The Right Framework, The Right Questions: Advancing Resilience Through a Multi‐Level Framework

This section on the Society to Cells Resilience Framework emerges at a pivotal moment. First, decades of nursing science have illuminated a crucial truth: focusing on individuals alone is necessary but not sufficient. Each person is shaped by the intersecting forces of family, community and societal context. Second, as science and expertise face growing attacks worldwide, demonstrating the power of strong theoretical foundations becomes essential–when we establish the right framework, we unlock the right questions and unleash our most impactful science. We have used the framework to undergird our own work. Dr. Gill's work examines when and how traumatic brain injuries (TBIs) (including those from assaultive trauma) impact the health and well-being of military personnel, veterans, and emergency department patients. Her research reveals why some individuals thrive after trauma and some do not. Her work has shown that cumulative trauma and TBIs can impact individuals as they age, leading to compromises in neuronal functioning and cognition—but the striking finding is that while a subset is vulnerable, most are not; they are able to overcome these risks without developing any long-term consequences. However, one-fifth to one-third experience a cascade of health problems after multiple TBIs and traumatic events—cardiovascular disease, post-traumatic stress disorder (PTSD), depression, substance abuse—that compromises their resilience to future challenges, including biological aging. By studying cohorts with similar experiences, but differential outcomes, she identifies both protective and vulnerability factors. Her recent work has connected increased central inflammation—measured through cytokine activities within neuronally derived exosomes—to brain inflammation on positron emission tomography (PET), neuronal degradation, and overall reductions in health and well-being. These findings reveal that the brain has a tipping point in resilience that varies based on an individual's lifetime experiences and highlights the need for promoting brain health on all levels. Her future studies will integrate biomarkers of brain health into practical tools that help individuals understand their resilience and work with patients and their families to promote resilience to brain injury. Dr. Gill has also published a series of papers demonstrating how social determinants of health impact biological recovery from traumatic events and injuries. Her work has consistently shown that sex and gender fundamentally shape health responses to stress and trauma. This goes beyond simply noting gender differences—instead its understanding the individual as an embedded person, shaped by all aspects of their environment, and developing biological adaptations that enhance flexibility in responding to future stressors—a hallmark of resilience. This honours each person's complete experience rather than simply categorising them as different from a dominant norm. 'Cellular resistance' captures this phenomenon—across cell types, complex processes including epigenetic modifications create these flexible personalised responses. Dr. Szanton's work has focused on building resilience across multiple levels—from individuals to entire communities. First, she co-developed the CAPABLE programme, which restores function to older adults living with disability. The programme works by focusing on older adults' strengths and goals and providing physical changes to the home with support from an Occupational Therapist, a Nurse, and a Handyworker. Over four months, the occupational therapist and nurse help older adults problem-solve around their personal goals with particular attention to reducing difficulty with vital daily tasks such as bathing and dressing. This focus on daily function is critical—it determines whether older adults can age independently in their communities or require institutional care. CAPABLE has been validated through multiple clinical trials in diverse settings and scaled to 23 states through multiple policy mechanisms such as Medicaid and Medicare Advantage. CAPABLE intervenes upon older adults and their home setting. Beyond these more individual level interventions, she has developed the Neighbourhood Nursing programme, which seeks to provide each person in the US with a nurse and a community health worker, door to door and in laundromats, libraries, schools, and other trusted community hubs—building individual, family, community, and ultimately, societal resilience. Starting in Maryland in several neighbourhoods, it is poised to grow through policy. Like a school nurse for each neighbourhood, this model of preventive and restorative care can provide a supportive resilient infrastructure for individuals, families, communities, and the nation's health. If only the authors used the theory, it would not have much impact. From what we can find in the literature as of mid-2025, there are 170 papers and multiple grants that are using the Society to Cells Resilience framework. These papers are a mix of literature reviews, intervention studies, and observational ones in a mix of nursing, education, and analysis of resilience interventions (Jin et al. 2023; Nelson et al. 2022; Taylor-Swanson et al. 2018; Mancus et al. 2021; Ang et al. 2022). The three main tenets from the resilience framework that have the most impact on resilience science are the following: First, that interventions have more power if they address more than one 'level' such as built environment plus family coping. That is, intervening with more than one of the six 'levels' of possible resilience (society, community, family, individual, organ, cellular) at a time is particularly effective. As one example, CAPABLE addresses the home environment and individual problem solving/self-efficacy. And each reinforces the other. For example, if an older adult who has been prone to falling at night wakes up and sees a grab bar on the side of their bed, they have a visual cue to hold on to it and sit up briefly before standing up. This is a physical change to the home that impacts their memory to practise a new habit. A second tenet most used from the framework is that just as there are particularly 'vulnerable' periods in development such as adolescence, there are also particular periods in people's and families lives that are attuned for resilience. Examples include caregiving for a child, or receiving a new medical diagnosis which can launch healthy habits that are maintained after treatment is finished. Additionally, brain fluid biomarkers that depict cellular resilience in the brain can help individuals and families make informed lifestyle modifications. Five key areas for future resilience research: When the Cells to Society Framework was first published in 2010, we were new scientists and the framework was our way to connect concepts in our areas of study to the strengths we saw in the people with whom we worked. This spirit remains at the core of our work over the 15 years since then. We have developed parallel careers with ups and downs. Through the successes, and even more so, through the challenges, both within our careers and lives, our science has been guided by an integrative view of the world and founded in the value that we, and other nurse scientists and leaders, can make substantial advances in all areas of practice, education, policy, and research to improve our shared communities. In using the framework to guide our research and the research of others, we see that the framework itself is flexible enough to grow and support many scholars and their work. At the metaphorical level, in this time of change, we live in a shared world, in which changes occur across layered domains. Everyone has an impact. By improving the lives of others, together we can create lasting and sustainable change. The authors declare no conflicts of interest. The authors have nothing to report.