique ethical terrain for nurses [34,35]. Studies from Western contexts have examined nurses’ experiences with dementia care ethical dilemmas [12] and involuntary treatment [16], but research examining resilience development in Chinese cultural contexts remains limited.\u003c/p\u003e\n\u003ch3\u003eStudy aim\u003c/h3\u003e\n\u003cp\u003eThis study aimed to explore nursing home nurses’ experiences of psychological resilience development in dementia care, using Transformative Learning Theory as a theoretical lens. The research questions were:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eWhat experiences do nurses perceive as challenging or dilemma-inducing in their dementia care work?\u003c/li\u003e\n \u003cli\u003eHow do nurses adapt and reconstruct their professional practice through these challenging experiences?\u003c/li\u003e\n \u003cli\u003eWhat wisdom, meaning, or transformed perspectives do nurses derive from their experiences?\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Methods","content":"\u003ch3\u003eDesign\u003c/h3\u003e\n\u003cp\u003eA qualitative descriptive approach was adopted based on naturalistic inquiry to gain a rich description of nursing home nurses\u0026rsquo; experiences of resilience development [36]. The study was informed by Interpretative Phenomenological Analysis (IPA) principles, which emphasize detailed examination of participants\u0026rsquo; lived experiences and the meanings they attach to these experiences [37]. While traditional IPA studies typically employ smaller samples (6\u0026ndash;10 participants) for deep idiographic analysis, we adopted IPA as an analytic lens rather than a strict phenomenological methodology. This methodological adaptation was justified for three reasons: (1) the need to capture regional variations across two geographically and culturally distinct Chinese cities; (2) the importance of representing diverse nursing backgrounds including varying education levels, experience, and institutional contexts; and (3) alignment with recent methodological guidance suggesting that IPA principles can be applied flexibly when the research aims require broader sampling while maintaining interpretive depth [38]. This approach allowed for in-depth exploration while accommodating the larger sample size necessary for capturing diverse perspectives across the Chinese nursing home context.\u003c/p\u003e\n\u003cp\u003eData analysis was guided by the Qualitative Analysis Guide of Leuven (QUAGOL), a method inspired by the constant comparative approach of Grounded Theory [39]. QUAGOL provides systematic procedures for moving from raw data to conceptual themes while maintaining close connection to participants\u0026rsquo; own words and meanings [40]. Transformative Learning Theory provided the theoretical framework for understanding how challenging experiences might catalyze perspective transformation [26]. While TLT encompasses ten phases of transformation, we focused analytically on three core phases most relevant to resilience development: disorienting dilemmas (phase 1), critical reflection on assumptions (phases 2\u0026ndash;7 consolidated), and perspective transformation with action (phases 8\u0026ndash;10 consolidated). This selective application was informed by the recognition that in naturalistic workplace learning contexts, the intermediate phases often occur simultaneously or iteratively rather than sequentially, and our focus on the experiential dimensions of resilience development necessitated attention to these consolidated phases [27,30]. To ensure rigour, we followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [41].\u003c/p\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eParticipants were recruited from nursing homes in two major Chinese cities: Guangzhou (Guangdong Province, Southern China) and Jinan (Shandong Province, Northern China). This dual-site approach captured regional variations in dementia care practices and cultural traditions. Both public and private facilities were included to capture variation in organizational contexts.\u003c/p\u003e\n\u003cp\u003eSelection criteria for participating institutions included: (1) operational for at least 3 years; (2) dementia residents comprising at least 30% of total residents; (3) bed capacity of at least 100; and (4) institutional approval for research participation. Four nursing homes meeting these criteria (two in each city, one public and one private in each location) agreed to participate.\u003c/p\u003e\n\u003ch3\u003eSampling\u003c/h3\u003e\n\u003cp\u003eMaximum variation sampling was employed to create a diverse sample capturing the breadth of nursing experiences [42]. Sampling dimensions included gender, age, educational background, total nursing experience, dementia care training status, and institution type.\u003c/p\u003e\n\u003cp\u003eInclusion criteria required participants to be: (1) registered nurses currently working in a participating nursing home for at least 6 months; (2) directly involved in providing care to residents with dementia; (3) able to articulate their experiences in sufficient depth; and (4) willing to participate voluntarily. Exclusion criteria were: (1) solely administrative roles without direct care responsibilities; (2) on extended leave during the study period; and (3) unwillingness to have interviews audio-recorded.\u003c/p\u003e\n\u003cp\u003eSample size was determined by data saturation [43]. Data collection and preliminary analysis proceeded iteratively, with regular team discussions to assess theme development and saturation status.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003ch4\u003eResearch team and reflexivity\u003c/h4\u003e\n\u003cp\u003eInterviews were conducted by two researchers with extensive qualitative research training. The primary interviewer was a nurse supervisor with 5 years of clinical experience in geriatric care. The secondary interviewer was a junior nurse with 3 years of experience.\u0026nbsp;Neither interviewer had prior relationships with any participants. Reflexive journals were maintained throughout the research process, documenting assumptions, emotional responses, and evolving interpretations.\u003c/p\u003e\n\u003ch4\u003eInterview procedures\u003c/h4\u003e\n\u003cp\u003eInterviews were conducted in private meeting rooms at each nursing home. Before each interview, written informed consent was obtained, including permission for audio recording. The semi-structured interview guide was developed based on TLT\u0026rsquo;s core phases and refined through expert review and pilot testing [26,27]. Two pilot interviews were conducted to assess question clarity; minor refinements were made based on pilot feedback.\u003c/p\u003e\n\u003cp\u003eThe semi-structured interview guide was developed based on TLT\u0026rsquo;s core phases and refined through expert review and pilot testing [26,27]. Two pilot interviews were conducted to assess question clarity; minor refinements were made based on pilot feedback. The interview guide is presented in \u003cstrong\u003eTable 1\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Interview guide\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"574\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDimension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 226px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMain Questions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 221px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProbe Questions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eOpening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 226px;\"\u003e\n \u003cp\u003ePlease describe your overall experience caring for dementia residents. How did you come to work in dementia care?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 221px;\"\u003e\n \u003cp\u003eWhat drew you to this work? What were your initial expectations?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eTriggering dilemmas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 226px;\"\u003e\n \u003cp\u003eWhat difficulties or challenges have impressed you deeply while caring for dementia residents?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 221px;\"\u003e\n \u003cp\u003eWhat exactly happened? What caused this situation? What were your feelings at the time?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eAdaptive reconstruction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 226px;\"\u003e\n \u003cp\u003eHow did you cope with and adjust to these difficulties?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 221px;\"\u003e\n \u003cp\u003eWhat strategies did you adopt? How effective were they? How did your understanding change over time?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eSupport and resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 226px;\"\u003e\n \u003cp\u003eWhat support and help did you receive in coping with these difficulties?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 221px;\"\u003e\n \u003cp\u003eWhat support did colleagues, supervisors, or family provide? What was most helpful?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eResilience wisdom\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 226px;\"\u003e\n \u003cp\u003eWhat impact have these experiences had on your personal growth and professional development?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 221px;\"\u003e\n \u003cp\u003eWhat new understanding do you have about the meaning of care? What wisdom have you gained?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eClosing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 226px;\"\u003e\n \u003cp\u003eIs there anything else you would like to share? What advice would you give to newly hired nurses?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 221px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eNote: Probe questions were flexibly adjusted based on participants\u0026rsquo; responses.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eInterviews lasted 45\u0026ndash;90 minutes and were audio-recorded. Data collection occurred between January and June 2025. Data saturation was reached after the 21st interview; three additional interviews confirmed saturation.\u003c/p\u003e\n\u003ch4\u003eSupplementary data sources\u003c/h4\u003e\n\u003cp\u003eResearchers conducted 3-month periods of on-site observation at each site prior to and during the interview phase, focusing on care routines, staff interactions, and institutional practices. Relevant institutional documents were also reviewed, including training materials and care protocols. While interview data formed the primary basis for thematic analysis, observational and documentary data contributed to the researchers\u0026rsquo; interpretive framework and strengthened confirmability [44].\u003c/p\u003e\n\u003ch3\u003eData analysis\u003c/h3\u003e\n\u003cp\u003eData analysis employed IPA principles [37] combined with QUAGOL procedures [39], proceeding through preparatory and actual coding phases.\u003c/p\u003e\n\u003cp\u003eDuring the preparatory phase, interview recordings were transcribed verbatim within 24 hours and verified for accuracy. Four researchers independently read each transcript multiple times to achieve immersion. Initial annotation involved descriptive comments, linguistic comments, and conceptual comments. Team meetings were held after every 3-4 interviews to compare themes and reach consensus.\u003c/p\u003e\n\u003cp\u003eThe actual coding phase began once preliminary themes were established. A hierarchical coding framework was developed, informed by TLT phases while remaining open to inductively emerging themes. The primary researcher systematically coded all transcripts using NVivo 12.0 software. Coding verification involved team discussions to ensure consistency. Two researchers independently developed storylines, which were then compared and integrated. The full research team reviewed findings at multiple stages until consensus was reached.\u003c/p\u003e\n\u003ch3\u003eRigour and trustworthiness\u003c/h3\u003e\n\u003cp\u003eTrustworthiness was established according to Lincoln and Guba\u0026rsquo;s criteria [44].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCredibility\u003c/strong\u003e was enhanced through triangulation (combining interviews, observations, and document analysis), member checking (summarizing key points at interview conclusion and returning findings to five participants for review), peer debriefing (discussing findings with five experienced dementia care nurses), and prolonged engagement (3 months of on-site observation at each site).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDependability\u003c/strong\u003e was ensured through a detailed audit trail and researcher triangulation (four team members independently analyzing data).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConfirmability\u003c/strong\u003e was supported through thick description and reflexive journaling.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTransferability\u003c/strong\u003e was facilitated through detailed description of the research setting, participant characteristics, and study procedures.\u003c/p\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003eThis study received ethical approval from the Ethics Committee of the 960th Hospital of the PLA Joint Logistic Support Force in Jinan, China. All procedures followed the Declaration of Helsinki. Written informed consent was obtained from each participant. Participants were informed of their right to withdraw at any time. Contact information for counseling services was provided to all participants. Audio recordings were stored on encrypted devices, and transcripts were anonymized.\u003c/p\u003e"},{"header":"Results","content":"\u003ch3\u003eParticipant characteristics\u003c/h3\u003e\n\u003cp\u003eTwenty-four nurses participated from nursing homes in Guangzhou (n=14) and Jinan (n=10). Table 2 presents participant characteristics. The majority were female (n=21, 87.5%) with ages ranging from 24 to 56 years (mean 38.2\u0026plusmn;8.6). Educational backgrounds included diploma (n=3), associate degree (n=8), bachelor\u0026rsquo;s degree (n=11), and master\u0026rsquo;s degree (n=2). Nursing home experience ranged from 1 to 18 years (mean 7.3\u0026plusmn;4.2), and dementia care experience ranged from 0.5 to 12 years (mean 5.6\u0026plusmn;3.8). Most participants (n=15) had received specialized dementia care training. Interview duration ranged from 45 to 90 minutes (mean 62.8\u0026plusmn;12.4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e Characteristics of participants (n=24)\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"574\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%) or Mean\u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e21 (87.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e3 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e38.2\u0026plusmn;8.6 (range: 24-56)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003e20-29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e5 (20.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003e30-39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e9 (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003e\u0026ge;40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e10 (41.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003eDiploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e3 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003eAssociate degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e8 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e11 (45.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003eMaster\u0026rsquo;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e2 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNursing home experience (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e7.3\u0026plusmn;4.2 (range: 1-18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDementia care experience (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e5.6\u0026plusmn;3.8 (range: 0.5-12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReceived dementia training\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e15 (62.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e9 (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInstitution type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003ePublic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e14 (58.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 341px;\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e10 (41.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003ch3\u003eOverview of findings\u003c/h3\u003e\n\u003cp\u003eAnalysis generated 427 initial codes organized into three main themes and nine subthemes following the TLT framework. \u003cstrong\u003eFigure 1\u003c/strong\u003e presents a conceptual model illustrating nurses\u0026rsquo; psychological resilience development through three interconnected phases: triggering dilemma experiences, adaptive reconstruction processes, and resilience wisdom generation. The themes and subthemes, along with their correspondence to Transformative Learning Theory, are presented in \u003cstrong\u003eTable 3\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e Themes and subthemes with correspondence to Transformative Learning Theory\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"575\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTLT Phase\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubtheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eDisorienting dilemma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003eTriggering dilemma experiences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\n \u003cp\u003eProfessional value concealment/emergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\n \u003cp\u003eEmotional investment vs.\u0026nbsp;boundary tension\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\n \u003cp\u003eTherapeutic expectations vs.\u0026nbsp;reality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eCritical reflection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003eAdaptive reconstruction processes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\n \u003cp\u003eProfessional identity questioning/rebuilding\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\n \u003cp\u003ePractical wisdom accumulation/integration\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\n \u003cp\u003eCaring wisdom integration/innovation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003ePerspective transformation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003eResilience wisdom generation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\n \u003cp\u003eExistential meaning re-examination\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\n \u003cp\u003eReciprocal relationship value discovery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\n \u003cp\u003eCultural context professional reshaping\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003ch3\u003eTheme 1: Triggering dilemma experiences\u003c/h3\u003e\n\u003cp\u003eConsistent with TLT\u0026rsquo;s concept of disorienting dilemmas, participants described experiences that profoundly challenged their existing assumptions about nursing, dementia, and their professional role.\u003c/p\u003e\n\u003ch4\u003eProfessional value concealment and emergence\u003c/h4\u003e\n\u003cp\u003eThe majority of participants reported that their professional contributions were systematically ignored or devalued by families and society. This invisibility of nursing work created a painful sense that their expertise went unrecognized.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Families come to visit maybe once a week. They see one small thing out of place and immediately complain. But they don\u0026rsquo;t see the hours we spend bathing her, turning her to prevent bedsores, coaxing her to eat when she refuses. All that daily care is invisible to them.\u0026rdquo; (N6, female, 34, 3 years experience)\u003c/p\u003e\n\u003cp\u003eHowever, many participants also described meaningful moments when they were able to make residents\u0026rsquo; personhood visible\u0026mdash;to recognize the individual identity that remained despite cognitive decline. These moments of \u0026ldquo;seeing\u0026rdquo; and \u0026ldquo;being seen\u0026rdquo; emerged as powerfully restorative.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Grandma Wang has severe dementia. She barely communicates. But I learned she was a teacher before retirement. One morning, while combing her hair, I softly called her \u0026lsquo;Teacher Wang.\u0026rsquo; Her eyes suddenly lit up. She grasped my hand tightly and murmured, \u0026lsquo;Someone remembers me.\u0026rsquo;\u0026rdquo; (N12, female, 37, 5 years experience)\u003c/p\u003e\n\u003cp\u003eSeveral participants described similar experiences of making residents\u0026rsquo; hidden identities visible through small but meaningful interactions.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;When I first started, I saw only the disease. But gradually I learned to see the person. Mr. Chen was a calligrapher. His hands shake now, but when I put a brush in his hand, something changes in his eyes. He may not remember writing, but his hands remember.\u0026rdquo; (N1, female, 45, 8 years experience)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Society thinks we are just \u0026lsquo;elderly sitters.\u0026rsquo; They don\u0026rsquo;t understand the complexity of what we do\u0026mdash;the constant assessment, the therapeutic communication, the crisis prevention. When a resident with dementia becomes calm because I remembered her favorite song from fifty years ago, that\u0026rsquo;s not luck. That\u0026rsquo;s professional skill.\u0026rdquo; (N5, female, 39, 6 years experience)\u003c/p\u003e\n\u003ch4\u003eEmotional investment and professional boundary tension\u003c/h4\u003e\n\u003cp\u003eMost participants reported ongoing tension between the deep emotional bonds they developed with residents and professional boundaries they had been taught to maintain. The intimate, extended nature of nursing home care naturally fostered attachment that felt more like family than professional relationship.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;After caring for them so long, they really do become like family. I know Grandpa Li\u0026rsquo;s habits better than his own children do. There\u0026rsquo;s genuine love there.\u0026rdquo; (N3, male, 28, 2 years experience)\u003c/p\u003e\n\u003cp\u003eYet this emotional investment created vulnerability. The unpredictable nature of dementia meant that the same resident who smiled at a nurse one day might fail to recognize her the next.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;But then suddenly, he doesn\u0026rsquo;t recognize me. Or worse, he becomes hostile. That sense of being pushed away is particularly strong. Over time, I learned I had to find balance\u0026mdash;to care deeply, but also to maintain some distance to protect myself.\u0026rdquo; (N3, continued)\u003c/p\u003e\n\u003cp\u003eThis emotional vulnerability was echoed by other participants who struggled to maintain professional boundaries while providing compassionate care.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I cried when Grandma Liu passed away. My supervisor said I was too emotionally involved. But how can you care for someone for three years and not feel something? I think the real question is how to hold both\u0026mdash;the professional and the personal\u0026mdash;without losing yourself.\u0026rdquo; (N11, female, 33, 4 years experience)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;In nursing school, they teach you about professional boundaries. But no one tells you what to do when a resident calls you \u0026lsquo;daughter\u0026rsquo; and holds your hand like you\u0026rsquo;re her only connection to the world. Those moments are both beautiful and heartbreaking.\u0026rdquo; (N14, female, 27, 2 years experience)\u003c/p\u003e\n\u003ch4\u003eTherapeutic expectations versus reality limitations\u003c/h4\u003e\n\u003cp\u003eMany participants described profound conflict between their therapeutic expectations and the irreversible nature of dementia. Traditional nursing education had prepared them to expect that good care would lead to patient improvement.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;In the beginning, I kept thinking there must be something more I could do. Maybe if I tried a different approach, I could stop the decline. But no matter what I did, the trajectory was always the same\u0026mdash;always downward.\u0026rdquo; (N9, female, 36, 4 years experience)\u003c/p\u003e\n\u003cp\u003eThis collision between therapeutic hope and disease reality created a crisis of professional identity. For some, this struggle was resolved through reconceptualization of meaningful care.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;It took a long time, but eventually I understood. The process itself\u0026mdash;maintaining dignity, reducing distress, preserving moments of connection\u0026mdash;is meaningful. Every day they feel loved and safe, that\u0026rsquo;s a victory, even if they forget it tomorrow.\u0026rdquo; (N9, continued)\u003c/p\u003e\n\u003cp\u003eOther participants described similar journeys of redefining what successful care means in the context of progressive cognitive decline.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I used to measure success by whether residents improved. Now I measure it differently\u0026mdash;did she smile today? Did he eat without distress? Did I help her feel safe during a confusing moment? These small victories are actually huge.\u0026rdquo; (N13, female, 44, 7 years experience)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;My biggest struggle was accepting that I cannot fix dementia. In hospital nursing, you work toward discharge, toward recovery. Here, the goal is different\u0026mdash;it\u0026rsquo;s about quality of life, about presence, about making each moment count even when they won\u0026rsquo;t remember it.\u0026rdquo; (N17, female, 38, 5 years experience)\u003c/p\u003e\n\u003ch3\u003eTheme 2: Adaptive reconstruction processes\u003c/h3\u003e\n\u003cp\u003eThe second theme captures how nurses engaged in critical reflection and active reconstruction in response to triggering dilemmas.\u003c/p\u003e\n\u003ch4\u003eProfessional identity questioning and rebuilding\u003c/h4\u003e\n\u003cp\u003eMost participants described experiences of professional identity crisis triggered by the perceived inadequacy of their training for dementia care realities. The biomedical model emphasized in their education proved insufficient for the relational and emotional dimensions of dementia care.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;In nursing school, we learned about IV skills, wound care, medication administration. But here in the nursing home, what matters is how to respond to residents\u0026rsquo; emotional fluctuations, how to complete care when they\u0026rsquo;re uncooperative. I felt lost, like everything I knew was useless.\u0026rdquo; (N7, female, 42, 9 years experience)\u003c/p\u003e\n\u003cp\u003eThrough practice experience, nurses developed what might be termed a \u0026ldquo;biographical approach\u0026rdquo; to care\u0026mdash;recognizing that effective dementia care required knowing residents as whole persons with histories and continuing identities.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;An experienced care worker taught me that Grandpa Zhang was a teacher before retirement. One afternoon when he was agitated, we simply gave him a briefcase and said it was time for work. He immediately calmed down. I realized that understanding life stories may be more important than mastering techniques.\u0026rdquo; (N20, female, 56, 10 years experience)\u003c/p\u003e\n\u003ch4\u003ePractical wisdom accumulation and integration\u003c/h4\u003e\n\u003cp\u003eExperienced participants described developing tacit knowledge that could not be articulated in procedural terms but proved essential for effective care.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;This kind of knowing isn\u0026rsquo;t learned from books. Grandma Wang can\u0026rsquo;t speak anymore, but she has her own language. A slight frown might mean discomfort. Wandering eyes might mean she needs the toilet. I can\u0026rsquo;t explain how I know these things; I just do.\u0026rdquo; (N4, female, 52, 12 years experience)\u003c/p\u003e\n\u003cp\u003eLess experienced participants recognized the value of this practical wisdom and sought to learn from senior colleagues, though tacit knowledge proved difficult to transmit through formal teaching.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The older nurses know things that aren\u0026rsquo;t in any textbook. They made it look easy, but when I asked how they did it, they couldn\u0026rsquo;t really explain. \u0026lsquo;You\u0026rsquo;ll learn,\u0026rsquo; they said. And eventually, I did\u0026mdash;through doing, through making mistakes, through paying attention.\u0026rdquo; (N8, female, 29, 1 year experience)\u003c/p\u003e\n\u003cp\u003eThis process of developing intuitive understanding through accumulated experience was described by multiple participants as essential yet difficult to formalize.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;After years of experience, I can sense when something is wrong before the resident shows obvious symptoms. It\u0026rsquo;s like reading a book without words. A change in breathing, a different look in their eyes, subtle restlessness\u0026mdash;these tell me stories that medical charts cannot capture.\u0026rdquo; (N16, female, 48, 11 years experience)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Every resident with dementia is unique. What works for one person might agitate another. I\u0026rsquo;ve learned to be a detective\u0026mdash;observing, experimenting, remembering what works. This knowledge lives in my hands and my heart, not just my head.\u0026rdquo; (N18, female, 35, 4 years experience)\u003c/p\u003e\n\u003ch4\u003eCaring wisdom integration and innovation\u003c/h4\u003e\n\u003cp\u003eMany participants described developing \u0026ldquo;indigenous innovations\u0026rdquo;\u0026mdash;novel approaches to care that integrated formal knowledge, practical wisdom, and creative problem-solving.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Standard approaches often don\u0026rsquo;t work with dementia. For one resident who was very agitated every evening, we developed our own reminiscence therapy approach. We found music she loved, displayed photos of her family, created familiar rituals. It worked better than any medication.\u0026rdquo; (N2, female, 46, 8 years experience)\u003c/p\u003e\n\u003ch3\u003eTheme 3: Resilience wisdom generation\u003c/h3\u003e\n\u003cp\u003eThe third theme captures the outcomes of transformation\u0026mdash;the new perspectives, meanings, and ways of being that emerged from nurses\u0026rsquo; journeys through challenging experiences.\u003c/p\u003e\n\u003ch4\u003eExistential meaning re-examination\u003c/h4\u003e\n\u003cp\u003eMany participants described developing transcendent care philosophies\u0026mdash;new understandings of meaning and purpose that extended beyond conventional professional frameworks.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Caring for dementia residents completely changed how I view life. Watching residents who had lost memory, lost cognitive function\u0026mdash;and yet remained somehow present, somehow worthy of love and care\u0026mdash;I began to question everything. Who are we, really, if not our memories and achievements?\u0026rdquo; (N19, female, 41, 6 years experience)\u003c/p\u003e\n\u003cp\u003eThis philosophical deepening had practical implications. Nurses who developed transcendent perspectives described experiencing greater peace in their work.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Once I understood that the person is still there\u0026mdash;not the same, but still there\u0026mdash;everything became easier. I stopped grieving for who they used to be and started appreciating who they are now.\u0026rdquo; (N23, female, 47, 9 years experience)\u003c/p\u003e\n\u003cp\u003eSeveral participants described how this work prompted profound personal reflection on life, aging, and human connection.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;This work has made me think about my own aging, my own mortality. I\u0026rsquo;ve become more present in my own life, more appreciative of small moments. My residents have taught me that identity goes deeper than memory\u0026mdash;there\u0026rsquo;s something essential that remains.\u0026rdquo; (N21, female, 50, 15 years experience)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Before this work, I defined myself by what I could do, what I could achieve. Now I understand that human worth isn\u0026rsquo;t about productivity. When I hold the hand of a resident who cannot speak, who cannot remember my name, I feel a connection that transcends words. That has changed how I see everything.\u0026rdquo; (N22, male, 32, 3 years experience)\u003c/p\u003e\n\u003ch4\u003eReciprocal relationship value discovery\u003c/h4\u003e\n\u003cp\u003eMany participants recognized the bidirectional nature of caring relationships\u0026mdash;discovering that care was not merely something they provided but something they also received.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;At first, I thought I was just giving. But over time, I realized that wasn\u0026rsquo;t true. These residents teach me patience, acceptance, presence. They remind me what really matters in life.\u0026rdquo; (N8, female, 29, 1 year experience)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Grandpa Chen can\u0026rsquo;t remember my name. But he remembers that someone cares for him. And in his forgetting, he\u0026rsquo;s taught me to find meaning in each moment rather than expecting continuity.\u0026rdquo; (N15, female, 31, 3 years experience)\u003c/p\u003e\n\u003cp\u003eThis sense of mutual benefit and reciprocal learning was a recurring theme across participants with varying levels of experience.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I came into this work thinking I would help them. I didn\u0026rsquo;t expect them to help me. But they have\u0026mdash;they\u0026rsquo;ve taught me to slow down, to be present, to find joy in simple things. When Grandma Zhou laughs at something only she understands, her joy is contagious. That\u0026rsquo;s a gift she gives me every day.\u0026rdquo; (N24, female, 26, 1.5 years experience)\u003c/p\u003e\n\u003ch4\u003eProfessional reshaping within cultural context\u003c/h4\u003e\n\u003cp\u003eMany participants described negotiating the tension between Western-derived person-centred care principles and Chinese cultural traditions, particularly regarding family involvement and truth-telling.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;In Western models, respecting patient autonomy is paramount. But in Chinese care environments, family is often the decision-making center. Some families ask us not to tell the elderly person they have dementia. In Chinese culture, it\u0026rsquo;s understood as protection\u0026mdash;shielding the elder from distressing information.\u0026rdquo; (N10, female, 45, 10 years experience)\u003c/p\u003e\n\u003cp\u003eNavigating this complexity required nuanced judgment about when and how to apply different ethical frameworks.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I\u0026rsquo;ve learned that there\u0026rsquo;s no universal right answer. What works for one family might be wrong for another. My job is to figure out what serves this particular person, in this particular situation, within this particular cultural context.\u0026rdquo; (N10, continued)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored how nursing home nurses in China develop psychological resilience through their experiences caring for residents with dementia. Using Transformative Learning Theory as a guiding framework, we identified a three-phase developmental pathway: triggering dilemma experiences, adaptive reconstruction processes, and resilience wisdom generation. Our findings suggest that resilience in this context is not merely a capacity to endure adversity but a dynamic process of transformation through which nurses develop new perspectives, competencies, and sources of meaning.\u003c/p\u003e\n\u003ch3\u003eTransformative pathway to resilience\u003c/h3\u003e\n\u003cp\u003eOur results align with Mezirow’s theory that transformative learning begins with disorienting dilemmas—experiences that challenge existing frames of reference [26,27]. The triggering experiences identified in this study—professional value concealment, emotional boundary tension, and therapeutic expectation-reality conflict—functioned as classic disorienting dilemmas, presenting fundamental challenges to nurses’ assumptions about their professional role. Notably, these dilemmas correspond to Mezirow’s first phase of transformation, wherein individuals encounter experiences that their existing meaning perspectives cannot adequately address.\u003c/p\u003e\n\u003cp\u003eSimilar to findings from Moermans and colleagues regarding involuntary treatment in dementia care [16], our participants experienced cognitive dissonance when their professional values conflicted with care realities. The adaptive reconstruction phase reflected the critical reflection processes central to TLT, encompassing what Mezirow described as self-examination (phase 2), critical assessment of assumptions (phase 3), recognition that others share similar transformations (phase 4), exploration of new roles and relationships (phase 5), planning courses of action (phase 6), and acquiring knowledge and skills for implementing plans (phase 7) [26]. In our data, these phases manifested as an integrated process rather than discrete sequential steps, with nurses simultaneously questioning their professional identities, seeking guidance from experienced colleagues, and experimenting with new care approaches. Our finding that nurses rebuilt their professional identities around biographical and relational approaches rather than biomedical frameworks represents a fundamental paradigm shift [34], echoing nursing education research demonstrating that reflection facilitates professional development [28,45].\u003c/p\u003e\n\u003cp\u003eThe final phase represents what Mezirow termed perspective transformation, corresponding to phases 8–10: provisional trying of new roles, building competence and self-confidence in new roles, and reintegration into life on the basis of new perspectives [26]. Participants who reached this phase described experiencing their work through entirely new lenses—no longer focusing on what residents had lost but on what remained, no longer seeking cure but valuing care processes themselves. This reintegration was not merely cognitive but embodied, as nurses described a fundamental shift in how they experienced their daily work and relationships with residents.\u003c/p\u003e\n\u003ch3\u003eProfessional identity reconstruction\u003c/h3\u003e\n\u003cp\u003eA key finding was nurses’ transition from biomedical to person-centred paradigms as a central component of resilience development. Traditional nursing education emphasizes technical competencies and cure-oriented outcomes [13,33]—frames that proved inadequate for dementia care complexity. Our participants developed new professional identities centred on residents’ life stories rather than disease processes, aligning with theoretical work on person-centred dementia care [46].\u003c/p\u003e\n\u003cp\u003eThe development of tacit knowledge parallels Benner’s novice-to-expert progression [47]. However, in dementia care, expertise development involves fundamentally reconceptualizing what nursing expertise means, consistent with Polanyi’s concept of tacit knowledge [48]. Our findings also resonate with research on moral distress in long-term care [11,23,24]. Rather than simply experiencing these as sources of distress, participants who developed resilience learned to navigate tensions through perspective transformation and practical wisdom.\u003c/p\u003e\n\u003ch3\u003eCultural dimensions of resilience\u003c/h3\u003e\n\u003cp\u003eChinese cultural context significantly shaped resilience development pathways. The tension between Western person-centred principles emphasizing individual autonomy and Chinese family-centred decision-making traditions created unique ethical challenges [34,35]. Participants developed hybrid approaches honoring both perspectives—respecting family involvement while maintaining focus on resident wellbeing. Beyond the autonomy-family tension, other cultural dimensions influenced resilience development. The concept of “face” (mianzi) shaped how nurses navigated conflicts with families, often employing indirect communication strategies to preserve relational harmony while advocating for residents. Collectivist values meant that nurses frequently drew upon peer support networks rather than individual coping strategies, and organizational harmony was prioritized alongside individual professional development.\u003c/p\u003e\n\u003cp\u003eThis cultural negotiation represents a sophisticated form of resilience resonating with Ungar’s concept of cultural resilience [18]. The influence of filial piety deserves particular attention, as this value profoundly shapes Chinese families’ decisions about elder care [49,50,51]. These findings have implications for transferability of resilience interventions developed in Western contexts; strategies emphasizing individual coping may be less appropriate in collectivist cultural contexts.\u003c/p\u003e\n\u003ch3\u003eImplications for practice\u003c/h3\u003e\n\u003cp\u003eOur findings suggest several strategies for supporting nurse resilience:\u003c/p\u003e\n\u003cp\u003eFirst, structured debriefing opportunities should be created for processing challenging experiences. Regular case discussions or reflective practice groups could provide forums for nurses to examine experiences and develop new perspectives together.\u003c/p\u003e\n\u003cp\u003eSecond, mentorship programs pairing novice with experienced nurses may facilitate tacit knowledge transmission, as practical wisdom develops through extended experience and cannot easily be conveyed through formal teaching.\u003c/p\u003e\n\u003cp\u003eThird, organizational cultures that value emotional labour and relational aspects of care should be cultivated. Organizations should communicate that relational care is as important as task completion.\u003c/p\u003e\n\u003cp\u003eFourth, training programs should incorporate biographical approaches and life story work, equipping nurses with skills for eliciting and incorporating life histories into care planning.\u003c/p\u003e\n\u003cp\u003eFifth, institutionalized reflective practice through case conferences should be established, framed as core professional activities rather than additional requirements.\u003c/p\u003e\n\u003ch3\u003eImplications for research\u003c/h3\u003e\n\u003cp\u003eSeveral directions for future research emerge. First, longitudinal studies could track resilience development over time, providing stronger evidence about developmental trajectories. Second, intervention studies could test whether programs based on transformative learning principles enhance resilience more effectively than conventional training. Third, comparative studies across cultural contexts could illuminate how resilience processes vary across different value systems. Fourth, research should examine organizational factors that facilitate or impede resilience development.\u003c/p\u003e\n\u003ch3\u003eMethodological considerations\u003c/h3\u003e\n\u003cp\u003eSeveral limitations should be acknowledged. First, the study was conducted in nursing homes in two Chinese cities, which may limit transferability to other regions or international contexts. However, thick descriptions of context, participant characteristics, and setting were provided. Similar themes regarding professional identity transformation and meaning-making have been identified in international studies [16,25,12], suggesting broader relevance.\u003c/p\u003e\n\u003cp\u003eSecond, our cross-sectional design captured retrospective accounts rather than prospective documentation. Participants’ narratives may have been influenced by memory reconstruction or post-hoc meaning-making. Longitudinal designs would provide stronger evidence about developmental processes.\u003c/p\u003e\n\u003cp\u003eThird, we interviewed only nurses who had continued working in dementia care; those who left the field may have had different experiences. This potential survivor bias means our findings may overrepresent successful resilience development.\u003c/p\u003e\n\u003cp\u003eFourth, while TLT provided a useful organizing framework, other theoretical lenses might reveal additional dimensions. Future research could explore alternative frameworks such as post-traumatic growth theory or self-determination theory.\u003c/p\u003e\n\u003cp\u003eFifth, our sample size (n=24) exceeds that typical for pure IPA studies (typically 6–10 participants). However, we employed IPA as an analytic lens rather than strict methodology, prioritizing diversity while maintaining interpretive depth through detailed individual analysis and team-based verification. This approach aligns with recent guidance suggesting that IPA principles can be flexibly applied when research aims require broader sampling, provided that idiographic commitment is maintained through careful attention to individual cases before moving to cross-case patterns [38]. Our team-based analysis process, involving independent coding by four researchers with regular consensus meetings, ensured that individual participant experiences were not lost in the pursuit of broader themes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study illuminates how nursing home nurses develop psychological resilience through dementia care experiences, following a transformative learning pathway from disorienting dilemmas through critical reflection to perspective transformation. Our findings reveal that resilience in this context is not merely endurance but transformation\u0026mdash;a process of questioning existing frameworks, experimenting with new approaches, and developing new perspectives on professional identity and care meaning.\u003c/p\u003e\n\u003cp\u003eThe three-phase model we identified\u0026mdash;triggering dilemma experiences, adaptive reconstruction processes, and resilience wisdom generation\u0026mdash;provides a framework for understanding resilience development as an ongoing process requiring active engagement. Support strategies should target each phase: helping nurses recognize and process triggering dilemmas, facilitating critical reflection during adaptive reconstruction, and supporting integration of new perspectives during wisdom generation.\u003c/p\u003e\n\u003cp\u003eChinese cultural context shapes resilience development in distinctive ways, particularly regarding negotiation between person-centred principles and family-centred traditions. Culturally adapted support strategies should recognize family involvement, address filial piety dynamics, and equip nurses with skills for ethical negotiation across value systems.\u003c/p\u003e\n\u003cp\u003eFuture research should examine the effectiveness of transformation-informed resilience interventions, explore organizational factors that facilitate or impede resilience development, and compare resilience processes across cultural contexts. As dementia care needs continue to grow globally, understanding and supporting nurse resilience becomes increasingly critical for ensuring quality care for persons living with dementia.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBPSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBehavioral and psychological symptoms of dementia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOREQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConsolidated criteria for reporting qualitative research\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIPA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInterpretative Phenomenological Analysis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePerson-centred care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePLWD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePerson(s) living with dementia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQUAGOL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eQualitative Analysis Guide of Leuven\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTLT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTransformative Learning Theory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eThe authors would like to thank all the nurses who participated in this study and shared their valuable experiences. We also thank the nursing home administrators who facilitated this research.\u003c/p\u003e\n\u003ch3\u003eAuthors\u0026rsquo; contributions\u003c/h3\u003e\n\u003cp\u003eStudy design was performed by Bing Han under the supervision of Yan Shao; data collection by Bing Han and Yan Shao; data analysis by Bing Han with methodological guidance from Yan Shao; and manuscript preparation by Bing Han with critical revision and final approval by Yan Shao.\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to ethical restrictions protecting participant confidentiality but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This study is not a clinical trial.\u003c/p\u003e\n\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eThis study received ethical approval from the Ethics Committee of the 960th Hospital of the PLA Joint Logistic Support Force in Jinan, China.\u0026nbsp;All procedures followed the Declaration of Helsinki. Written informed consent was obtained from each participant before interviews.\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e The 960th Hospital of the PLA Joint Logistic Support Force, Jinan, China\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWorld Health Organization. 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BMC Nurs. 2024;23(1):115.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Dementia care, Nursing home, Psychological resilience, Transformative learning, Qualitative research, China, Person-centred care","lastPublishedDoi":"10.21203/rs.3.rs-8543600/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8543600/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDementia care presents significant psychological challenges for nursing home nurses, yet knowledge about how these nurses develop psychological resilience through their caring experiences remains limited. Understanding the mechanisms of resilience development is crucial for designing effective support interventions and improving the quality of dementia care in institutional settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA qualitative descriptive study informed by Interpretative Phenomenological Analysis (IPA) principles was conducted. Semi-structured interviews were conducted with 24 nurses from nursing homes in Guangzhou and Jinan, China between January and June 2025. Maximum variation sampling ensured diversity across gender, age, educational background, work experience, and institution type. Data were analysed using IPA combined with the Qualitative Analysis Guide of Leuven (QUAGOL). Transformative Learning Theory (TLT) provided the theoretical framework. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines were followed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNurses’ psychological resilience development followed a transformative learning pathway comprising three interrelated phases. In the first phase, nurses encountered triggering dilemma experiences including professional value concealment, emotional boundary tensions, and therapeutic expectation conflicts. During the second phase of adaptive reconstruction, nurses engaged in professional identity questioning and rebuilding, practical wisdom accumulation, and caring innovation. The third phase of resilience wisdom generation encompassed existential meaning re-examination, reciprocal relationship discovery, and cultural context negotiation. Nurses who actively engaged in critical reflection developed resilience more effectively, while those lacking reflective support experienced more prolonged struggles with adaptation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNursing home nurses develop psychological resilience through transformative learning involving cognitive restructuring, professional identity reconstruction, and meaning-making. Support strategies should target each transformation phase. Chinese cultural context, particularly the interplay between person-centred principles and family-centred traditions, significantly shapes resilience development pathways. Interventions should foster critical reflection, provide mentorship opportunities, and create organizational cultures that value emotional labour in dementia care.\u003c/p\u003e","manuscriptTitle":"Nursing home nurses’ experiences of psychological resilience development in dementia care: A qualitative descriptive study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-06 08:44:11","doi":"10.21203/rs.3.rs-8543600/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-02T05:29:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-01T17:22:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-15T17:58:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"215683109310546445412137409998231935521","date":"2026-03-05T15:34:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"242434772828265277661204678185681917817","date":"2026-02-10T14:28:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"45884167706138806817909443128212329262","date":"2026-02-03T21:51:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-03T18:42:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-22T04:00:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-21T05:17:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-21T05:14:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2026-01-07T15:56:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ace887f5-7bd4-4d08-9071-b5664d4773e2","owner":[],"postedDate":"February 6th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:05:25+00:00","versionOfRecord":{"articleIdentity":"rs-8543600","link":"https://doi.org/10.1186/s12912-026-04657-1","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2026-04-15 15:59:28","publishedOnDateReadable":"April 15th, 2026"},"versionCreatedAt":"2026-02-06 08:44:11","video":"","vorDoi":"10.1186/s12912-026-04657-1","vorDoiUrl":"https://doi.org/10.1186/s12912-026-04657-1","workflowStages":[]},"version":"v1","identity":"rs-8543600","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8543600","identity":"rs-8543600","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}