Introduction

Our interest in resilience arose from long experience treating men and women
with posttraumatic stress disorder (PTSD), as well as from our broad-range
research into the disorder, which covered treatment assessment, diagnosis,
biological characterization, cross-cultural study, epidemiology, risk factors and
the development of measures for PTSD and other forms of anxiety.

Among the measures which we felt needed a stronger presence in the field of
PTSD assessment was that of resilience. Although several scales addressing
aspects of resilience have existed for some time, they had largely failed to
penetrate into the world of clinical practice. In our treatment studies of PTSD we
noticed that besides reducing the symptoms of the disorder, subjects became
better able to handle stress and seemed to become more resilient.

After a search of the resilience literature, which for a long time was heavily
influenced by contributions from the specialties of developmental psychology
and child psychiatry, we selected 17 domains, as outlined in Table 1 of our
publication in 2003, and developed a 25 item scale (Connor KM, Davidson JRT.
Depression and Anxiety 2003; 18: 71-82). This report presented psychometric
data establishing validity and reliability of the scale (known as the Connor-
Davidson Resilience Scale or CD-RISC), as well as briefly describing each of the
25 items (see table 2 of that citation), and giving general scoring directions.
However, the complete wording for each item and full directions did not appear
in the report and the scale cannot be adequately reconstructed from the
information given in this publication.

In the original validation study, mean scores in specific populations were reported
as follows:

Besides the full 25-item CD-RISC (or CD-RISC 25), there are two briefer
versions, the 10 item (CD-RISC 10) and two item (CD-RISC 2) scales. The 10
item version (score range 0-40) comprises items 1, 4, 6, 7, 8, 11, 14, 16, 17, 19
from the original scale, and was developed by Drs. Campbell-Sills and Stein, at
the University of California, San Diego, on the basis of factor analysis. In a
community survey of 764 US adults, a mean score of 31.8 (SD = 5.4) was
obtained for the CD-RISC 10 (Campbell-Sills L, Forde DR, Stein MB. J
Psychiatric Research (2009), doi:10.1016/[Link].2009.01.013). The
population quartile scores for the CD-RISC-10 are as follows: 25th % = 29; 50th
% = 32; 75th % = 36. An almost identical mean score was obtained by Davidson
in the US general population sample studied in the 2003 report above.
The CD-RISC 2 is based on items 1 and 8 (score range from 0-8), and was
developed as a measure of "bounce-back" and adaptability by the original authors
(Vaishnavi et al, 2007). In a general population survey of US adults, mean CD-
RISC 2 score was 6.91, while lower scores were observed in psychiatric groups
with depression (5.12), GAD (4.96) and PTSD (4.70) (Vaishnavi et al, 2007) and
in survivors of the Southeast Asian Tsunami of 2004 (4.67) (Irmansyah et al,
2010).

The 2-, 10- and 25-item versions are the only ones that have been adequately
tested and validated and are the only ones authorized for use.

The CD-RISC literature continues to grow: the scale has now been translated into
many different languages and studied in a variety of populations, including large
community samples, survivors of various traumas, Alzheimer's caregivers,
adolescents, elders, patients in treatment for PTSD, members of different ethnic
groups and cultures, and selected professional or athletic groups (e.g. university
students, nurses, social workers, physicians, military medical personnel, medical
students, missionaries, cricketers). The CD-RISC has been included in functional
neuroimaging studies, studies which utilized genotyping and studies which
assessed treatment outcome. Psychometric properties of the RISC hold up in
nearly all studies, although its factor structure and mean score varies with setting.
For this reason, we do not recommend separate scoring of the factor subscales
which were originally reported by Connor and Davidson, even though some
interesting findings have been reported when specific factors or items were
selected (e.g. Laff, 2008; Garcia-Izquierdo et al, 2009).

Questionnaire, Scoring, Norm and Interpretation

1. Able to adapt to change

2. Can deal with whatever comes
3. See the humorous side of things
4. Coping with stress strengthens
5. Tend to bounce back after illness or hardship
6. You can achieve your goals
7. Under pressure, focus and think clearly
8. Not easily discouraged by failure
9. Think of self as strong person
10. Can handle unpleasant feeling

Scoring, Norms and Interpretation

all of them carry a 5-point range of responses, as follows: not true at all

(0), rarely true (1), sometimes true (2), often true (3), & true nearly all of the time
(4).

The population quartile scores for the CD-RISC-10 are as follows: 25th % = 29;
50th % = 32; 75th % = 36. An almost identical mean score was obtained by
Davidson in the US general population sample studied in the 2003 report above.

1st Quartile (Q1): 0 to 29- Low

2nd Quartile (Q2): 30 to 32- Average

3rd Quartile (Q3): 33 to 36- High

4th Quartile (Q4): 37 to 40- very high

Interpretation
The CD-RISC-10 was extracted from the original CD-RISC(Campbell-
Sills and Stein, 2007). Item responses range from 0 (“not true at all”) to 4
(“true nearly all of the time”). The overall score ranges from 0 to 40, with
higher scores reflecting a greater ability to cope with adversity.

Reliability and Validity

The CD-RISC-10 showed good internal consistency in all subsamples
(Cronbach's α of > 0.93 and McDonald's ω of > 0.93) and good test-retest
reliability (ICC = 0.88). Moreover, concurrent and predictive validity
with the SAS and SDS scores were good (r = -0.68 to -0.49, p < 0.001)
 DEPRESSION AND ANXIETY 18:76–82 (2003)

Research Article
DEVELOPMENT OF A NEW RESILIENCE SCALE:
THE CONNOR-DAVIDSON RESILIENCE SCALE (CD-RISC)
n
Kathryn M. Connor, M.D., and Jonathan R.T. Davidson, M.D.

Resilience may be viewed as a measure of stress coping ability and, as such, could
be an important target of treatment in anxiety, depression, and stress reactions.
We describe a new rating scale to assess resilience. The Connor-Davidson
Resilience scale (CD-RISC) comprises of 25 items, each rated on a 5-point scale
(0–4), with higher scores reflecting greater resilience. The scale was
administered to subjects in the following groups: community sample, primary
care outpatients, general psychiatric outpatients, clinical trial of generalized
anxiety disorder, and two clinical trials of PTSD. The reliability, validity, and
factor analytic structure of the scale were evaluated, and reference scores for
study samples were calculated. Sensitivity to treatment effects was examined
in subjects from the PTSD clinical trials. The scale demonstrated good
psychometric properties and factor analysis yielded five factors. A repeated
measures ANOVA showed that an increase in CD-RISC score was associated
with greater improvement during treatment. Improvement in CD-RISC score
was noted in proportion to overall clinical global improvement, with greatest
increase noted in subjects with the highest global improvement and deterioration
in CD-RISC score in those with minimal or no global improvement. The CD-
RISC has sound psychometric properties and distinguishes between those with
greater and lesser resilience. The scale demonstrates that resilience is modifiable
and can improve with treatment, with greater improvement corresponding to
higher levels of global improvement. Depression and Anxiety 18:76–82, 2003.
& 2003 Wiley-Liss, Inc.

Key words: resilience; stress coping; wellbeing; posttraumatic stress disorder;

anxiety; depression

with these events is influenced by both successful and

INTRODUCTION unsuccessful adaptations to previous disruptions. In
R esilience embodies the personal qualities that enable some situations, such adaptations, or protective
one to thrive in the face of adversity. Research over the
last 20 years has demonstrated that resilience is a
multidimensional characteristic that varies with con- Department of Psychiatry and Behavioral Sciences, Duke
text, time, age, gender, and cultural origin, as well as University Medical Center, Durham, North Carolina
within an individual subjected to dif ferent life circum- Contract grant sponsor: Smith Kline Beecham; Contract grant
stances [e.g., Garmezy, 1985; Garmezy and Rutter, sponsor: Pfizer Pharmaceuticals; Contract grant sponsor: Pure
1985; Rutter et al., 1985; Seligman and Csikszentmi- World Botanicals, Inc.; Contract grant sponsor: Organon; Con-
halyi, 2000; Werner and Smith, 1992]. One theory for tract grant sponsor: NIH; Contract grant number: R01 MH56656-
this variability was developed by Richardson and 01A1
colleagues, who proposed the following resiliency n
Correspondence to: Dr. Connor, Box 3812, DUMC, Durham, NC
model [Richardson et al., 1990; Richardson, 2002]. 27710. E-mail: [Link]@[Link]
Beginning at a point of biopsychospiritual balance
(‘‘homeostasis’’), one adapts body, mind, and spirit to Received for publication 15 September 2002; Accepted 1 April 2003
current life circumstances. Internal and external DOI: 10.1002/da.10113
stressors are ever-present and one’s ability to cope Published online in Wiley InterScience ([Link]).

& 2003 WILEY-LISS, INC.

 Research Article: Resilience Scale: (CD-RISC) 77

factors, are ineffective, resulting in disruption of the anxiety, depression, and stress reactions. This interest
biopsychospiritual homeostasis. In time, response to this arose in part from a finding that fluoxetine produced
disruption is a reintegrative process, leading to one of greater therapeutic benefit on stress coping than
four outcomes: (1) the disruption represents an oppor- placebo in PTSD [Connor et al., 1999]. Furthermore,
tunity for growth and increased resilience, whereby in reviewing the account of Sir Edward Shackleton’s
adaptation to the disruption leads to a new, higher level heroic expedition in the Antarctic in 1912 [Alexander,
of homeostasis; (2) a return to baseline homeostasis, in 1998], it was noted that the expedition’s leader
an effort to just get past or beyond the disruption; (3) possessed many personal characteristics compatible
recovery with loss, establishing a lower level of home- with resilience and that this may perhaps have
ostasis; or 4) a dysfunctional state in which maladaptive contributed to the successful survival of each member
strategies (e.g., self-destructive behaviors) are used to of the expedition in the face of overwhelming odds.
cope with stressors. Resilience may thus also be viewed Together, these observations prompted the authors to
as measure of successful stress-coping ability. undertake the development of a short self-rated
The clinical relevance of resilience and related resilience measure.
constructs has been noted previously. Maddi and The content of the scale was drawn from a number
Khoshaba theorized that hardiness was an index of of sources. From Kobasa’s work with the construct of
mental health [Maddi and Khoshaba, 1994] and recent hardiness [Kobasa, 1979], items reflecting control,
data has supported this hypothesis [Ramanaiah et al., commitment, and change viewed as challenge were
1999]. Tsuang [2000] has emphasized the substantial included. The following features were drawn from
clinical implications that follow a better understanding Rutter’s work [Rutter, 1985]: developing strategy with a
of the forces that mould resilience. With regard to clear goal or aim, action orientation, strong self-
trauma and posttraumatic stress disorder (PTSD), it esteem/confidence, adaptability when coping with
has been shown that hardiness contributes to protec- change, social problem solving skills, humor in the
tion against developing chronic PTSD after combat face of stress, strengthening effect of stress, taking on
[King et al., 1998; Waysman et al., 2001]. responsibilities for dealing with stress, secure/stable
The growing focus on health promotion and well- affectional bonds, and previous experiences of success
being, shifting emphasis away from pathology and and achievement (these last two features may reflect the
problem-orientation, provides an opportunity to revisit underpinnings of resilience). From Lyons [1991], items
the role of resilience in health. Yet there is relatively assessing patience and the ability to endure stress or
little awareness about resilience or its importance in pain were included. Lastly, from Shackleton’s experi-
clinical therapeutics. Conventionally, therapeutic trials ences, it was noted that the role of faith and a belief in
have focused more heavily on measuring morbidity, benevolent intervention (‘‘good luck’’) were likely
although quality of life elements are now included in important factors in the survival of the expedition,
many trials. A number of scales have been developed to suggesting a spiritual component to resilience. Table 1
measure resilience [Bartone et al., 1989; Wagnild and summarizes the salient features of resilience.
Young, 1993] or aspects of resilience [e.g., hardiness: With the above considerations, the CD-RISC was
Hull et al., 1987, Kobasa, 1979; perceived stress, Cohen constructed, with the following goals in mind: to
et al., 1983]. However, these measures have neither develop a valid and reliable measure to quantify
been widely used nor applied to specific populations
[Carlson, 2001; Mosack, 2002] and thereby lack
generalizability. Of striking note, a textbook of psy- TABLE 1: Characteristics of resilient people
chiatric measures recently published by the American
Psychiatric Association contains not a single resilience Reference Characteristic
measure [American Psychiatric Association, 2000]. Kobasa, 1979 View change or stress as a challenge/opportunity
The need for well-validated measures of resilience Kobasa, 1979 Commitment
that are simple to use is thus evident. While several Kobasa, 1979 Recognition of limits to control
scales have been developed, they have not gained wide Rutter, 1985 Engaging the support of others
acceptance and no one scale has established primacy. Rutter, 1985 Close, secure attachment to others
With these considerations in mind, the Connor- Rutter, 1985 Personal or collective goals
Davidson Resilience Scale (CD-RISC) was developed Rutter, 1985 Self-efficacy
Rutter, 1985 Strengthening effect of stress
as a brief self-rated assessment to help quantify resilience
Rutter, 1985 Past successes
and as a clinical measure to assess treatment response. Rutter, 1985 Realistic sense of control/having choices
Rutter, 1985 Sense of humor
Rutter, 1985 Action oriented approach
METHODS Lyons, 1991 Patience
Lyons, 1991 Tolerance of negative affect
SCALE DEVELOPMENT Rutter, 1985 Adaptability to change
We recently became interested in the concept of Current Optimism
resilience as being relevant to treatment outcome in Current Faith
78 Connor and Davidson

TABLE 2: Content of the Connor-Davidson Resilience Institutional Review Board and all subjects provided
Scale informed consent.
Demographic characteristics of Groups 1–5 (n ¼
Item no. Description 806) were as follows: female 65% (n ¼ 510), male
1 Able to adapt to change 35% (n ¼ 274); white 77% (n ¼ 588), non-white 23%
2 Close and secure relationships (n¼181); and mean (sd) age 43.8 (15.3) years (n ¼ 763).
3 Sometimes fate or God can help Some missing data occurred for all of these compar-
4 Can deal with whatever comes isons, which explains why the figures do not total 806
5 Past success gives confidence for new challenge in the various comparisons (e.g., data were not always
6 See the humorous side of things available for gender, ethnic status, etc.).
7 Coping with stress strengthens
8 Tend to bounce back after illness or hardship
9 Things happen for a reason DATA ANALYSIS
10 Best effort no matter what
11 You can achieve your goals
The data were analyzed with the following objec-
12 When things look hopeless, I don’t give up tives: (1) to establish reference scores for the CD-RISC
13 Know where to turn for help and to assess whether scores were affected by clinical
14 Under pressure, focus and think clearly category or demographic factors, (2) to assess the
15 Prefer to take the lead in problem solving reliability and validity of the scale, (3) to assess the
16 Not easily discouraged by failure factor composition of the CD-RISC in the general
17 Think of self as strong person population, and (4) to assess the extent to which CD-
18 Make unpopular or difficult decisions RISC scores can change with clinical improvement
19 Can handle unpleasant feelings with treatment and over time.
20 Have to act on a hunch
Given that several of the samples were not normally
21 Strong sense of purpose
22 In control of your life
distributed, median CD-RISC scores were calculated
23 I like challenges for each group and pairwise comparisons were per-
24 You work to attain your goals formed using the Wilcoxon Rank Sum test, with
25 Pride in your achievements Po.05 being regarded as significant. A Bonferroni
correction was used for multiple comparisons to derive
the z score. Of note, mean CD-RISC scores are also
presented for clinical reference. A Kruskal-Wallis test
was used for multiple group comparisons, with the
resilience, to establish reference values for resilience in
expectation that degrees of resilience would be lower in
the general population and in clinical samples, and to
psychiatric outpatients than in the general population
assess the modifiability of resilience in response to
or primary care patients.
pharmacologic treatment in a clinical population.
Descriptive statistics were used to characterize
The CD-RISC contains 25 items, all of which carry
CD-RISC scores in the full sample by gender,
a 5-point range of responses, as follows: not true at all
ethnicity, and age. Analysis of variance was used
(0), rarely true (1), sometimes true (2), often true (3),
to analyze categorical variables (e.g., gender and
and true nearly all of the time (4). The scale is rated
ethnicity) and correlation with the continuous measure
based on how the subject has felt over the past month.
of age.
The total score ranges from 0–100, with higher scores
The reliability and validity of the scale were assessed
reflecting greater resilience. The individual items
as follows. Test retest reliability was examined in
comprising the scale are listed in Table 2.
subjects from Groups 4 and 5 in whom no clinical
change was noted between two consecutive visits.
Internal consistency was evaluated by using Cronbach’s
STUDY SAMPLE alpha for the total and item-total scores in subjects
Subjects were drawn from the following study from Group 1. Convergent validity was assessed in
samples: a random-digit dial based general population various groups by correlating the CD-RISC with
sample [i.e., non help-seeking (Group 1, n ¼ 577; measures of hardiness [Kobasa Hardiness Scale; Koba-
included subjects with complete data only); primary sa et al., 1979], perceived stress [Perceived Stress Scale
care outpatients (Group 2, n ¼ 139); psychiatric out- (PSS-10); Cohen et al., 1983], and stress vulnerability
patients in private practice (Group 3, n ¼ 43); subjects [Stress Vulnerability Scale (SVS); Sheehan et al., 1990],
in a study of generalized anxiety disorder (GAD; as well as measures of disability [Sheehan Disability
Group 4, n ¼ 25); and subjects in two clinical trials of Scale(SDS); Sheehan et al., 1983] and social support
PTSD (Group 5, n ¼ 22; Group 6, n ¼ 22)]. Of note, [Sheehan Social Support Scale (SSSS); Sheehan, 1990].
subjects in Group 6 are included only for between- Divergent validity was assessed by correlating CD-
group diagnostic comparisons and in the assessment of RISC scores with the Arizona Sexual Experience
pre- to post-treatment change. Each study protocol Scale [ASEX; McGahuey et al., 2000] in subjects from
was approved by the Duke University Medical Center Group 4.
 Research Article: Resilience Scale: (CD-RISC) 79

An exploratory factor analysis using an ORTHO- TABLE 4: Pairwise comparisons of Connor-Davidson

MAX rotation was conducted by using data from the Resilience Scale scores
general population sample (Group 1).
The ef fects of time and treatment on resilience were Statistically
assessed by comparing pre- and post-treatment CD- Mean rank Critical rank significant
RISC scores in treatment responders and non-respon- Groupn difference difference differencenn
ders in the clinical trial samples (Groups 4, 5, and 6) by Group1 vs.
using a repeated measures analysis of variance (ANO- Group2 114.70 66.36 Yes
VA), with response as the grouping variable and time as Group3 193.80 111.02 Yes
the repeated measure. Response was defined by a Group4 290.50 146.31 Yes
Clinical Global Improvement (CGI-I; Guy; 1976) Group5 362.80 152.56 Yes
score of 1 (very much improved) or 2 (much improved). Group6 329.70 152.56 Yes

Group2 vs.
Group3 79.10 122.55 No
RESULTS Group4 175.80 155.24 Yes
Group5 248.10 161.15 Yes
CD-RISC SCORES BY CLINICAL CATEGORY Group6 215.00 161.15 Yes
AND DEMOGRAPHIC GROUP
Group3 vs.
Mean (sd) and median (1st, 4th quartile) CD-RISC Group4 96.70 178.95 No
scores were calculated for the full sample (Groups 1–5) Group5 169.00 184.09 No
and for the individual study groups (Table 3). Results of Group6 135.90 184.09 No
pairwise comparisons are listed in Table 4 and Group4 vs.
significant differences were found for the following Group5 72.30 207.29 No
groups: general population (Group 1) vs. each of Group6 39.20 207.29 No
the other groups, primary care (Group 2) vs. GAD
(Group 4), and primary care vs. PTSD (Groups 5 Group5 vs .
Group6 33.10 211.75 No
and 6). Statistical significance was obtained in the n
Group 1¼general population; Group 2¼primary care; Group
overall multiple comparison model (w2 ¼ 142.80, df ¼ 5,
3¼psychiatric outpatients; Group 4¼GAD clinical trial subjects;
Po.0001). Groups 5 and 6¼PTSD clinical trial subjects.
Mean (sd) scores were also calculated by demo- nn
ao.05; Bonferonni correction used to derive z score; z¼2.94
graphic grouping, and no dif ferences were observed in GAD ¼ generalized anxiety disorder; PTSD ¼ posttraumatic stress
the characteristics evaluated. A gender comparison disorder.
revealed a mean score of 77.1 (16.3) for women and
77.2 (14.2) for men (P ¼.63). Mean CD-RISC scores by
racial group were as follows: white subjects, 77.4 (14.8)
and non-white subjects, 76.7 (18.1) (P ¼ .83). The
mean (sd) age of the full sample was 43.8 (15.4) years, Test–retest reliability. Test–retest reliability was
and no correlation was found between age and CD- assessed in 24 subjects from the clinical trials of GAD
RISC score (Pearson r ¼ .06, n.s.). (Group 4) and PTSD (Group 5) in whom little or no
clinical change was observed from time 1 to time 2.
RELIABILITY AND VALIDITY The mean (sd) CD-RISC scores at time 1 [52.7 (17.9)]
and time 2 [52.8 (19.9)] demonstrated a high level
Internal consistency. Cronbach’s a for the full of agreement, with an intraclass correlation coefficient
scale was 0.89 for Group 1 (n ¼ 577) and item-total of 0.87.
correlations ranged from 0.30 to 0.70 (Table 5). Convergent validity. CD-RISC scores were posi-
tively correlated with the Kobasa hardiness measure in
TABLE 3: Connor-Davidson Resilience Scale scores by psychiatric outpatients (Group 3, n ¼ 30; Pearson
study group r ¼ 0.83, Po.0001). Compared to the Perceived Stress
Scale (PSS-10), the CD-RISC showed a significant
Group Median negative correlation (Group 3, n ¼ 24; Pearson
Study group no. N Mean (sd) (1st, 4th Q) r ¼
0.76, Po.001), indicating that higher levels
of resilience corresponded with less perceived
General population 1 577 80.4 (12.8) 82 (73, 90)
Primary care 2 139 71.8 (18.4) 75 (60, 86)
stress. The Sheehan Stress Vulnerability Scale (SVS)
Psychiatric outpatients 3 43 68.0 (15.3) 69 (57, 79) was similarly negatively correlated with the CD-RISC
GAD patients 4 24 62.4 (10.7) 64.5 (53, 71) (Spearman r ¼
0.32, Po.0001) in 591 subjects
PTSD patients 5 22 47.8 (19.5) 47 (31, 61) from the combined sample. This result also indicates
6 22 52.8 (20.4) 56 (39, 61) that higher levels of resilience correspond to
GAD ¼ generalized anxiety disorder; PTSD ¼ posttraumatic stress lower levels of perceived stress vulnerability. As a
disorder. measure of disability, the CD-RISC demonstrated a
80 Connor and Davidson

TABLE 5: Item-total correlations and rotated factor pattern for the Connor-Davidson Resilience Scale

Factor (Eigenvalue)
n
Item Item-total correlation 1 (7.436) 2 (1.563) 3 (1.376) 4 (1.128) 5 (1.073)
24 0.61 0.70870 0.14250 0.04339 0.19253 0.01779
12 0.62 0.63998 0.22255 0.20851 0.05018 0.11083
11 0.62 0.62497 0.11656 0.13206 0.21732 0.06408
25 0.56 0.60385 0.04385 0.14600 0.22531 0.11798
10 0.52 0.59601 0.17001 0.16642
0.03336 0.10776
23 0.59 0.55800 0.32628 0.00758 0.12202
0.04681
17 0.70 0.40381 0.35512 0.12714 0.35236 0.00409
16 0.62 0.39651 0.37804 0.26274 0.18958 0.03547
20 0.40 0.08774 0.67393 0.05234
0.06238 0.23265
18 0.58 0.29395 0.57585
0.01006 0.19034 0.08147
15 0.57 0.29967 0.53047 0.04440 0.23134
0.01552
6 0.58 0.11507 0.52564 0.40443 0.12267 0.03711
7 0.55 0.14586 0.46703 0.30584
0.01699 0.27429
19 0.64 0.17227 0.43428 0.27115 0.39728
0.01199
14 0.64 0.25215 0.42942 0.26572 0.36228
0.10734
1 0.55 0.07334 0.08512 0.75885 0.10762 0.03223
4 0.64 0.07074 0.19156 0.61921 0.40002 0.02811
5 0.69 0.26961 0.37932 0.55332 0.09561 0.08239
2 0.36 0.23482
0.08203 0.53775
0.14060 0.31552
8 0.67 0.34423 0.34073 0.43996 0.16462 0.04038
22 0.63 0.21396 0.12493 0.09219 0.77469 0.02935
13 0.62 0.15177 0.03725 0.20513 0.54772 0.40077
21 0.64 0.36495 0.15438
0.02278 0.53186 0.32889
3 0.30 0.01386 0.01460 0.15972 0.15786 0.77820
9 0.40 0.12061 0.24612
0.00029 0.05145 0.73662
n
Calculated from standardized variables; Chronbach’s a¼0.93.

significant negative correlation with the Sheehan influences. The factor pattern for the scale is presented
Disability Scale (SDS) (Pearson r ¼
0.62, in Table 5.
P o.0001) in psychiatric patients (Groups 3 and 4,
n ¼ 40). Lastly, the Sheehan Social Support Scale
(SSS) correlated significantly with the CD-RISC in
SENSITIVITY TO THE EFFECTS OF
589 subjects (Spearman r ¼ ; 0.36, Po.0001). Thus,
greater resilience, as expected, is associated with less TREATMENT
disability and greater social support. In subjects with PTSD (Groups 5 and 6), non-
Discriminant validity. The CD-RISC was not responders (n ¼ 30) had mean (sd) pre and post
significantly correlated with the ASEX at baseline treatment scores of 54.0 (16.5) and 54.9 (18.8),
(Group 4, n ¼ 23; r ¼
0.34, P ¼ .11) or at endpoint respectively. Among responders (n ¼ 19), mean
(n ¼ 19; r ¼
0.30, P ¼ .21). pre- and post-treatment scores were 56.8 (18.4) and
68.9 (19.8), respectively. Significant effects were
observed for time (F ¼ 17.36; df 1, 47; Po.0001)
and for time  response category (F ¼ 12.87; df 2, 47;
FACTOR ANALYSIS P o 001), indicating that CD-RISC scores increased
Analysis of data from subjects in the general significantly with overall clinical improvement.
population sample yielded five factors whose eigenva- Greater improvement was noted in CD-RISC
lues were, respectively, 7.47, 1.56, 1.38, 1.13, and score in proportion to the degree of global clinical
1.07. These factors could be broadly interpreted in improvement. For example, in subjects with a CGI-I
the following manner. Factor 1 reflects the notion score of 1 (n ¼ 7), there was a mean increase of 19.9
of personal competence, high standards, and tenacity. (26.6%) in the CD-RISC score, compared to an
Factor 2 corresponds to trust in one’s instincts, increase of 7.9 (16.2%) for those with a CGI-I score
tolerance of negative affect, and strengthening effects of 2 (n ¼ 7), and a deterioration of 0.8 (1.3%) in those
of stress. Factor 3 relates to the positive accept- with a CGI-I of 3 or more (minimal or no improve-
ance of change, and secure relationships. Factor 4 ment; n ¼ 18) (F ¼ 3.42, df 2, Po.05). Significant
was related to control and Factor 5 to spiritual effects for time (F ¼ 14.82; df 2, 29; P ¼ .006) and for
 Research Article: Resilience Scale: (CD-RISC) 81

time  CGI group ef fect (F ¼ 7.70; df 2, 29; P ¼.002) activities or occupations. For example, resilience
were noted. (hardiness) was identified as a strong predictor of
protection from PTSD in a cohort of Vietnam veterans
[King et al., 2000]. Lyons [1991] noted a strengthening
DISCUSSION effect of extreme trauma in many trauma survivors and
The CD-RISC has been tested in the general a scale such as the CD-RISC might be useful in
population, as well as in clinical samples, and studying such individuals.
demonstrates sound psychometric properties, with The authors note several limitations of this
good internal consistency and test–retest reliability. report. The CD-RISC is a wave two resilience
The scale exhibits validity relative to other measures of measure, using the scheme outlined by Richardson
stress and hardiness, and reflects dif ferent levels of [Richardson, 2002], assessing characteristics of resi-
resilience in populations that are thought to be lience, and does not assess the resiliency process or
dif ferentiated, among other ways, by their degree of provide information about the theory of resilience.
resilience (e.g., general population vs. patients with While divergent validity was demonstrated, the mea-
anxiety disorders). Clinical improvement with even sure used to assess divergence (ASEX, a measure of
short-term pharmacotherapy in patients with PTSD, a sexual functioning) was weakly, albeit nonsignificantly,
condition with a propensity toward heightened vulner- correlated with CD-RISC and this finding most likely
ability to the effects of stress, is accompanied by up to reflects the heterogeneity of the resilience construct.
25% or greater increase in resilience, depending upon The CD-RISC has not been validated against an
level of global improvement. Furthermore, subjects objective (i.e., behavioral or third party) measure, or
with PTSD who showed very much improvement against biological measures of resilience, such as
attained CD-RISC scores close to the mean of the neuropeptide Y responses to extreme stress [Morgan
general population. To the authors’ knowledge, this et al., 1999]. The authors also recognize that it is
is the first demonstration that increased resilience, possible to perform well in one area in the face of
as operationally defined, can be associated with a adversity (e.g., work) but to function poorly in another
pharmacologic intervention. (i.e., interpersonal relationships). Would such a person
Three areas can be identified where the CD-RISC be considered resilient? Furthermore, resilience may
might be usefully applied. A number of investigators either be a determinant of response or an effect of
have considered possible biologic aspects of resilience. exposure to stress. Assessment of such directional
For example, resilience is characterized by a response factors was not undertaken in this report. A prospective
profile to major stress in which low baseline catecho- study would be able to inform whether resilience pre-
laminergic activity is transformed into high catechola- dated exposure to trauma, protected against post-
mine production, along with increased tissue-specific trauma problems, or, if through circumstances, some
response (e.g., glucose levels) and an attenuated survivors developed further resilience post-trauma.
cortisol response [Dienstbier, 1991]. Gormley [2000]
has opined that SSRI drugs may facilitate this
process in depressive, obsessive-compulsive, and panic
CONCLUSIONS
disorders but provides no actual evidence in support of The CD-RISC is a brief, self-rated measure of
his assertion. The authors have shown previously that resilience that has sound psychometric properties. By
fluoxetine has such an ef fect in PTSD [Connor et al., using the CD-RISC, the findings of this study
1999]. It is also possible that relationships exist demonstrate the following: resilience is quantifiable
between resilience and central serotonergic function and influenced by health status (i.e., individuals with
[Andrews et al., 1988; Healey and Healey, 1996]. Thus, mental illness have lower levels of resilience than the
the CD-RISC might prove useful in studies of the general population); resilience is modifiable and can
biology of resilience. improve with treatment; and greater improvement in
A second application of the scale could be in clinical resilience corresponds to higher levels of global
practice with contemporary resiliency interventions. improvement. The CD-RISC could have potential
Such interventions explore resilience qualities with utility in both clinical practice and research.
individuals, identify them, and nurture them [Rak,
2002]. In focusing on strengths and positive attributes, Acknowledgements We thank Larry Tupler and
an individual tends to become engaged in more Erik Churchill for their statistical support and Dr. George
adaptive pursuits, and their problems tend to diminish. Parkerson for facilitating access to primary care subjects.
The CD-RISC is compatible with such interventions,
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Article Not peer-reviewed version

Psychometric Properties of the

Greek Version of the Connor-

Davidson Resilience Scale (CD-

RISC-10) in a Sample of Nurses

Petros Galanis , Maria Elissavet Psomiadi , Chrysovalantis Karagkounis , P Liamopoulou ,

* *
Georgios Manomenidis , George Panayiotou , Thalia Bellali

Posted Date: 15 August 2023

doi: 10.20944/preprints202308.1080.v1

Keywords: CD-RISC; translation; Greek; validation; resilience; nurses

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Article
Psychometric Properties of the Greek Version of the
Connor- Davidson Resilience Scale (CD-RISC-10) in
a Sample of Nurses
Galanis P. 1, Psomiadi ME. 2, Karagkounis C. 3, Liamopoulou P. 4, Manomenidis G. 5,
Panayiotou G. 6 and Bellali Th. 4,7
1 Clinical Epidemiology Laboratory, Faculty of Nursing, National and Kapodistrian University of Athens, Athens, Greece
2 Directorate of Operational Preparedness for Public Health Emergencies, Greek Ministry of Health, Athens,
Greece
3 Department of Social Welfare, Education and Equality, Municipality of Katerini, Katerini, Greece
4 Department of Nursing, School of Health Sciences, International Hellenic University, Thessaloniki, Greece
5 Nursing Department (Didimoteicho Branch) International Hellenic University, Greece

6 Laboratory of Exercise, Health and Human Performance, Applied Sport Science Postgraduate Program,

Department of Life Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus
7 Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus

* Correspondence: Thalia Bellali, 6, Diogenes Str. Engomi, CY-2404, Nicosia, Cyprus thalia@[Link]; bel
lalithalia@[Link]

Abstract: Resilience has been defined as one's competence to maintain a mental health state and
overall well-being when undergoing grave stress or facing significant adversities. Numerous
resilience-investigating research tools were developed over the years, with the Connor-Davidson
Resilience Scale (CD-RISC), a self-rated tool presenting valuable psychometric properties,
remaining one of the most prominent. We aimed to translate and validate the brief CD-RISC-10 in
a convenient sample of 584 nurses in Greece's secondary and tertiary health care system. We
conducted a confirmatory factor analysis and known-groups validity and estimated the reliability
of the CD-RISC-10. Our confirmatory factor analysis revealed that the scale had a unifactorial
structure since all the model fit indices were very good. Moreover, the reliability of the CD-RISC-10
was very good since Cronbach's alpha was 0.924 and McDonald's omega was 0.925. Therefore, the
Greek version of the CD-RISC-10 confirmed the factor structure of the original one and had very
good validity and reliability.

Keywords: CD-RISC; translation; Greek; validation; resilience; nurses

1. Introduction
Resilience comprises a psychological construct developed in the last quarter of the 20th century
to encompass innate mechanisms and 'individuals’ characteristics that protect people from psychotic
disorders [1–5]. It has been defined as a dynamic capacity fostered throughout one’s life course [2,4]
via distinct mechanisms while subjected to numerous determinant factors [2,4,5]. Despite being
primarily identified as a positive personality trait in children and psychiatric patients [6,7],
nowadays, there is a consensus on the construct of resilience formulating a metatheory depicting and
rationalizing the continuous evolution of ‘one’s innate predisposition to adapt and recover from
adversities rather quickly that can be either enhanced or diminished under each respective life
circumstances [8–11].
In particular, the constructs’ origins run back to the early psychiatric literature that primarily
described it as a personality trait with a preventive effect in children under adverse circumstances
that lessened their vulnerability [6]. Later on, resilience was recognized as an integral yet regular
developmental trait with an interactive nature and the term was attributed to a dynamic character
[10]. With the prominence of positive psychology and the consequence of kinship towards

© 2023 by the author(s). Distributed under a Creative Commons CC BY license.

Preprints ([Link]) | NOT PEER-REVIEWED | Posted: 15 August 2023 doi:10.20944/preprints202308.1080.v1

strengthening competencies instead of targeting flaws and limitations [12], resilience was
acknowledged as the determining factor of one’s well-being regardless of whether a person suffers
from a psychiatric disease [12].
Even though there is no concrete definition of resilience, it has been recognized as this multitude
of behaviours, thoughts, and actions [13,14] that enable individuals to retain a sense of coherence
under distress, consequently leading them to adopt and manifest efficient coping skills, to maintain
their composure under challenging circumstances they perceive as manageable and yet meaningful
[15–18]. Pan-human contextual qualities have also been ascribed to it and thus regarded as the
capability related to self-regulation and socially appropriate demeanours within the socio-culture
construct of communities [13,19].
Over the last four decades, research in the field has highlighted that resilience forms a
multifaceted quality that, due to its dynamic core, varies significantly over time depending on the
concurrent circumstances, one’s age, gender, ethnicity, and cultural background [7,20–23]. Resilience
has been found to correlate positively with physical and mental well-being, self-efficacy, gratitude,
and optimism while negatively with depression, post-traumatic stress disorder (PTSD) and
generalized anxiety disorder [24–29].
A theory developed to elaborate more on this ever-changing nature of resilience was the one by
Richardson and colleagues, suggesting that one’s resilience capacity at a time is the sole outcome of
his “biopsychospiritual homeostasis” processes- competence of fully adapting his/her body, spirit,
and mind in the circumstances he/she is under at this point, despite any stressors, given his
determined coping abilities, constructive or not. This outcome which might be positive or negative,
can be manifested as a higher homeostasis level, i.e., an opportunity for personal growth, a comeback
to his baseline homeostasis levels, a lower homeostasis level, or a problematic state full of
dysfunctional coping mechanisms and self-destructive behaviours [7].
It has been suggested that resilient persons come across as more adaptive, especially within
social settings that require an essential sense of morale [30], as they appear to be experiencing more
positive emotions despite the adverse circumstances and challenges they may face [29]. That is why
personality facets such as hope have been found to enhance the sense of self-efficacy, leading
individuals to deploy more efficient and effective adaptive behaviours [7]. Furthermore, mutual
support within groups has been positively associated with one’s mental health [31], reinforcing
coping abilities [31]. Therefore, resilience was recognized as a mental health index measuring one’s
coping capacity. Besides recognizing hardiness, a protective factor against developing trauma and
PTSD, resilience has been centrefold for health promotion and well-being in recent years [23].
In the early 90s, Wagnild and Young developed the 25-item Resilience Scale [30] to explore
resilience in adolescent populations; a research tool deemed suitable for adult resilience assessment
as validated via its deployment in numerous studies [32–38]. The 25-item scale depicted resilience’s
five primary components: Equanimity, perseverance, self-reliance, meaningfulness, and existential
aloneness [32], while an abridged 14-item scale, with significant psychometric properties translated
to numerous languages [12,36], has been formulated from the original one to encompass stress-
related protective factors that result in better-coping outcomes [32]. From the validation processes
across different populations, it was suggested that scoring in the Resilience Scale was positively
correlated with age due to the construct’s dynamic character, whereas no statistically significant
correlation with gender was identified [12]. Many relevant scales have been established, with the
Resilience Attitudes and Skills Profile, the Resilience Scale for Adults, and the Brief Resilience Scale
[34–37] being among them.
However, one of the most prominent remains the Connor-Davidson Resilience Scale [39], a brief,
25-item self-rated resilience tool with valuable psychometric properties [39]. The CD-RISC is
synthesized by 25 affirmations answered via a 5-item Likert scale where “0” equals to “not true at
all” and “4” to “true nearly all of the time”. The basis for rating lies in the frequency with which one
experiences what the affirmations describe hence total scoring ranging from 0 to 100, and the highest
ones reflecting greater resilience [39]. Its preliminary analyses in differing samples from the general
population, psychiatric inpatients, primary healthcare, and clinical trials established reference values
Preprints ([Link]) | NOT PEER-REVIEWED | Posted: 15 August 2023 doi:10.20944/preprints202308.1080.v1

for being or not resilient. In particular, for the general population, the exploratory factor analysis
resulted in highlighting the constructs of “personal competence, high standards and tenacity”, “trust
in one’s instincts, tolerance of negative affect, and strengthening effect of stress”, “positive acceptance
of change and secure relationships”, “control”, and “spirituality” [39].
In a recent study among 744 critical care nurses, the factor structure of the CD-RISC abridged
version was intended to be established while further validating it by analyzing its construct validity
[40]. The factors identified were “personal competence”, “perseverance”, and “leadership”, all
portraying successful examples of coping mechanisms adopted by nurses to overcome the stressors
of the Intensive Care Unit (ICU) environment, with eigenvalues>1.0 and an explained variance of
59%. In addition, in this study, it was found that CD-RISC can differentiate between nurses that cope
well after having experienced a traumatic event and those who do not, noting that those nurses that
met the PTSD diagnostic criteria presented as less resilient [40].
Additionally, in a study assessing participants’ levels of resilience while identifying associating
personal factors and physical activity behaviours, the interrelation between resilience and physical
activity emerged [41]. Through the CD-RISC deployment in a sample of 93 New Zealand ICU nurses,
resilience was found to be correlated positively with physical job demanding factors, including
occupational physical demands, physical activity level, moderate to vigorous occupational physical
activity engagement, and dynamic standing at work, highlighting that resilient nurses present greater
tolerance to high physical work stress [42].
The 25-item CD-RISC was applied in a 2020 study exploring social support, resilience, and
mental health associations in 1521 Chinese healthcare professionals following the COVID-19
pandemic outbreak [43]. Personnel with less overall experience or lesser crisis management
experience appeared less resilient, with significantly lower scores on the scale compared to the more
experienced ones in tenacity, strength, and optimism. Resilience, especially in tenacity and strength,
was also a predictive factor for novel personnel’s mental health status amid adversities [44]. A
corresponding study on 114 healthcare professionals sent to the Hubei area to support the regional
health system’s operation identified occupation, education, and mental health training as resilience-
determining factors [45]. Doctors, bachelor holders, and those who spent extended time on mental
health training appeared more resilient, while resilience positively correlated to active coping and
training [45]. In another study among 52 critical care professionals with the 10-item CD-RISC [44],
resilience was found to be positively correlated to mental health, all the while casting a mediating
role to the three burnout dimensions “emotional exhaustion”, “depersonalization”, and “personal
accomplishment”. A mix-methods approach was adopted to estimate healthcare professionals’
distress and resilience status during the COVID-19 pandemic to study crucial resilience metatheory
parameters [46].
This study aimed to translate into Greek and validate the psychometric properties of the CD-
RISC-10 and investigate the resilience levels among a convenience sample of nurses currently
working in the Greek public healthcare system.

2. Materials and Methods

2.1. Sample and data collection

A convenient sample of 584 male and female nurses (response rate 89.3%), recruited from 10
Greek public general hospitals of secondary and tertiary health care system, participated in this cross-
sectional study from September to December 2022. The study description was uploaded to the
hospitals’ official web page with the invitation to participate, while printed wall announcements were
also placed in all hospital departments. Following the participants’ briefing about the research
procedures and the voluntary and anonymous nature of their participation throughout all the study
stages, all subjects gave their informed consent for inclusion before participating. The study was
conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the
Ethics Committee of the Faculty of Nursing, National and Kapodistrian University of Athens
(reference number; 417, September 2022).
Preprints ([Link]) | NOT PEER-REVIEWED | Posted: 15 August 2023 doi:10.20944/preprints202308.1080.v1

2.2. Measures
The Connor- Davidson Resilience Scale (CD-RISC-10)
The Greek CD-RISC version consists of 10 affirmations describing different aspects of resilience
corresponding to flexibility, self-efficacy, emotion regulation, optimism, and cognitive
focus/maintaining attention under stress. Each affirmation is assigned to a 5-item Likert scale ranging
from 0 “not true” to 4 “true nearly all time”. Overall score can range from 0 to 40, with higher scores
indicating greater resilience. The respondent is asked to provide his/her answer based on his/her
experiences over the previous 30 days, whether those affirmations are true for him/her and to what
extent.
The license to adapt CD-RISC was granted by its developers following dedicated electronic
communication. Translation to Greek was performed following the proposed procedure for
intercultural adaptation of self-reference questionnaires [47]. Two independent, experienced
researchers fluent in English translated the questionnaire into Greek. Consequently, the two texts
were compared question by question until a consensus was reached. The revised text of the resulting
Greek version was translated into English by two bilingual researchers who compared their
translations for inconsistencies. The final text was compared with the original English scale text to
confirm its linguistic accuracy. The cognitive debriefing process involved pre-testing the translated
questionnaire in a few nurses to identify linguistic issues and adequate translation alternatives while
assessing participants’ comprehension of the questions included. Due to COVID-19 restrictions, an
electronic questionnaire was constructed using Google Forms with approximately 10-15 minutes of
completion time.

2.3. Data analysis

Mean (x̄), standard deviation (SD), median, minimum value and maximum values are used to
describe continuous variables, and numbers (percentages) to describe categorical variables.
We conducted confirmatory factor analysis (CFA) to confirm the unifactorial structure of the
Greek version of CD-RISC-10. The scale followed the normal distribution; thus, we used the
maximum likelihood estimator. We checked the goodness of fit indices in CFA by measuring the
following: chi-square/degree of freedom (x2/df); root mean square error of approximation (RMSEA);
goodness of fit index (GFI); adjusted goodness of fit index (AGFI); Tucker–Lewis index (TLI);
incremental fit index (IFI); normed fit index (NFI); comparative fit index (CFI). The acceptable value
for x2/df is less than 5, for RMSEA is less than 0.10, and for all other indices higher than 0.90 [48–51].
Additionally, we calculated standardized regression weights between the 10 items and the one factor.
We used AMOS version 21 (Amos Development Corporation, 2018) to conduct CFA.
Additionally, we estimated the known-groups validity of the CD-RISC-10. In that case, we
assessed the relationship between nurses’ demographic and job characteristics and the total score on
CD-RISC-10. We used Pearson’s correlation coefficient to assess the correlation between age and CD-
RISC-10 score, Spearman’s correlation coefficient to assess the correlation between experience and
CD-RISC-10 score, and independent samples t-test to assess the relationship between gender, marital
status, children, job position, and educational level and CD-RISC-10 score. P-values less than 0.05
were considered statistically significant. We used IBM SPSS 21.0 (IBM Corp. Released 2012. IBM SPSS
Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) to perform the analysis.
Finally, we estimated the reliability of the CD-RISC-10 by calculating the following: Cronbach’s
alpha, McDonald’s Omega, corrected item-total correlations, and Cronbach’s alpha when a single
item was deleted for the ten items of the CD-RISC-10. Cronbach’s alpha and McDonald’s Omega
values higher than 0.7 are considered acceptable [52].

3. Results
Respondents included 584 registered nurses. The mean age was 45.8 years (SD: 6.4), ranging
from 23 to 65. Among our sample, 51.7% were females, and 48.3% were males. Most nurses were
married (86.7%), and more than half had children (58.6%). Most nurses have been working in internal
Preprints ([Link]) | NOT PEER-REVIEWED | Posted: 15 August 2023 doi:10.20944/preprints202308.1080.v1

departments (71.2%). One out of two nurses possessed an MSc/PhD diploma (52.5%). Mean years of
work experience were 14.1 (SD: 9.8), ranging from 1 to 31. The demographic and job characteristics
of the sample are shown in Table 1.

Table 1. Demographic and job characteristics of the sample

Characteristics n %

Gender
Males 282 48.3*
Females 301 51.5*
Age 45.8a 6.4b
Habitational status
Leaving alone 78 13.4
Leaving with Family/Partner/Spouce 506 86.6
Children
No 157 19.5*
Yes 424 58.6*
Job Position
Internal departments 447 76.5
ICU 137 22.5
MSc/PhD
No 277 47.4
Yes 307 52.6
Clinical experience 14.1a 9.8b
a mean. b standard deviation. * The deviation from the sum to 100% is caused by missing values

Descriptive statistics for the CD-RISC-10 are shown in Table 2. The mean score for the CD-RISC-
10 was 22.6 (SD: 8.0). The minimum and maximum score was 1 and 40, respectively.

Table 2. Descriptive statistics for the CD-RISC-10.

Mean Standard Median Minimum Maximum

CD-RISC-10 items
Deviation Value Value

Adapt to change 2.57 0.98 3 0 4

Deal with whatever comes my way 2.29 1.00 2 0 4
See humorous side of things 1.79 1.24 2 0 4
Stress makes me stronger 1.99 1.19 2 0 4
Bounce back after illness or injury 2.25 1.15 2 0 4
Believe I can achieve goals despite obstacles 2.44 0.97 2 0 4
Under pressure, I stay focused 2.33 0.92 2 0 4
Not easily discouraged by failure 2.06 0.99 2 0 4
Think of myself as a strong person when facing challenges 2.68 0.88 0.88 0 4
Able to handle unpleasant feelings 2.24 0.97 2 0 4

CFA for the CD-RISC-10 is shown in Figure 1. The fit indices of the model were very good: x2/df
= 4.662, RMSEA = 0.079, GFI = 0.951, AGFI = 0.905, TLI = 0.955, IFI = 0.972, NFI = 0.965, and CFI =
Preprints ([Link]) | NOT PEER-REVIEWED | Posted: 15 August 2023 doi:10.20944/preprints202308.1080.v1

0.972. Moreover, the standardized regression weights between the 10 items and the one factor ranged
from 0.670 to 0.810 (p < 0.001 in all cases). Therefore, the Greek version of the CD-RISC-10 confirmed
the factor structure of the original one.

Figure 1. Confirmatory factor analysis for the CD-RISC-10.

Cronbach’s alpha for the CD-RISC-10 was 0.924, and McDonald’s omega was 0.925 indicating
excellent reliability. Similarly, Cronbach’s alpha for the scale decreased if any item was deleted (Table
3). Additionally, corrected item-total correlation coefficients ranged from 0.636 to 0.776 (p-value <
0.001 in all items), indicating very good reliability (Table 3).

Table 3. Cronbach’s alpha when a single item was deleted and corrected item-total correlation
coefficient.
Cronbach’s alpha when a Corrected item-total
CD-RISC-10
single item was deleted correlation coefficient
Adapt to change 0.915 0.728

Deal with whatever comes my way 0.914 0.755

See humorous side of things 0.922 0.636

Stress makes me stronger 0.915 0.734

Bounce back after illness or injury 0.913 0.759

Believe I can achieve goals despite obstacles 0.913 0.776

Preprints ([Link]) | NOT PEER-REVIEWED | Posted: 15 August 2023 doi:10.20944/preprints202308.1080.v1

Under pressure, I stay focused 0.916 0.721

Not easily discouraged by failure 0.920 0.637

Think of myself as a strong person when
0.920 0.637
facing challenges
Able to handle unpleasant feelings 0.913 0.758

Known-groups validity of the CD-RISC-10 is shown in Table 4. We found that nurses with
children had higher levels of resilience (p<0.001). In particular, mean CD-RISC-10 score for nurses
with children was 23.6 and for those without children was 20.6. Also, we found that higher
educational level was associated with resilience since mean CD-RISC-10 score for nurses with
PhD/MSc was 23.8 and for those without PhD/MSc was 22.2 (p=0.02). Females’ resilience was higher
than males (23.2 vs. 22.1) but this relationship was not statistically significant (p=0.01).

Table 4. Known-groups validity of the CD-RISC-10.

Characteristics Mean CD-RISC-10 score Standard deviation P-value

Gender 0.11a

Males 22.1 7.9

Females 23.2 8.1

Age 0.03b 0.50b

Marital status 0.44a

Singles/divorced/widows 24.0 8.1

Married 23.0 7.8

Children <0.001a

No 20.6 7.4

Yes 23.6 8.0

Job Position 0.46

Internal departments 22.5 7.9

ICU 23.1 8.2

PhD/MSc 0.02a

No 22.2 8.2

Yes 23.8 7.5

Clinical experience 0.03c 0.50c

a independent samples t-test. b Pearson’s correlation coefficient. c Spearman’s correlation coefficient

4. Discussion
Our study aimed to translate into Greek the CD-RISC-10 scale while validating its psychometric
properties and exploring the levels of resilience among nurses currently working in the Greek public
healthcare system. In total, 584 nurses from 10 distinct public hospitals of secondary and tertiary
health care, 51.5% of whom were females and 48.3% males, with a mean age of 45.8±6.4 years;
corresponding demographic characteristics have been previously recorded for the Greek general
population [53]. Most of the nurses in the study were leaving with family/partner/spouce (89.6%) and
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had children (58.6%), while 3 out of 4 worked in internal departments. Across the study sample, mean
work experience was estimated at 14.1±9.8 years, ranging between 1 and 31 total work experience in
years.
According to participants’ answers, the affirmations with the highest mean score were “think of
myself as a strong person when facing challenges” (M=2.68, SD=0.88), “adapt to change” (M=2.57,
S.D.=0.98), “believe I can achieve goals despite obstacles” (M=2.44, SD=0.97) and “under pressure, I
stay focused” (M=2.33, SD=0.92). On the contrary, participants score the lowest on the affirmations
“see humorous side of things” (M=1.79, SD=1.00), “stress makes me stronger” (M=1.99, SD=1.19), and
“not easily discouraged by failure” (M=2.06, SD=0.99). The mean total score on the scale was 22.6 (SD:
8.0), with a minimum and maximum of 1 and 40, respectively, indicating average levels of resilience
among the study participants. From the respective scores in the scale’s items could be assumed that
the nurses working within the Greek public healthcare system hospitals tend to adapt to adverse
circumstances, challenges, and stressors, even though having not fully developed their resilience
competencies or adequate coping capacities.
The Confirmatory Factor Analysis resulted in deeming the tool highly reliable as Cronbach’s
alpha for the translated scale was estimated at 0.924 and McDonald’s omega at 0.925, while corrected
item-total correlation coefficients ranged from 0.636 to 0.776 (p-value < 0.001 in all items). Its sound
psychometric properties have been highlighted from the primary scale’s validating studies. Among
CD-RISC’s strengths as highly important have as well been acknowledged its potency to explore and
depict different levels of resilience across population groups that are characterized by their
differentiated degree of resilience, i.e., psychiatric patients and the general population, or adolescents
and adults, as well as its unwavering psychometric properties [39–44]. Our methods and analysis
approach agree with a suggestion that recently emerged in the literature claiming that besides CD-
RISC being the most widely applied unidimensional resilience scale, it is important to assess its factor
structure, reliability, discriminant, and predictive validity each and every time that the tool will be
deployed within a novel context [54].
From the correlations among participants’ demographics and professional characteristics with
the CD-RISC-10 score, statistically significant relations emerged between holding a PhD/MSc, having
children and resilience. In particular, nurses holding a PhD/MSc appeared to have higher levels of
resilience as their score on the CD-RISC-10 scale was 23.8, whereas those without a PhD/MSc scored
22.2 (p=0.02). This finding is consistent with a recent study where resilience was correlated positively
with educational level, on-the-job and continuous training [45]. Contrary to previous findings that
supported the positive association between work experience and resilience [43,45], in our study,
neither job position (p=0.46) nor work experience (p=0.50) were found to have a statistically
significant effect. Furthermore, in our sample, nurses with children presented with higher levels of
resilience (p<0.001) as their mean score on the scale were 23.6, while those without children 20.6.
Similarly, this finding was also observed in the study by Afshari et al. [59]. One possible explanation
for this finding could be that having children and worrying about the self and their children about
getting infected with COVID-19 have been among the factors contributing to anxiety and stress in
nurses, which may play an important role in reducing nurses’ resilience.
Concerning gender, in our sample, female nurses appeared more resilient than males (23.2 vs.
22.1), a relationship that was not statistically significant (p=0.01). Similar findings over the years have
emphasized that despite the differences in scoring in the CD-RISC scales between males and females,
gender does not affect one’s levels of resilience, as no statistically significant relations have been
identified in corresponding studies (i.e., focusing on adult nurses, adult healthcare professionals) [39–
44]. Interestingly, a study in healthcare professionals amid the challenges and adversities they faced
when combating the COVID-19 pandemic concluded that neither gender nor age impact resilience
capacity[55]. Our findings agree with that, as no statistically significant association was found
between participants’ age and scoring on the scale.
Notwithstanding, this study is characterized by a few limitations and strengths. The
convenience sampling method adopted for this survey might entail potential selection bias. However,
the study sample exhibits analogous demographics and gender distribution to the recorded ones for
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the Greek general population [53], affecting the tool’s psychometric evaluation slightly, if none at all,
given women’s predominant role in the nursing profession [56]. Additionally, the source
population’s demographic and professional characteristics of the hospitals participating in the study
remain unknown, impeding us from comparing the study sample with the source population. A
significant strength of the study is that it offers a reliable tool that its use in future research could
provide a deeper understanding of factors that determine resilience, especially in heavily burdened
professional groups such as nursing personnel.
Nowadays, healthcare professionals significantly struggle as many stressors impact them, apart
from their personal lives and their professionals. Occupational ones, including time constraints,
scheduling, burdened workloads, spiritual and ethical distress, uncertainty, and a sense of
cancellation, trigger negative emotional and behavioural responses to the suffering of patients they
care for [42]. Healthcare professionals, especially nurses in closed departments, are predominantly
exposed to grave stressors, as indicated by the high prevalence of burnout syndrome [40], a secondary
indicator of their challenged mental health and consequently reduced resilience capacity. Given this
predicament, additional studies in the field are required to explore their levels of resilience and
provide a better understanding of the factors that primarily affect it.
With researchers’ interest being progressively more focused on exploring healthcare
professionals coping mechanisms and resilience potential, different studies deploy the CD-RISC to
address them, all the while translations and cultural adaptations of validated scales [57], such as CD-
RISC, are imperative for the facilitated administration of potent research tools across more
populations, to identify as well individuals’ psychosocial deficits and mental health needs [53].To
this end, future studies are important to explore the potential role of biological factors (e.g.,
catecholamines) in determining one’s resilience capacity over and above the implementation of
behavioural interventions, such as physical activities and exercise, that preliminary evidence
suggests [39].
The importance of investigating healthcare professional’s resilience with a scale as the CD-RISC
lies with the scale’s main properties, which, apart from remaining unchanged independently of the
scale’s length and cultural adaptations, facilitates the identification of factors that may enhance or
hinder it, all the while indicating adequate strategies for improving one’s coping skills [54].
Investigating healthcare professional’s resilience through the CD-RISC in different populations while
investigating additional contributing parameters would assist in ascertaining any potentially
contributing factors to burnout and adverse outcomes creating a series of implications leading to
changing the organizational culture of healthcare organizations and even encourage the adoption of
human resource management resilience dedicated policies [58].

5. Conclusions
The Greek version of the CD-RISC-10 confirmed the factor structure of the original one and
validated its prominent psychometric properties. The CD-RISC-10 Greek version showed great
validity and reliability, a highly suitable tool for investigating the Greek population's resilience
capacity. The mean total score on the scale indicates average resilience levels among the study
participants. We found that while age and gender do not affect one’s resilience competence, having
children and/or a higher educational level (i.e., holding an MSc/PhD degree) do so. Future studies
should involve other healthcare professionals as well while focusing on obtaining a robust tool
suitable for assessing levels of resilience among professionals in the field and exploring the impact of
biological parameters and behavioural interventions, such as sleep patterns, nutritional habits, and
physical activity/ exercise participation etc. might pose.

Author Contributions: Conceptualization, Bellali, Th.; Methodology and formal analysis, Galanis, P.; Writing
original draft preparation, Psomiadi, M.E.; Writing, review and editing, Karagkounis, C., Psomiadi, M.E.,
Manomenidis, G, Liamopoulou, E., Bellali, Th. Panayiotou, G., Galanis, P.; Supervision, Bellali, Th., Galanis, P.
and Panayiotou, G. All authors have read and agreed to the published version of the manuscript.
Funding: Please add: This research received no external funding.
Preprints ([Link]) | NOT PEER-REVIEWED | Posted: 15 August 2023 doi:10.20944/preprints202308.1080.v1

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Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Conflicts of Interest: The authors declare no conflict of interest.

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