Original Article

Yonago Acta medica 2016;59:196–203

Qualitative Analysis of the Resilience of Adult Japanese Patients with Type 1
Diabetes
Ikuko Nishio and Masami Chujo

Department of Adult and Elderly Nursing, School of Health Science, Tottori University Faculty of Medicine, Yonago 683-8503, Japan

ABSTRACTType 1 diabetes (T1D) is a disease characterized by
deficient insulin production and it requires daily insulin
administration.1 Patients with T1D require lifelong selfcare, including daily management of their blood glucose
levels to maintain their health and prevent future complications. Patients with T1D must suitably modify their
behavior after diagnosis, and it is important that theylearn to self-manage their condition.
Good self-managers have been defined as individuals who have learned the skills to cope with their illness,know how to continue with their daily activities, and canregulate their ever-changing emotions related to theirchronic illness.2 For patients with T1D, self-management can be difficult because they experience physical,
emotional, and social distress, and often need to communicate this to co-workers and supporters. Notably,
however, while some T1D patients who face such distress struggle to manage it, others excel in doing so. Thisphenomenon is evident across the academic, social, anddevelopmental domains. Those who excel in dealing
with distress related to their disease are considered “resilient,” and these individuals are the focus of the present
study. Resilience has been studied both domestically andinternationally, and many studies of it have been considered to support “positive health” approaches. Thus, it
is important to promote knowledge of resilience among
both the research and lay populations.
Previous studies of patients with T1D have focusedon the negative psychological aspects of their disease,such as anxiety, depressive symptoms, or feelings ofstruggle.3–6 Therefore, we focused on a positive aspect—
namely, their resilience. Resilience has been defined as
the capacity to deal with, overcome, learn from, or betransformed by life’s inevitable adversities.7–10 Resilient
youths overcome challenges expected to derail themfrom their expected progress and demonstrate competence at or above common levels of functioning.11–13
People with chronic diseases often talk about how theirdiagnosis helped them to recognize their own resilience;that is, they felt able to tap into sources of strength andto be resourceful in ways that they had never thoughtpossible. At the same time, one of life’s “curveballs,” ora series of curveballs, can leave anyone feeling depleted.
Hilliard and Harris (2012)11 performed a study of re-

Background Resilience strategies are what we use to
avoid and recover from error. In this study, we used thegrounded theory approach to evaluate the resilience ofJapanese patients with Type 1 diabetes.
Methods Semi-structured interviews were conducted with 15 adults with Type 1 diabetes. Then, using
grounded theory, we created a new model of resiliencein this population.
Results The results suggested a core category, “tomake progress along the resilience path,” comprising
seven concepts classified into three stages. These sevenconcepts were as follows: “suffering from treatment,”“damaged trust as a person,” “persistence of afflictions,”“awareness of supporters,” “joy to be kept alive by insulin,” “actively seeking a future,” “being able to manage by oneself.” Individuals with Type 1 diabetes useddifficult experiences to motivate their resilience and to
improve their situation. Additionally, resilience was animportant contributor to these individuals’ beliefs intheir ability to face difficulties, to accept their illness
and insulin therapy, and to control their illness. Resilience was also important to these individuals’ faith in
the future and in medical care. Our results are applicable
to clinical care and research, such as the development ofpreventive interventions aimed at building or strengthening protective skills related to diabetes and its management.
Conclusion Ultimately, our goal is to equip adults
with Type 1 diabetes with the tools to obtain sufficient
behavioral and health-related resilience. Furthermore,these results highlight that maintaining resilience-related coping skills is important for adults and indicatethat different psychological processes underlie resilience
across the lifespan.
Key words

adult; comparative analysis; grounded theory; resilience; type 1 diabetes

Corresponding author: Ikuko Nishio, RN, PhD
ikurin@med.tottori-u.ac.jp
Received 2016 June 8
Accepted 2016 July 6
Abbreviation: T1D, type 1 diabetes

196

Resilience of adult Japanese T1D patientssilience theory regarding T1D management and control,
wherein they constructed a theoretical model of pediatric (i.e., adolescent) T1D resilience. However, very little
qualitative research is available of the resilience of people diagnosed with T1D, and none of it was conducted inJapan.
The aim was to clarify the process of resilience inadult Japanese patients with T1D and to devise a modelof resilience in this population.

the interview at any time they wished and could refuse
to answer any unwanted questions. Pseudonyms wereallocated to all the patients to ensure confidentiality andall data were stored securely during the research process.
Data collection

Data were collected from 15 patients with T1D between
July 2013 and March 2014 via in-depth semi-structured
interviews that took place in the clinic waiting rooms.
The author conducted all interviews using a standardized interview schedule.
Participants were asked to share their experiences,since being diagnosed, of coping with self-managementand diabetes control issues, the meaning of living withdiabetes, and their support from family and friends. The
participants were initially informed of the topics andthen were asked to freely reflect on and discuss theirexperiences of living with T1D. Follow-up questions
were posed to obtain more detailed descriptions or explanations. The interviews (which each lasted for 60–75
minutes) were audio-recorded, transcribed verbatim, andstored for analysis. Data collection was stopped when
we reached saturation—namely, when no new findingsor themes were extracted from newly collected data.

MATERIALS AND METHODS
DesignTo ascertain a model of the resilience process in adults
with T1D, we used the grounded theory method.14, 15
This method was used because it focuses on exploringprocesses and generating new understanding of theseprocesses from available data.14, 15 It was suitable because it allowed us to use the participants’ own words tounderstand the effects of a T1D diagnosis on the meaning of resilience.
Participants

Inclusion criteria were being a Japanese speaker with
T1D and being aged 20 years or over. All participants
resided in Tottori Prefecture, Japan and were recruitedfrom two diabetes outpatient clinics that specificallyserved adults with T1D. All patients were recruited fromthe short-term wards (i.e., wards for short-term care) inthese clinics. Approximately 5% of patients who visit
these wards have a diagnosis of T1D with hypoglycemia
or hyperglycemia symptoms, and nurses in these wards
provide self-care management and group therapy withthe goal of discharge. We recruited 15 individuals with
T1D who were recommended by health professionals,
and whose reactions, behaviors, and facial expressions
we had observed before conducting the study. Sampling
was then used to continue recruitment until data saturation occurred. Sampling involved having participants
recommend other participants to join the study because
it was difficult to identify appropriate and willing participants. Details of the study were explained to all clinic
patients, after which they were invited to participate; interested patients who agreed to participate contacted theresearchers for further information.

Data analysis

In grounded theory, data analysis follows a constantcomparative method of simultaneous interviewing, transcribing, and analysis until data saturation occurs.14-15
Constant comparison methods involve concurrently
asking questions, creating memos and diagrammaticrecords, and reading literature from data collectioncommencement until achievement of theoretical saturation.14–15 Before coding each interview, the first author
listened to the interview tape several times and read thetyped transcripts through completely. This ensured a fullunderstanding of the raw data. The verbatim translations
were then coded and analyzed in the same way as theinterview transcripts. All transcripts were translated into
English and subjected to the same coding and analysis
process as the Japanese interview transcripts were. The
results did not differ from the Japanese language analysis. The next step was line-by-line in vivo coding. The
codes were then compared according to their differences
and similarities and sorted into categories and subcategories. Subsequently, we identified the linkages among
these categories and subcategories.
Finally, the core category was identified, whichallowed us to build a new resilience model for T1D(Fig. 1). In other words, the core category—namely, thecategory to which all other subcategories are related—

Ethical considerations

This study was approved by the ethics committee of
Tottori University (Record Number 2307, January 2013).
Informed consent was obtained from all patients using
the procedure approved by the ethics committee, and theconfidentiality of the participants’ information was protected. Furthermore, they were told that they could stop197

I. Nishio and M. Chujo

To make progress along the resilience path
Ad ap ti ve co nv ictio ns
Being able to manage by oneself

3 rd Stage
Actively seeking a furture

Co nfi d enc e in th e situatio n
Joy to be kept alive by insulin

2 nd Stage
Awareness of supporters	 Persistence of afflictions

1 st Stage

Damaged trust as apersonSuffering fromtreatment

Im p ose d p o we rle ssne ss

Fig. 1. A model of resilience among adult Japanese patients with type 1 diabetes.

Fig. 1. A model of resilience among adult Japanese patients with type 1 diabetes.
was named and used to build a conceptual framework of
RESULTS
resilience in adult T1D patients. The core category was
Table 1 shows the study participants’ basic attributes.
established upon completion of the 15th interview; thisTable 2 shows an outline of the concepts, subcategories,
was confirmed in later interviews with participants who
categories, and core category. The core category idenwere interested in discussing the research, during which
tified was “to make progress along the resilience path,”
we explained the categories and subcategories to them.
which comprised three categories: “imposed powerData analysis was undertaken using the QSR NVivo 10
lessness,” “confidence in the situation,” and “adaptive
software (QSR International, Melbourne, Australia).
convictions.” These categories, in turn, comprised seven
198

Resilience of adult Japanese T1D patientsconcepts in three stages related to participants’ attempts
to reduce stress and develop resilience in the face ofadverse experiences from T1D. The concepts were as
follows: “suffering from treatment,” “damaged trust as aperson,” “persistence of afflictions,” “awareness of supporters,” “joy to be kept alive by insulin,” “actively seeking a future,” and “being able to manage by oneself.”
Figure 1 shows the model of T1D resilience comprising“to make progress along the resilience path” and concepts related to it. The aforementioned processes formed
three stages of coping with T1D.

Table 1. Demographic characteristic of the 15 study
participants with type 1 diabetes
Participant characteristics
GenderFemaleMale
Employment status
Full time
Part time
UnemployedAge groups (years old)
20–30
31–40
41–50
51–60
> 60
Time living with Type 1 diabetes (years)
<5
6–10
11–20
> 21
Living
Alone
Cohabiting†HbA1c (NGSP) (%)
Insulin therapy
MDI
CSII

First stage: imposed powerlessness (sufferingfrom treatment, damaged trust as a person, persistence of afflictions)This first stage comprised three concepts describing
how patients with T1D had strong negative feelings
about their disease because of their numerous exhausting experiences related to it. However, they had no otherchoice but to endure these negative feelings, which gavethem additional inner strength and led to the “resiliencepath.”
Suffering from treatment

This concept reflected participants’ experiences such as“troubles related to injections,” “not correctly adjusting
the insulin dose,” and “being unable to explain one’s
suffering from hypoglycemia.” Participants were highly
aware of the “presence of visible injection sites,” which
for them reinforced the notion that there is no cure for
their lifelong disease. Furthermore, although patientswith T1D understood that they had to continue with insulin therapy for the rest of their lives, they experienced
a “resistance to injections”:“I just hated injections. I didn’t like that I had to take abreak from work to inject in the restroom.” (Participant
B)“Adjusting my insulin dose according to the volume I eat
is a little stressful. The pain of injecting [insulin] hasn’t
been a problem. I worry [instead] about the numbers[blood sugar levels] and about messing up the dose because I don’t quite know how to adjust it.” (Participant K)“My job kept me so busy that I had no time for it [the insulin injection]. I didn’t even have time to eat. Therefore,
results were always bad on my regular [clinic] visits. I
couldn’t do anything about it. It became a kind of dilemma for many years. I was sometimes reluctant to go to
the clinic knowing that I would be told something bad [bythe doctor] or get scolded again.” (Participant J)

n
13
2
7
3
5
1
7
3
2
2
8
6
0
1
6
9
5.3–9.0 (7.1 ± 1.1)
12
3

†glycated hemoglobin.
CSII, continuous subcutaneous insulin infusion; MDI, multiple
daily injection; NGSP, National Glycohemoglobin Standardization
Program.

closing their feelings to others because others reacted
poorly to the participant’s disclosures. This led to participants’ trust being unconsciously damaged around others and shutting them out. Often, participants reported
feeling emotionally unstable for a number of reasons:“caregivers worry too much” and “others have biased
attitudes.” Participants had to cope with “not working
because of sickness,” which caused them to feel socially isolated from others. Notably, some disclosed theirprivate experiences about coping with T1D to membersof patient-support programs and received considerable
sympathy by having done so.
Participants were highly aware of their worsening
relationships with others because of others’ insensitive
words and behaviors. Furthermore, they experienced a“distorted view of character building” when others suddenly softened their attitudes toward them:“People built a wall around me. They treated me likea sick person. They felt they should not invite me out.

Damaged trust as a person

Some participants had negative experiences when dis199

I. Nishio and M. Chujo
Table 2. Outline of the concepts, subcategories, categories and core category
Core Category

Category

Imposedpowerlessness

To make progressalong the resiliencepath
Confidence
in the situation

Adaptive
convictions

Concept

Codes

Resistance to injections
Troubles related to injections
Suffering from treatment
Presence of visible injection sites
Not correctly adjusting the insulin dose
Being unable to explain one’s suffering from hypoglycemia
Distorted view of character building
Not working because of sickness
Damaged trust as a person
Caregiver worry too much
Others have biased attitudes
Unable to avoid giving injections
Not talking about sickness
Persistence of afflictions
Resignation to absence of cureMarginal physical ability
Presence of famous people
Encouragement from other diabetics
Awareness of supporters
Care from family
Cooperation with co-workers
Joy to be kept alive by insulin
Escaped death thanks to insulin
Advantage of experience
Actively seeking a future
Control of their situation
Realizing that this situation isn’t uncommon
Living a normal life
Attitude of self-relianceBeing able to manage by oneself Creation of new lifestyle
Realization of gain from disease
Hope for a fresh start

They asked me if I could eat this and that and I would
say, “Yes, of course!” (Participant D)“When I first developed symptoms of T1D, I told people[around me] about it. But, I gradually shut down because
people said things that hurt my feelings when I mentioned the disease. I have learned to hide my condition
ever since.” (Participant O)“I didn’t like it when people treated me like an invalid
just because I had this condition. They said things like“Don’t you have to get an [insulin] injection?” or “Areyou okay?” over and over again.” (Participant E)“I was told by my boss that I could not be a caregiverbecause my body required care. I basically got fired.”(Participant B)

This led to embarrassment and feelings of despair due
to “not talking about their sickness.” Furthermore, participants had to cope with absence due to sickness andnot working, which caused them to feel socially isolated
from others. They reported being deeply hurt by others’
careless behaviors and shut them out.
Patients with T1D experienced a range of daily life
restrictions, such as “marginal physical ability”; they did
not feel free. Participants were also “unable to avoid giving injections,” which reinforced the notion that there isno cure for their lifelong disease:“Well, I felt comfortable [talking about the disease] withsome people at work. One day, I casually mentioned mycondition. This person I talked to advised me to tell ourboss. I was told that he should know so that he could
prepare for when something happens. I simply couldn’ttell our boss.” (Participant B)“The things I used to do without any problems are now
difficult because of hypoglycemic reactions. For example, [it used to be that] when I cleaned, I was able to do it
all day long without feeling tired but now I can’t. I haveto take that [my condition] into account [when doing

Persistence of afflictions

The concept of “persistence of afflictions” refers to thephenomenon in which patients endured increased suffering because of “resignation to the absence of a cure” andhaving to live with the disease. Patients with T1D feltthat others did not understand the disease and that they
had a prejudiced view of those with chronic illnesses.
200

Resilience of adult Japanese T1D patients

their difficulties from experience and thereby acquire astate of “making progress along the resilience path.”anything].” (Participant A)“The fact that I had to give myself an insulin injection
made me realize that I had a disease. I used to feel thatway every time I injected insulin back then.”

Actively seeking a futureParticipants completely changed their lifestyles as aresult of their T1D diagnosis. Although the diagnosis
caused them to experience a loss of pleasure and enjoyment, they eventually became aware that their situation
could only improve if they changed their negative mindset. Participants often could only take a step forward dueto the “advantage of experience.” Indeed, as time passed,
they experienced “realizing that this situation is not uncommon” and “receiving good treatment,” and were able
to find sources of pleasure. By being confronted withan uncertain future, they were forced to perform carefulassessments of their present status and capacity in orderto “control their situation”:“I was very happy [with this treatment]. I would give it
an A++! I’ve been living with it [T1D] for years. I got it [aninsulin injection] when I didn’t get to eat and other times
I could not get it [an insulin injection] when I was able toeat. It was like that for many years. Now that I have theinsulin pump, my condition has been stable.” (ParticipantJ)“I wasn’t working particularly hard. It wasn’t because I
was sick. I did what I could. I asked for help with what I
couldn’t do. I couldn’t work too much on what I wanted
to do.” (Participant N)“I decided not to let the disease affect the way I lived.
Injecting [insulin] was what differentiated me from others but we lived in the same way after all. I just had tobe careful of more things [than they did]. I tried not tothink about it too much; I thought that this way of thinking was my strength.” (Participant M)

Second stage: confidence in the situation (awareness of supporters, joy to be kept alive by insulin)This stage comprised two concepts that outlined how
patients with T1D gradually bridge a gap from theirpain.
Awareness of supporters

This stage described how participants became aware of
the support that they received from others to overcome
their difficulties. Participants were able to talk freely
about their physical, emotional, and social distress withother patients with T1D (“encouragement from other diabetics”), which helped them to become more resilient.
Furthermore, the knowledge that famous people also
suffered from T1D made participants feel more positive
about their future expectations (“presence of famous
people”). “Care from family” and “cooperation withco-workers” represented how patients with T1D became
conscious of avoiding hypoglycemia and were often given a room wherein they could perform insulin injectionsprivately:“When I got the disease, the doctor and nurses told me
about people with diabetes who are famous in society;for example, professional athletes. That kind of information made me realize that I didn’t need to change and it
was okay to stay the way I was.” (Participant G)“When I was hospitalized, my doctor introduced me toanother patient from the same generation. We became
good friends and this friendship really saved me.” (Participant A)“I went [back] to work after I got out of the hospital.
People [at work] were worried about hypoglycemia andalways gave me sweets. It was a nice environment.”(Participant I)

Being able to manage by oneself

Participants overcame their weaknesses by drawing
on their experiences. For instance, they devised coping
methods, such as “living a normal life” and “adopting an
attitude of self-reliance,” which they used in the “creationof a new lifestyle.” Additionally, by drawing on their pastexperiences, they could obtain a clearer perspective of
their future prospects. Ultimately, participants felt readyto “hope for a fresh start.” Furthermore, participants felt
more positive and began to “expect medical advances”:“Being aware of my disease, I set short-term goals, suchas that I should try hard for three months or maintaina 5% (HbA1c) level for that three-month period. I split
up the future into short periods and tried to feel happy
about short-term goals.” (Participant I)“I might not be able to get the kind of job I wish to, but
I will and want to work someday. I [also] want to grad-

Joy to be kept alive by insulin

This concept involved participants’ experiences of having “escaped death thanks to insulin”:“When I was diagnosed with T1D, I was very happy because I knew I could get treatment. If an insulin injection
enables me to work, that’s a good thing.” (Participant J)
Third stage: adaptive convictions (actively seeking
a future and being able to manage by oneself)

This stage comprised two concepts that outlined how patients with T1D gradually overcame their difficulties. It
reflected how participants learned strategies to overcome201

I. Nishio and M. Chujo

ually start seeing the friends I stopped seeing again.”(Participant E)“You know iPS [induced pluripotent stem] cells? I haveread news articles that said they might cure the disease. I
have really begun to hope that I could be free from having to inject insulin sometime soon.” (Participant H)

patients with T1D sought the support of others to help
them overcome their difficult situation. During thisstage, participants became dedicated to working throughtheir crisis. They consulted with trusted others about
their thoughts, which helped them to feel recognized
and supported. Previous research has shown that sympathetic supporters are strong sources of encouragement
for coping with difficult feelings.18–20 Furthermore, “joyto be kept alive by insulin” was considered the first stage
because it reflected how patients with T1D began to appreciate that insulin was beneficial for their lives, which
in turn helped to build their resilience.
In the third stage, which comprised the concepts of“actively seeking a future” and “being able to manage by
oneself,” patients with T1D felt weak and struggled withthe various restrictions of their disease; for instance, theyfelt “wounded” and experienced despair. Consequently, however, they experienced a state of emotional andmental maturation; by enduring difficulty, they realized
the meaning of truly being alive. This process of growthsuggested that they had adopted a new mental state inwhich they could accept their own feelings. Furthermore, they were not confused by others’ opinions. Relatedly, Travelbee (1971)21 reported that acceptance does
not differ from optimism; in other words, people who
accept their difficulties can overcome them. This wasvery similar to the process of resilience described herein, where patients with T1D learned to accept their difficulties. Affleck and Tennen (1996)22 similarly reported
the benefits of perceived positive changes in personality,
such as the development of greater patience, tolerance,
empathy, and courage. Other common benefits are positive changes in values, life priorities, and personal goals.
In this study, a key aspect of the participants’ realization of functional perpetual resilience was talking
with supporters about their experiences. This is notablebecause nurses, being closely acquainted with patients,
can be directly involved in eliciting patients’ resilience.23, 24 To do so, however, nurses must first understand the totality of patients’ accumulated experiencesof their disease. This qualitative study highlights theprocess of resilience that patients with T1D experiencein managing their diabetes and responding to new social
circumstances. By studying resilience and exploring thepossibilities presented by resilience-based interventions,practitioners from many fields could capitalize on anumber of unique opportunities for promoting positive
adaptation.16 Functional perpetual resilience underpins
other resilience strategies used by patients with T1D tostay well, minimize psychological maladjustment, andimprove mental health. Many patients experience T1D
as a catastrophic life event, after which they must con-DISCUSSION
The results of this study indicated that patients with T1D
experience three stages when developing resilience toface adversity. These three stages and related concepts
formed a model of resilience for adults with T1D, centered on the core concept of “to make progress along theresilience path.” In this study, the characteristic of theprocess of acquiring resilience in our country produced
a feeling of powerlessness related to the disease; however, T1D patients accepted the disease, and they could
gradually manage their disease to acquire resilience.
The resilience of T1D patients was important for reducing distress with T1D and to strengthen the management
skills and processes related to diabetes. 11, 12, 24 The
results of this study are the same as that of studies overseas.
The concepts inherent to each stage focused on
individuals’ development of inner strength via external
support and active personal effort. This is reminiscent of
the definition of resilience used by Werner (1993),8 Rutter (1985),9 and Grotberg (2003)10: namely, being able tocope with and overcome difficulties and, in the process,becoming strengthened or transformed by these difficulties. These authors proposed that resilience in copingwith diseases (including diabetes) could be organized
into the factors of external support, inner strength, andinterpersonal and problem-solving skills.
Regarding the structure of “to make progress along
the resilience path,” previous qualitative research has
shown that resilience is not a stable characteristic; rather, it
is a constantly changing and developing construct,16, 17 asreflected in the 10 concepts extracted in the present study,
which describe how adverse experiences stimulate andforge resilience.
The first stage involved their coping with various
burdens, such as “suffering from treatment,” “damaged
trust as a person,” and “persistence of afflictions.” At
this stage, patients with T1D expressed negative feelings about their experiences. Nevertheless, insulin benefited their lives, so they endured the treatment. This
endurance provided additional inner strength and led tofunctional resilience. This, in turn, resulted in greater
emotional stability because of the balance of negativeand positive experiences.
In the second stage (“awareness of supporters”),
202Resilience of adult Japanese T1D patients

front related challenges. Thus, resilience can be considered both a positive and negative consequence of T1D.
Our results indicate that nurses must understand patients’ experience of T1D in terms of both the social andpsychological perspectives. Furthermore, the findings
suggest that providers might consider asking patientswith T1D how they manage the disease and accept theirdisease through insulin therapy, as well as their expectations for medical care and hopes for the future.
In summary, resilient adults with T1D can offer
researchers practical, clinically relevant lessons andstrategies to support those who struggle with the same
condition. Through a synergistic emphasis on both alleviation of symptoms and promotion of positive processes in clinical care and research, we can prepare adults
with T1D to respond well to disease-related challenges
and, ultimately, set the stage for resilient behavioral andhealth outcomes.

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Limitations

The main limitation of this study was that participants
were recruited from only two clinics in one prefectureof Japan; thus, the results cannot be generalized to thewhole country. We recruited 15 individuals with T1D,
who were recommended by health professionals, for thisstudy; however, this may have introduced bias into theparticipant selection because they had an experience of
resilience. In addition, this study did not include participants who had difficulty in the acquisition of resilience.
Furthermore, this study was cross-sectional. Therefore, the impact of the resilience development process ofdiabetes must be explored in larger longitudinal studies.
Acknowledgments: We thank all patients with type 1 diabetes who
participated in this study.
The authors declare no conflict of interest.

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