Suicide resilience: A concept analysis. — TEI-tagged view

Xinlu WangpersName, Zhongqiu LupersName, Chaoqun DongpersName (2022date). “Suicide resilience: A concept analysis..” Frontiers in Psychiatrytitle·j.

Object of study — the concept of suicide resilienceterm·dom

Research question — what the antecedents, attributes and consequences of suicide resilienceterm·dom are

Contribution — a clearer definition and a conceptual model of suicide resilienceterm·dom

Full text — tagged

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Suicide resilienceterm·dom: A concept analysis.

Abstract Suicide resilienceterm·dom is gaining increasing attention from researchers because of its potential role in preventing suicide. However, it has not been clearly analyzed, and there are various meanings and terms regarding this issue. The purpose of this analysis, therefore, was to conceptualize the concept of suicide resilienceterm·dom.

Walker and Avant's method of concept analysis was used to identify the antecedents, attributes, and consequences of suicide resilienceterm·dom. The literature was searched using PubMed, PsychINFO, Embase, Web of Science, CINAHL, CNKI, and WanFang databases with no limitation on publication date. The search included peer-reviewed journal articles and dissertations related to suicide resilienceterm·dom published in English or Chinese.

52 articles were identified to provide information for this concept analysis. Five defining attributes of suicide resilienceterm·dom were identified: social supportterm·key, coping strategiesterm·dom, psychological capitalterm·dom, meaning in lifeterm·key, and sense of responsibilityterm·dom. Antecedents of suicide resilienceterm·dom were high suicide risk events, and consequences of suicide resilienceterm·dom were keeping vulnerable individuals stay away from or overcoming suicidalityterm·key.

The result of the analysis provided a more clear definition of suicide resilienceterm·dom. The identified defining attributes, antecedents, and consequences can be further tested and used to develop potential interventions. Future research is needed and will help to advance our understanding of the scope.

Introduction Suicide is a leading cause of death worldwide, presenting a significant public health issue ( 1 ). According to the World Health Organization (WHO), over 700,000 individuals die by suicide annually. It is estimated that for each suicide death, there are many more individuals who attempt suicide or have serious thoughts about taking their lives ( 2 ). Given the far-reaching harmful effects of suicide on individuals, families, and societies, it is crucial to advance suicide prevention. Currently, research on suicide prevention has mainly focused on the risk factors that increase an individual's vulnerability to suicide, and a bunch of these factors such as psychiatric disorders, suicidal ideation, and prior suicide attempts, have been identified ( 3 , 4 ). These studies enabled us to gain a much deeper understanding of suicide and find vulnerable individuals timely. However, several researchers have indicated that the predictive validity of these risk factors is limited, and a sole focus on suicide risk factors is not enough for suicide prevention strategies ( 5 ). Recently, there has been a shift toward additional consideration of factors that confer resilienceterm·dom against suicide ( 6 ).

Resilienceterm·dom is an emerging concept in suicide research. The notion was derived both from ecology and psychology, and used by various disciplines ( 7 ). Although it has different meanings in different contexts, resilienceterm·dom generally refers to the ability, outcome, or dynamic process of overcoming adversity adaptively ( 8 ). With the observation of the fact that a number of individuals exposed to high suicide risks would not be suicidal, researchers in the suicide field have become more and more interested in the phenomenon of resilienceterm·dom ( 9 ). Empirical findings have indicated that resilienceterm·dom represents an intermediate between suicide risk factors and suicidalityterm·key, and may mitigate the adverse effect of suicide risk factors ( 10 , 11 ). Furthermore, individuals with low resilienceterm·dom were associated with an increased risk of lifelong suicidal behaviors ( 12 ). Thus, resilienceterm·dom is increasingly recognized as a suicide protective factorterm·dom. In line with the broader research, resilienceterm·dom in suicide has also focused on identifying factors that can facilitate resilienceterm·dom, and a repertoire of potential factors from general resilienceterm·dom studies has been found ( 13 ). Nevertheless, it is suggested that some of these factors, such as positive attributional style and meaning in lifeterm·key, exhibit better protective qualities in the specific context of a suicidal crisis ( 14 , 15 ). Meanwhile, a cluster of these factors shows better predictive validity of who can be resilient to suicide risks ( 16 ). Hence, to better understand and investigate resilienceterm·dom in suicide, researchers have termed it suicide resilienceterm·dom ( 17 ).

While there is a growing body of work on suicide resilienceterm·dom, the concept remains ambiguous. Currently, there are several inconsistent definitions of the term. For example, Osman defines suicide resilienceterm·dom as the perceived ability, resources, or competence to regulate suicide-related thoughts, feelings, and attitudes ( 17 ); whereas Johnson asserts that suicide resilienceterm·dom is a perception or set of beliefs that buffer individuals from suicidalityterm·key in the face of stressors ( 14 ). Moreover, the process view of general resilienceterm·dom has dramatically influenced the definition of suicide resilienceterm·dom. Some scholars investigated suicide resilienceterm·dom as a dynamic process and used the term such as suicidal recoveryterm·key to describe it ( 18 ). Additionally, there are several other phrases for suicide resilienceterm·dom, such as resilienceterm·dom to suicidalityterm·key, psychological resilienceterm·dom to suicidal experience, and overcome suicidalityterm·key ( 14 , 19 , 20 ). Due to these existing fuzzy interpretations, the recent increase in literature on suicide resilienceterm·dom may cause more confusion than clarity among researchers and clinicians, impeding precise translation of the concept into practice.

It is increasingly acknowledged that resilienceterm·dom is a promising intervention target for individuals facing adversity, including suicidal risk. Few researchers have developed and implemented resilience-oriented programs, indicating that they can reduce participants' suicide risk ( 21 , 22 ). However, all of the programs targeted promoting general resilienceterm·dom, rather than suicide resilienceterm·dom. This may be because the suicide resilienceterm·dom concept is still unclear and our knowledge of suicide resiliency factors is limited. Although existing interventions have been proven to be beneficial, interventions specifically designed for suicide resilienceterm·dom are believed to be more effective for those in a suicidal crisis ( 14 ). Consequently, there is a dearth of research to clarify the concept of suicide resilienceterm·dom to further improve existing suicide prevention strategies.

In this study, we analyzed the concept of suicide resilienceterm·dom to address the above-mentioned research gap using Walker and Avant's concept analysis framework. Although there are various approaches for concept analysis, Walker and Avant's method is the most widely used one ( 23 ). Numerous researchers, particularly in nursing, have employed this method to examine the basic elements of health-related concepts, such as digital resilienceterm·dom, perinatal resilienceterm·dom, and vaccine literacy ( 24 – 26 ). Through its systematic steps, we expect to provide clarity for researchers and clinicians about suicide resilienceterm·dom and stimulate more research on the issue.

Methods Concept analysis method Walker and Avant's method of concept analysis was used. It involves eight iterative steps to guide a deeper understanding of a concept. The eight steps include selecting a concept, determining the aims of analysis, identifying all uses of the concept, determining the defining attributes, identifying a model case, identifying additional cases, identifying antecedents and consequences, and defining empirical referents ( 27 ). Adaptation of these steps in the study was shown in Table 1 .

Adaptation of Walker and Avant steps of concept analysis.

Data source A systematic search was conducted in online databases, including PubMed, PsychINFO, Embase, Web of Science, CINAHL, CNKI (Chinese), and Wanfang (Chinese) on Aug 30, 2022. We used the following terms in each database: “suicid * ,” “self-harm,” “self-injur * ,” “self-destruct * ,” “self-inflict * ,” “self-mutilat * ,” “overdos * ,” “self-poison * ,” “resilien * ,” “hardiness,” “buffer * ,” “bounce back,” “recover * ,” “resist * ,” “rebound,” “adapt * ,” “overcome * .” The online databases were searched for titles, abstracts, or topics/subjects containing these terms. The Boolean operator “OR” was used to connect the similar concept, and “AND” was used to combine diversity. No date limitation was applied in the search strategy. The search strings in each database are presented in Supplementary material . In addition, the reference lists of relevant literature were searched manually to reduce the risk of missing potentially important research.

Data selection The inclusion criteria for selecting relevant articles were: (i) discussing or investigating resilienceterm·dom specifically to suicidalityterm·key; (ii) referring to at least one of the following items of suicide resilienceterm·dom: definition, attributes, antecedents, consequences, or measurement techniques; (iii) peer-reviewed journal articles, or dissertations in English or Chinese. The exclusion criteria were: (i) only focusing on general resilienceterm·dom that is unrelated to suicide; (ii) focusing on resilienceterm·dom beyond the level of the individual (e.g., family resilienceterm·dom). Of the original 70,619 studies that were found, 39,312 studies remained after excluding duplicates as potential eligible citations. Based on the title and abstract screening level, 38,796 studies were removed, which was obviously against eligibility criteria. Afterward, we thoroughly read the full text of the remaining 516 studies and included 52 articles that were particularly relevant to this analysis. Figure 1 is the PRISMA flowchart of the whole selection process.

PRISMA literature search flowchart.

Data analysis To analyze data, we read each article in detail and extracted the following information from them: detailed characteristics, study sample, attributes, antecedents, consequences, and measurements of suicide resilienceterm·dom ( Table 2 ). Additionally, all listed attributes were put together in another file to more clearly find the characteristics frequently relevant to the concept of suicide resilienceterm·dom. In this separate file, we regrouped synonymous and closely related attributes into the same theme. We then counted the number of articles that mentioned the theme and selected the top-mentioned themes for further analysis. The selection of attributes was discussed and reviewed by all authors throughout.

Characteristics of the included literature.

Results The 52 articles included in the analysis were published between 2003 and 2022, and were from the following countries/regions: Australia ( N = 4), Canada ( N = 9), Germany ( N = 1), New Zealand ( N = 1), Norway ( N = 1), Spain ( N = 2), Sweden ( N = 2), Taiwan ( N = 5), United States ( N = 18), United Kingdom ( N = 9). The study design was quantitative ( N = 27), qualitative ( N = 21), and review ( N = 4). A summary of study information is presented in Table 2 .

Uses of the concept The first and second steps in the Walker and Avant analysis method have been described in the Introduction section. And the third step in this method is to identify various usages of the concept ( 27 ). To achieve this goal, dictionaries and literature were used.

Dictionary definitions of suicide resilienceterm·dom The concept of suicide resilienceterm·dom includes the two sub-concepts of suicide and resilienceterm·dom. Suicide is defined by Merriam-Webster's dictionary as “the act or an instance of taking one's own life voluntarily and intentionally” ( 73 ). The Oxford dictionary also defines the word as “the act of killing oneself deliberately” ( 74 ). Resilienceterm·dom, another concept, is defined by Merriam-Webster's dictionary as “an ability to recover from or adjust easily to misfortune or change” ( 75 ). According to the Oxford dictionary, resilienceterm·dom is “the ability of people or things to recover quickly after something unpleasant” ( 76 ). In this broad sense, suicide resilienceterm·dom would be described as an ability to recover from the adversity that may leads individuals to take their life deliberately.

Use of suicide resilienceterm·dom in literature The emergence of the suicide resilienceterm·dom concept is due to the increasing attention on psychological resilienceterm·dom. In psychology, resilienceterm·dom has three inconsistent definitions. It is a personal trait that helps people do well despite adversity, a positive outcome of maintaining mental health despite significant stress or a dynamic process of adapting well to unfavorable circumstances ( 77 , 78 ). These definitions were applied to the suicide field and greatly affected the concept of suicide resilienceterm·dom.

The term suicide resilienceterm·dom was first used by Osman as the perceived ability, resources, or competence to regulate suicide-related thoughts, feelings, and attitudes ( 17 ). Osman also mentioned that suicide resilienceterm·dom incorporated a set of suicide protective factorsterm·dom and divided them into three domains, including internal protective, external protective, and emotional stability. Johnson refers to suicide resilienceterm·dom as positive self-appraisals and suggests that it will buffer against the pernicious impact of stress ( 34 ). Later, Johnson defined suicide resilienceterm·dom as a perception or a set of beliefs that buffer individuals from suicidalityterm·key when facing stressors and developed the buffering hypothesisterm·key where suicide resilience factorsterm·dom are not merely protective factorsterm·dom ( 14 ). Meanwhile, some researchers directly take the definition of psychological resilienceterm·dom to investigate suicide resilienceterm·dom without giving a specific definition ( 29 , 30 ).

In the literature, the terms used to describe suicide resilienceterm·dom were also called several other similar terms. Notably, when the type of suicide phrase is a suicide attempt, recovery was found to be the most commonly used word, which can be interpreted as the process definition of suicide resilienceterm·dom ( 18 , 46 ). Except for suicide resilienceterm·dom, other terms included resilienceterm·dom to suicide, resilienceterm·dom to suicidalityterm·key, suicidal recoveryterm·key, overcome suicidalityterm·key, recovery from suicide, or psychological resilienceterm·dom to suicidal thoughts and behaviors ( 20 , 49 ).

Defining attributes of suicide resilienceterm·dom The fourth step in the method is to find defining attributes of suicide resilienceterm·dom, that is, the characteristics frequently associated with the concept. By doing so, the concept of suicide resilienceterm·dom can be distinguished from others ( 27 ). After an exhaustive screening of the included articles and consultation with the research team, the top five mentioned themes which have significantly higher sum scores than the others were selected as suicide resilienceterm·dom attributes. These attributes are social supportterm·key, coping strategiesterm·dom, psychological capitalterm·dom, meaning in lifeterm·key, and sense of responsibilityterm·dom.

Social supportterm·key Social supportterm·key is a central word in the reviewed literature, with a total of 28 articles mentioned ( 39 , 40 , 50 , 54 , 55 , 64 ). Across studies, individuals who have higher levels of social supportterm·key are less likely to consider suicide and can recover from being suicidal faster. Social supportterm·key can come from various sources, including family, partners, friends, relatives, healthcare professionals, community, religion, and pets ( 43 , 46 , 59 ). The social supportterm·key system for people at high risk of suicide has been identified as a significant influencer on resilient outcomes. Gulbas et al. ( 56 ) examined trajectories of wellbeing following a suicide attempt through a longitudinal qualitative research design within 17 Latina teens. They identified three distinct profiles which were labeled as “resilienceterm·dom trajectory” ( N = 5), “tenuous growth trajectory” ( N = 6), and “chronic stress trajectory” ( N = 6). Participants in the “resilienceterm·dom trajectory” categories reported improvements in relationships with family or peers over time, while the other two categories did not report that. Meanwhile, mental health professionals were shown to play a critical role in facilitating the recovery process for participants in every resilient case. Several studies also indicated that receiving support from significant others and professional services was of paramount importance, especially during times of high suicide risk ( 18 , 58 ).

Coping strategiesterm·dom The second suicide resilienceterm·dom attribute is coping strategiesterm·dom, with a total of 19 articles mentioned ( 18 , 28 , 35 , 43 , 54 ). Coping strategiesterm·dom refer to the cognitive and behavioral activities individuals engage in to deal with stressful situations encountered in life ( 79 ). Positive and healthy coping strategiesterm·dom are inversely related to suicidal ideation and behaviors. Gulbas et al. ( 56 ) reported that participants who developed more coping skills were more likely to belong to the resilienceterm·dom groups. Harris et al. ( 58 ) reported that talking to people and performing daily activities that demanded a level of concentration (e.g., exercising, listening to music, cooking, and playing computer games) were helpful for patients with schizophrenia diagnoses to suppress their suicidal ideation. Several other research also concluded that emotional expression through talking or writing played an essential role in a suicidal recoveryterm·key process ( 29 , 71 ).

Psychological capitalterm·dom A third suicide resilienceterm·dom attribute is psychological capitalterm·dom, which was mentioned in 18 articles ( 35 , 36 , 49 , 63 , 70 ). Psychological capitalterm·dom is defined as an individual's positive psychological state of development. Initially, it comprises four positive psychological resources: self-efficacy, optimism, hope, and resilienceterm·dom ( 80 ). Recently, there is growing discussion to include related nomological constructs such as wellbeing, gratitude, grit, emotional intelligence, mindfulness, and forgiveness into the concept ( 81 ). It is selected as an attributes to reflect the broad personal characteristics which are studied frequently in the suicide resilienceterm·dom field. For example, both Kumar et al. ( 66 ) and Yu et al. ( 70 ) reported that being optimistic could buffer against suicidalityterm·key risk in the face of PTSD or depressive symptoms. Kleiman et al. ( 36 ) reported that participants with a high level of gratitude and grit were characterized with greatest reduction in suicidal ideation over time. Other variables, such as self-efficacy and mindfulness, have been demonstrated to have the same functioning ( 9 , 49 ).

Meaning in lifeterm·key Meaning in lifeterm·key is linked to suicide resilienceterm·dom with a total of 16 articles mentioned ( 15 , 36 , 42 , 67 , 68 ). It is a strong protective factorterm·dom against suicide. Several studies have suggested that individuals with a higher level of meaning in lifeterm·key are less likely to develop suicide ideation with associated risk factors. There is no consistent definition of meaning in lifeterm·key, but all of them share three common features: cognitive component, motivational component, affective component ( 82 ). The first component is about making sense of one's experiences in life. Harris et al. ( 58 ) and Ridge et al. ( 72 ) reported that having an understanding of personal distress and suicidal experience could lead to reconciliation and acceptance of this experience, which was key aspects of establishing suicide resilienceterm·dom. The second component is about the pursuit and attainment of worthwhile goals, and the final component is about feelings of satisfaction, and happiness accompanying goal achievement. Zaheer et al. ( 59 ) and Everall et al. ( 29 ) reported that creating goals for the futureterm·dom had contributed to the increase of suicide resilienceterm·dom.

Sense of responsibilityterm·dom Sense of responsibilityterm·dom compared to the attributes above is linked to suicide resilienceterm·dom with a total of 7 articles mentioned ( 29 , 30 , 54 , 58 ). It is defined as awareness of one's obligation ( 40 ). Research demonstrates that sense of responsibilityterm·dom has two types, whether responsibility to others or personal responsibility. Several participants described being worried or realized about the effects their suicidal ideation or behaviors would have on their parents or peers. Chan et al. ( 43 ) reported this kind of awareness helped individuals to go on living. In addition, Sun et al. ( 18 ) reported the feeling of living for family could contribute to recovery after a suicide attempt. Other participants described that they need to take responsibility for themselves and their health. For example, Tofthagen et al. ( 48 ) reported that this awareness leads individuals to quit suicidal behaviors.

Cases According to the Walker and Avant method, several cases are required to further clarify the concept of suicide resilienceterm·dom ( 27 ). Here, we present cases that: include all defining attributes (i.e., model cases), contain some but not all of the defining attributes (i.e., borderline cases), and absence of the defining attributes (i.e., contrary cases). The cases were adapted from the literature or constructed by authors.

Model case Collin is a 22-year-old college student. He grew up in a rural family where his father did not talk about emotions. In his early adolescence, he secretly found out that his father had an affair which worsened their relationship. At the time, he also had a distant relationship with his mother and siblings, as well as school friends. Collin felt unhappy and perplexed by his negative emotions. He had suicidal thoughts often and once nearly attempted it. As time went by, he formed a close relationship with a new group of friends and began talking more openly about himself and his experiences (social supportterm·key, coping strategiesterm·dom). He found that his friends were very supportive and gave him a reason to be excited about life (meaning in lifeterm·key). His relationship with his siblings dramatically improved in his late teen years. His siblings would often choose him to turn to when they needed help or support, which made him feel he had a significant role in the family (sense of responsibilityterm·dom). Collin gradually gained the confidence to accept himself and sees himself as being a strong person who cannot be stopped and who will figure out a way to deal with everything (psychological capitalterm·dom). He is also optimistic about the future, believing that it will bring him success and happiness (meaning in lifeterm·key).

Borderline case Andy is a 36-year-old man who attempted suicide a few years ago. After realizing its negative impact on his family who always support him no matter what, he felt a strong responsibility to live for them. He found a new job as a salesman. He can find a little meaning in the job when helping his customers. However, he felt that he had become a lot more introverted and always had a sense of inferiority after a suicide attempt, which made him have great difficulties in interpersonal communication. Despite his family being supportive, he would not talk to them about his trouble. He found it effective to let out negative emotions through exercising, listening to music, and playing games. Nevertheless, sometimes he would be overwhelmed by the negative feelings and have suicidal thoughts during this tough time.

Contrary case Katie is a 14-year-old middle school student with a diagnosis of depressive disorder. She encountered school bullying and had a hard time going through the experiences. She also has a poor relationship with her parents and almost has no true friends. Her only pleasure in life was her pet cat. She always thought that she had no value in this world and life had no meaning at all. When she felt depressed, she could not find an effective coping strategy to deal with the torturing feeling. She considered suicide as a relief and had attempted suicide by self-poisoning several times. Although she was rescued in every attempt, she still felt suicidal all the time.

Antecedents Antecedents are the events or incidents that lead to the occurrence of the concept. The main antecedent of suicide resilienceterm·dom is the events that may place an individual at high risk of suicide. It may be adversity such as the coming-out process, stressful life events, combat distress, posttraumatic stress symptoms linked to sexual assault or childhood abuse, being in late life, depressive symptoms, and a diagnosis of schizophrenia ( 28 , 34 , 42 , 44 , 50 , 64 , 66 , 67 ). This adversity also includes events directly relating to suicide, which are the strongest predictors of future suicide, such as suicide ideation or suicide attempt ( 71 , 72 ).

Consequences Consequences are the events or incidents that occur as a result or outcome of the concept. When individuals demonstrate suicide resilienceterm·dom, outcomes are divided into two types. For those who have not been suicidal yet, suicide resilienceterm·dom enables them to cope effectively with a feeling of despair and buffer them from adversity which heightens suicide risk against the development of suicidal thoughts and behaviors ( 28 , 39 , 50 ). For those who have already been suicidal, suicide resilienceterm·dom can help them overcome suicidalityterm·key and regain the desire to be alive or transition them from a higher to lower risk of suicide ( 15 , 32 , 49 ). Regardless, the nature of the event is the reduction of suicide risk.

Empirical referents The final step of this analysis is defining the empirical referents which can be used to measure the existence or attributes of the concept. In total, six specific instruments of suicide resilienceterm·dom were identified ( 16 , 17 , 34 , 47 , 61 , 65 ). The detail of each measure's information and involved attributes are shown in Table 3 . None of these measures mentioned all defining attributes. Hence, the existing dimensions of them may miss some features of individuals with suicide resilienceterm·dom. Overall, suicide resilienceterm·dom inventory, the suicidal recoveryterm·key ability scale, and the scale of resilienceterm·dom to suicide attempts cover the most attributes, which suggests they may be more probable measures. Except for suicide resilienceterm·dom inventory and resilienceterm·dom appraisal scale, other scales were all developed in recent years and have not been tested in different cultures.

Involved defining attributes in six suicide resilienceterm·dom instruments.

Discussion In this concept analysis, we identified defining attributes, antecedents, consequences, and empirical references of suicide resilienceterm·dom by applying the Walker and Avant's method, providing a clearer and comprehensive insight into the concept of suicide resilienceterm·dom. Considering all results, we propose the definition of the concept as: suicide resilienceterm·dom is the ability and dynamic process of an individual who is under high suicide risks to avoid being suicidal, transition from a higher to lower risk of suicide, or recover from suicidalityterm·key, which can be enhanced by the presence of attributes such as social supportterm·key, coping strategiesterm·dom, psychological capitalterm·dom, meaning in lifeterm·key and sense of responsibilityterm·dom. A conceptual model of suicide resilienceterm·dom was presented in Figure 2 .

Conceptual model of suicide resilienceterm·dom[[Inline Image]].

Our analysis showed that social supportterm·key, coping strategiesterm·dom, psychological capitalterm·dom, meaning in lifeterm·key, and sense of responsibilityterm·dom were the five attributes of the concept of suicide resilienceterm·dom. The use of case studies further assists in understanding the concept of individuals applying the presence or absence of the attributes in their lives. Some of our results are in line with other studies on resilienceterm·dom. Both social supportterm·key and coping strategiesterm·dom are commonly mentioned as attributes whether in general or specific resilienceterm·dom research ( 25 , 83 , 84 ). Several positive personalities contained in psychological capitalterm·dom such as optimism and self-efficacy are also popular attributes in similar research ( 83 , 85 ). However, the other two seem to be specific attributes of suicide resilienceterm·dom.

The existing body of research indicated that events proven to increase suicide risk are the antecedents of suicide resilienceterm·dom. This is in accordance with several other research which reveals that the antecedents of specific resilienceterm·dom are related adversity ( 86 ). Harris et al. ( 58 ) also demonstrated that individuals can find out whether they have suicide resilienceterm·dom or not unless they have experienced such problems. When encountering suicide-related adversity, individuals with greater suicide resilienceterm·dom levels are more likely to have positive consequences, such as avoiding the development of suicide ideation. Otherwise, they may be trapped in a suicidal circle. Fortunately, more and more studies have revealed that suicide resilienceterm·dom was not a static state, but a dynamic process ( 18 , 58 ). According to these findings, high level of suicide risks can not only be a challenge but also serve as an opportunity to cultivate or improve suicide resilienceterm·dom.

To prevent suicide risk by enhancing the level of suicide resilienceterm·dom, effective empirical referents are essential. Populations who are vulnerable to suicidalityterm·key can be identified by using these tools, which can help facilitate the design of early intervention programs. Nevertheless, we only find six scales to measure suicide resilienceterm·dom in literature, and none of them have been widely used. This is consistent with the fact that the concept of suicide resilienceterm·dom has not been widely acknowledged. Based on our analysis, there are no matching measurements that contain all defining attributes. In the future, the existing scales need to be further tested, especially in different cultures, and more suicide resilienceterm·dom scales should be developed. Our suicide resiliency attributes can provide a reference when designing such scales.

This concept analysis has great implications for practice. First, this study informs researchers and clinicians of a growing body of literature on suicide resilienceterm·dom and provides them with a deep understanding of the concept. By doing so, researchers and clinicians can be more aware of the crucial role suicide resilienceterm·dom played in the suicide field, facilitating them to conduct more research on this theme. Second, suicide resiliency attributes identified in this analysis can offer valuable points of intervention to support populations under high suicide risks. Currently, there is rarely explicit or implicit attention to attributes such as meaning in lifeterm·key in mainstream clinical interventions for suicide, which have been found to be useful ( 36 ). Hence, more clinical interventions targeting attributes are needed in the future. Third, suicide resilienceterm·dom is defined as a dynamic process which means it will change over time. However, most existing studies on suicide resilienceterm·dom adopt cross-sectional design. Therefore, in order to better understand the concept, more investigation using longitudinal study designs is essential.

Finally, some limitations to this study need to be acknowledged. First, in the selection process of included articles, there might be a risk of bias without quality assessment. Second, we only included articles available in English or Chinese and, therefore, the results might not generalize beyond the settings. Third, suicide resilienceterm·dom research is evolving, which means the results are tentative. It is essential to regularly revisit this analysis to see whether there has anything new.

Conclusion This research tried to clarify the concept of suicide resilienceterm·dom and defined it by way of the Walker and Avant concept analysis method. The clarification of the concept may improve researchers' and clinicians' understanding of the nature of suicide resilienceterm·dom, raise their awareness of the importance of assessment, and stimulate more interventions aiming at promoting suicide resilienceterm·dom. Considering that research investigating suicide resilienceterm·dom still use different terms and concepts, which may cause confusion and hinder more research in this area, we hope that this analysis will help to guide future research and interventions by providing a more consistent understanding.

Author contributions XW and CD contributed to the design of the study. XW performed the literature research, article selection, data extraction and created the first draft of the manuscript. CD and ZL reviewed and edited the manuscript. All authors contributed to the article and approved the submitted version.

Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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