Society-to-Cells Resilience Theory

Contributors: Sarah Szanton & Jessica Gill
February 22, 2019

Sarah L. Szanton, PhD, ANP, FAAN and Jessica M. Gill, PhD, R.N.

Year First Published – 2010

The Society to Cells Theoretical Framework (from Szanton, S. L., & Gill, J. M. (2010). Facilitating resilience using a society-to-cells framework: a theory of nursing essentials applied to research and practice. Advances in Nursing Science, 33(4), page 333.)

Major Concepts

Society (Natural ecosystems, Safety in environment, Educational and career opportunities, gender)

Community (Institutions, Social support, Social capital, Built environment, Diversity)

Family (Developmental opportunities, Behavior modeling, Connectedness, Sense of safety and security)

Individual (View of self, View of world, Coping strategies, Spirituality, Sex, Race)

Physiological (Neurochemical activity, Hormone balance, Glucose regulation, Inflammation)

Cellular (Genetic inheritance, Epigenetics, DNA repair, Oxidative stress, Mitochondrial function, Nuclear Factor Kappa-Light-Chain-Enhancer of Activated B Cells, Cellular senescence)


Conceptual Framework


The society-to-cells resilience theory is based on 6 fundamental tenets.

  1. Each person is born with resilient potential. That potential changes over time depending on interactions between society, community, and family, and individual psychological, physiologic, and cellular factors and how each factor reacts to a challenge.
  2. Resilience includes 3 aspects: (a) resistance to a challenge, resulting in the continual maintenance of health, (b) recovery from a challenge, resulting in a return to previous levels of functioning after a period of compromised functioning, or (c) rebounding from a challenge, resulting in the attainment of a higher level of functioning than before the challenge.
  3. Nurses can foster resilience through action affecting one or more factors, and this action has increased possibility of affecting comprehensive change if it addresses multiple factors.
  4. Each factor may interact with all the other factors.
  5. Just as there may be particularly vulnerable periods of risk, there are times during which an individual, community, or society may be particularly resilient in meeting a challenge.
  6. Resilience is both a process and a capacity. Resilience can be measured in studies as an outcome but is also a measure of theoretical resilient capacity. This perspective is essential, as all individuals are in constant adaptation, and the process of adaptation must also be considered a facet of resilience, not only the final outcome.
Primary Source

 Szanton, S. L., & Gill, J. M. (2010). Facilitating resilience using a society-to-cells framework: a theory of nursing essentials applied to research and practice. Advances in Nursing Science, 33(4), 329-343.

Application Sources

Used as the framework for the PROMOTE research center at the Johns Hopkins School of Nursing (JHSON). Funded through a National Institute of Nursing Research P30 grant, the center is advancing the science by supporting patients with multiple chronic conditions and providing an opportunity for researchers to drive culture change and develop sustainable health care initiatives through innovative research design.

Pan, C. J., Liu, H. C., Liang, S. Y., Liu, C. Y., Wu, W. W., & Cheng, S. F. (2019). Resilience and coping strategies influencing the quality of life in patients with brain tumor. Clinical nursing research, 28(1), 107-124.

Park, S., & Schepp, K. G. (2018). A theoretical model of resilience capacity: Drawn from the words of adult children of alcoholics. Nursing forum, 53(3), 314-323.

Taylor-Swanson, L., Wong, A. E., Pincus, D., Butner, J. E., Hahn-Holbrook, J., Koithan, M., … & Woods, N. F. (2018). The dynamics of stress and fatigue across menopause: attractors, coupling, and resilience. Menopause, 25(4), 380-390.

Eicher, M., Ribi, K., Senn‐Dubey, C., Senn, S., Ballabeni, P., & Betticher, D. (2018). Interprofessional, psycho‐social intervention to facilitate resilience and reduce supportive care needs for patients with cancer: Results of a noncomparative, randomized phase II trial. Psycho‐Oncology, 27(7), 1833-1839.

Leyva, E. W. A., Beaman, A., & Davidson, P. M. (2017). Health impact of climate change in older people: An integrative review and implications for nursing. Journal of Nursing Scholarship, 49(6), 670-678.

Reinert, K. G., Campbell, J. C., Bandeen-Roche, K., Lee, J. W., & Szanton, S. (2016). The role of religious involvement in the relationship between early trauma and health outcomes among adult survivors. Journal of child & adolescent trauma, 9(3), 231-241.

Rusch, H. L., Shvil, E., Szanton, S. L., Neria, Y., & Gill, J. M. (2015). Determinants of psychological resistance and recovery among women exposed to assaultive trauma. Brain and behavior, 5(4), e00322.

Dubey, C., De Maria, J., Hoeppli, C., Betticher, D. C., & Eicher, M. (2015). Resilience and unmet supportive care needs in patients with cancer during early treatment: A descriptive study. European Journal of Oncology Nursing, 19(5), 582-588.

Reinert, K. G., Campbell, J. C., Bandeen‐Roche, K., Sharps, P., & Lee, J. (2015). Gender and race variations in the intersection of religious involvement, early trauma, and adult health. Journal of nursing scholarship, 47(4), 318-327.

Gill, J. M., Saligan, L., Lee, H., Rotolo, S., & Szanton, S. (2013). Women in recovery from PTSD have similar inflammation and quality of life as non-traumatized controls. Journal of psychosomatic research, 74(4), 301-306.

About the authors

Sarah L. Szanton

Sarah L. Szanton, PhD, ANP, FAAN is the Health Equity and Social Justice Endowed Professor and Director of the Center for Innovative Care in Aging at the Johns Hopkins School of Nursing. She holds a joint appointment in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health. She tests interventions to reduce health disparities among older adults. Her work particularly focuses on ways to help older adults “age in place” as they grow older. These include ways to improve the social determinants of health such as modifying housing and improving access to food. In 2016, she was named to the PBS Organization’s “Next Avenue 2016 Influences in Aging” a list of thought-leaders who are changing how we age and think about aging in America. Szanton completed undergraduate work in African-American Studies at Harvard University and earned a bachelor’s degree from the Johns Hopkins School of Nursing. She holds a nurse practitioner master’s degree from the University of Maryland and a doctorate from Johns Hopkins University. She is Core Faculty at the Center on Aging and Health, the Hopkins Center for Health Disparities Solutions and Adjunct Faculty with the Hopkins Center for Injury Research and Policy. She has been by funded by the National Institutes of Health, the Center for Medicare and Medicaid Services Innovation Center, the Robert Wood Johnson Foundation, the John A. Hartford Foundation, the Rita and Alex Hillman Foundation, and the AARP Foundation.

Jessica M. Gill

Dr. Jessica Gill’s interest in research began during her nursing undergraduate (B.S.N.) career, during which she volunteered with women and children whose lives were negatively affected by violence. She observed that this extreme stress resulted in differing outcomes with some women being substantially impaired, whereas others were able to recover. She questioned the mechanisms underlying these divergent responses to extreme stress. This line of questioning led her to pursue a graduate degree (M.S.) from Oregon Health and Science University in psychiatric nursing, which included clinical training in the PTSD program at the U.S. Department of Veterans Affairs.

Research questions about trauma and resiliency were amplified during her work with Vietnam veterans who remained impacted by their combat service decades after returning home. Based on these volunteer and clinical experiences, she decided to pursue a doctorate at Johns Hopkins University’s School of Nursing. Her dissertation research demonstrated the presence of high rates of PTSD in urban health care seeking women, and that a PTSD diagnosis was associated with perceived health declines as well as with higher concentrations of inflammatory markers and a dysregulation of endocrine functioning.

Following completion of her Ph.D., she obtained a post-doctoral fellowship at the National Institute of Nursing Research (NINR) to better understand the biological mechanisms of PTSD and depression, finding central and peripheral alterations in the in-vivo functioning of both immune and endocrine systems. This line of research also led her to become a Clinical Investigator in the Center for Neuroscience and Regenerative Medicine (CNRM).

At the CNRM, her program of research and clinical practice expanded to examining the biological mechanisms of PTSD and traumatic brain injury related impairments in service members where, again, she observed a high degree of differential response to combat trauma and TBIs. This experience led to questions regarding the mechanisms underlying these differential responses, a line of inquiry that could only be determined using a prospective design of patients immediately following a trauma. Dr. Gill returned to NINR as a Lasker Clinical Research Scholar to develop this program of research, which aims to determine the clinical and biological risks that predict PTSD onset and neurological compromise following a traumatic injury.

Szanton – additional notable works

Szanton, S. L., Xue, Q. L., Leff, B., Guralnik, J., Wolff, J. L., Tanner, E. K., … & Gitlin, L. N. (2019). Effect of a Biobehavioral Environmental Approach on Disability Among Low-Income Older Adults: A Randomized Clinical Trial. JAMA Internal Medicine, 179(2), 204–211.

Szanton, S. L., Alfonso, Y. N., Leff, B., Guralnik, J., Wolff, J. L., Stockwell, I., … & Bishai, D. (2018). Medicaid cost savings of a preventive home visit program for disabled older adults. Journal of the American Geriatrics Society, 66(3), 614-620.

Szanton, S. L., Samuel, L. J., Cahill, R., Zielinskie, G., Wolff, J. L., Thorpe, R. J., & Betley, C. (2017). Food assistance is associated with decreased nursing home admissions for Maryland’s dually eligible older adults. BMC Geriatrics, 17(1), 162.

Szanton, S. L., Roberts, L., Leff, B., Walker, J. L., Seplaki, C. L., Soones, T., … & Ornstein, K. A. (2016). Home but still engaged: participation in social activities among the homebound. Quality of life research, 25(8), 1913-1920.

Szanton, S.L., Leff, B.L., Wolff, J.L., Roberts, L. Gitlin, L.N. (2016). “Home-based care model reduces disability and promotes aging in place.” Health Affairs, 35(9), 1558-1563.

Szanton, S.L., Wolff, J.W., Roberts, L. Leff, B.L., Thorpe, R.J., Tanner, E.K., Boyd, C., Xue, Q., Guralnik, J. Bishai, D. Gitlin, L.N. (2015). “Preliminary data from CAPABLE, a patient directed, team-based intervention to improve physical function and decrease nursing home utilization: the first 100 completers of a CMS Innovations Project.” Journal of the American Geriatrics Society, 63(2), 371-374.

Gill – additional notable works

Olivera, A., Lejbman, N., Jeromin, A., French, L. M., Kim, H. S., Cashion, A., … & Gill, J. (2015). Peripheral total tau in military personnel who sustain traumatic brain injuries during deployment. JAMA Neurology, 72(10), 1109-1116.

Heinzelmann, M., Reddy, S. Y., French, L. M., Wang, D., Lee, H., Barr, T., … & Gill, J. (2014). Military personnel with chronic symptoms following blast traumatic brain injury have differential expression of neuronal recovery and epidermal growth factor receptor genes. Frontiers in Neurology, 5, 198.

Gill, J., Merchant-Borna, K., Jeromin, A., Livingston, W., & Bazarian, J. (2017). Acute plasma tau relates to prolonged return to play after concussion. Neurology, 88(6), 595-602.

Gill, J., Motamedi, V., Osier, N., Dell, K., Arcurio, L., Carr, W., … & Yarnell, A. (2017). Moderate blast exposure results in increased IL-6 and TNFα in peripheral blood. Brain, Behavior, and Immunity, 65, 90-94.