Managing Resilience and Exhaustion Among Health Care Workers Through Psychological Self-Care: The Impact of Job Autonomy in Interaction With Role Overload

Abstract

Purpose: Drawing on the conservation of resources theory, we explore how job autonomy affects resilience and emotional exhaustion through psychological self-care (PSC). In addition, we study the impact of role overload as a boundary condition which dampens the beneficial effects of job autonomy.

Methods: Cross-sectional data was collected through an online survey among Canadian health care workers (HCWs) across multiple organizations. We performed structural equation modeling (SEM) to test the proposed hypotheses (N=860).

Results: Job autonomy had a positive relationship with resilience and negative with emotional exhaustion, both through PSC. However, high role overload hinders these relationships.

Conclusion: Job autonomy combined with reasonable workload allows HCWs to invest in themselves in the form of PSC, which in turn alleviates their emotional exhaustion and fosters their resilience. Accordingly, this helps HCWs in overcoming both current and future adverse events at work. Valuing autonomy and PSC through communication and contextualized human resource management practices will help support HCWs and health care organizations in turn. Indeed, nurturing resilience and reducing emotional exhaustion will provide and protect the needed individual resources to face future disruptive events, consequently leading to strengthen health care organizations.

Introduction

Working in health care is inherently challenging, as professionals face daily stressors and emotional demands that significantly impact their well-being.¹ Pandemics, persistent staffing shortages, and the accelerating pace of organizational changes have intensified these challenges, underscoring the critical need to support the psychological well-being of health care workers (HCWs).² This need aligns with the principles of the Quadruple Aim in healthcare, which emphasizes the balance between patient care, the efficiency of healthcare systems, population health, and the well-being of healthcare providers.³ Addressing HCWs’ psychological health is not only essential for their well-being, but also for the quality of the care provided to patients.⁴ Consequently, researchers and practitioners are increasingly focusing on strategies to bolster HCWs’ resilience while mitigating emotional exhaustion to foster a healthier and more effective workforce.

Psychological self-care (PSC) — the initiatives taken by HCWs to take greater ownership of their well-being at work⁵ — can be a promising avenue for fostering resilient HCWs, as it is known to reduce frustration and secondary trauma.⁶ However, research on PSC have often focused on patients (see⁷) rather than caregivers, limiting our understanding of its beneficial outcomes among this invaluable population. To address this, our study explores the factors that enable HCWs to engage in PSC, guided by the following research questions: (RQ1) To what extent does PSC help HCWs become more resilient to their pressure? (RQ2) What are the factors that increase HCWs’ PSC?

Building on the conservation of resource theory (COR),^8,9 we suggested that job autonomy —allowing HCWs to decide when, where, and how their tasks are performed¹⁰—plays a pivotal role in promoting PSC. As HCWs are granted with the discretion to organize their work to their needs and priorities, it creates opportunities for more effective personal resource management, such as PSC. Over time, we propose that these self-care practices can lead to resource gain spirals, which enhance resilience and help mitigate emotional exhaustion. While job autonomy offers significant potential for fostering PSC, we suggest that its benefits may be context dependent. Role overload—where the demands placed on HCWs exceed their available resources—can disrupt the positive effects of autonomy by making resource investment appear too risky. We therefore position role overload as a boundary condition to the effect of job autonomy on PSC.

We contribute to the health care management literature in two ways. First, theoretically, studying PSC as a resource passageway within the COR theory allows to explore this construct in a novel manner and to predict its contribution to HCWs. Furthermore, introducing role overload better contextualizes the behavior of HCWs experiencing different work contexts and helps explain some limitations of job autonomy. Second, for practical implications, this study better informs human resources managers regarding the importance of developing job autonomy in a crucial sector and in a crisis context. The results also provide indications to managers and healthcare institutions alike as to how to balance autonomy without risking overburdening HCWs. Furthermore, we answer a call for research by resilience scholars to study the phenomenon during true adverse events.^11,12 We collected the data in various health care installations across Canada during the COVID-19 pandemic, a time of tremendous challenges for HCWs regarding workload¹³ and emotional strain.¹⁴

The Benefits of Autonomy

The COR is a theoretical framework developed to understand stress and motivation.¹⁵ It posits that individuals strive to obtain, retain, and protect what they value.⁸ They do so by investing their various available resources (eg, time, effort, empathy) into their social environment, including their workplace. Stress arises when there is a threat of resource loss, actual resource loss, or insufficient resource gain following an investment of resources. Certain working conditions enable employees to invest in a way that is more suitable for them, creating opportunities for more profitable resource investment. This is captured by the concept of resource passageway, defined as “environmental conditions that might accelerate change in resources”¹⁶ (p. 1352). Certain workplace conditions, such as supportive leadership or high involvement work practices, can create positive resource passageways, enabling employees to invest their personal and job resources more effectively. This can optimize resource gains and mitigate resource loss.

Having the necessary latitude to manage one’s resources pool allows individuals to invest their resources in an idiosyncratic, optimized, and beneficial way.¹⁵ Job autonomy captures this discretion with which employees can take decisions regarding task completion.¹⁷ With greater job autonomy, employees can first address what they deem urgent and administer a treatment that is coherent with the care trajectory they established. According to the COR theory, this latitude not only reduces the risk of resource depletion leading to emotional exhaustion, but can also facilitate the generation of additional resources, such as enhanced resilience.^9,15 This is especially true in times of crisis when resources are more volatile, which can have a detrimental impact on HCWs well-being.¹⁸

Resource Gain Through Psychological Self-Care

An emerging self-investment strategy is operationalised in the form of PSC. It is defined as “the individual effort to create a good social climate in the workplace”⁵ (p. 66). This is done by investing resources in different types of behaviors (eg, building relationships with patients and coworkers alike) that, over time, increases personal and work resources.¹⁹ According to the COR theory, this cascading effect of resources can lead to the development of additional resources, thereby initiating a resource gain spiral. PSC, as a proactive volitional behavior, can thus play an important role in improving overall health in this population by providing valuable emotional resources in a demanding work context.⁶ In this line, we theorize that when given the opportunity to autonomously manage their time and effort, HCWs will invest said resources in creating a positive work atmosphere.

Thereafter, developing coherent resource investment strategies enhances the emergence of resource gain spirals, a mechanism through which individuals accumulate resources over time “to counteract loss”¹⁵ (p. 107), operationalized here as individual resilience. In this study, we define resilience as the ability to bounce back from stress,²⁰ thus enabling HCWs to face challenges in their work. This capacity of individuals to adapt and recoup after adverse events is central,²¹ particularly in health care where the prevalence of such events is high.¹ Job autonomy nurturing PSC supports HCWs’ resilience by providing them with individual and collective occupational resources. Thus, when adversity strikes, HCWs have greater and more diversified resources, which reduces their vulnerability and helps them face the evolving challenges associated with daily work in health care.¹⁸ This aligns with the first corollary of the COR theory that posits that those with greater resources are less vulnerable to resource loss and more capable of resource gain. Therefore, as HCWs’ job autonomy allows them to engage PSC, it creates a work climate conducive to gain in resilience capacity.

H1a: Psychological self-care mediates the positive relationship between job autonomy and resilience.

Preventing Resource Loss Through Psychological Self-Care

Building on the points presented in the previous section, when employees with greater job autonomy engage in PSC, it shelters them from possible resource depletion cycles. According to the COR theory, acquiring resources through resource gain spirals, while a slow and fragile process,¹⁵ also hinders resource loss. Working in healthcare can be an emotionally demanding experience due to the nature of the tasks.²² Indeed, being in contact and managing individuals in ill health is a prime example of what Maslach and Jackson²³ identified as “people-work”, putting HCWs at an acute risk of emotional exhaustion. Defined as ”a lack of energy and a feeling that one’s emotional resources are used up”²⁴ (p. 623), emotional exhaustion is the manifestation of a resource loss spiral and a serious threat to an individual’s well-being. According to the second corollary of the COR theory, such spirals tend to be difficult to counteract as they gain both in magnitude and velocity over time.¹⁵

Fortunately, by combining previous empirical results, we theorize that PSC, supported by job autonomy, can shelter HCWs from these resource loss cycles. Job autonomy nurtures adaptability, allowing individuals to identify idiosyncratic and relevant ways to protect their emotional resources²⁵ in the form of PSC. These self-care behaviors act as a proactive resource investment strategy that can reduce emotional exhaustion²⁶ and increase levels of overall mental health.⁶ Such process aligns with the second principle of the COR theory, which emphasizes that “people must invest resources in order to protect against resource loss”(p.106).¹⁵ As such, HCWs invest in PSC, which generates an ecosystem that supports them through positive relationships and working atmosphere, and even “act preventively against negative phenomena”⁵ (p. 313). Through this dynamic, a positive resource passageway emerges, simultaneously reinforcing individual resource pools and reducing the risk of further resource depletion. Consequently, we hypothesize that greater job autonomy enhances PSC, which in turn diminishes emotional exhaustion among HCWs. Thus, we propose the following.

H1b: Psychological self-care mediates the negative relationship between job autonomy and emotional exhaustion.

Role Overload as the Limit of Autonomy

It must be noted that, despite the possible benefits of job autonomy, it is not intrinsically effective. It is a necessary, but not sufficient, condition to reach beneficial outcomes. For example, autonomy may support performance while also harming individual well-being.²⁷

As a highly prevalent aspect of working conditions in health care setting, we focus on the influence of role overload²⁸ as a potentially relevant boundary condition. Role overload is defined as “the subjective feeling of having too many role demands given the resources available”²⁹ (p. 759). According to Ahn and Logan,²⁸ this phenomenon is associated with negative physical symptoms as individuals perceive the lack of time and energy to meet work demands as a threat to their resources.

Feeling overloaded makes resource investment appear riskier,³⁰ not knowing which tasks should be prioritized as to whether they will generate the expected return on investment or not. This uncertainty can dampen the willingness to invest in further tasks, especially discretionary ones.²⁹ We thus theorize that role overload limits the value of job autonomy regarding investing in PSC behaviors because HCWs experiencing hindrance and strain might be discouraged to invest in themselves as they grapple with meeting core demands.

Following this logic, we theorize that role overload impacts the indirect relationship between job autonomy and resilience. Despite having job autonomy, perceiving role overload can diminish the propensity to invest in PSC,³⁰ in turn preventing the creation of effective resource passageways. As established, job autonomy is indirectly beneficial for the development of resilience by granting decisional latitude to invest in a constructive work climate.⁵ However, this process can be disrupted as HCWs disinvest from — or never start to invest in it — as they perceive an unfavorable gap between their work demands and available resources. This hampers the ability of HCWs to develop resource gain spirals which enhance their resilience.

Similarly, the relationship between job autonomy and emotional exhaustion through PSC is also affected by role overload. HCWs experience daily heavy demands due to the nature of their work.¹³ When said demands are perceived as overwhelming, HCWs should devote resources to mandatory rather than discretionary tasks.²⁹ As such, when role overload increases, the willingness or possibility to invest in PSC may falter. This puts HCWs at risk of exacerbated emotional exhaustion as the manifestation of resource loss spirals. In this line, we propose the following.

H2a: Role overload moderates the indirect relationship between job autonomy and resilience such that the positive indirect relationship is weaker when role overload is high.

H2b: Role overload moderates the indirect relationship between job autonomy and emotional exhaustion such that the negative indirect relationship is weaker when role overload is high.

Figure 1 summarizes our proposed theoretical model.

Figure 1 Proposed theoretical model.

Methods

Sample and Research Design

We contacted several health care organizations and health care worker associations by Email across Canada. Each was asked to disseminate the survey within their organization. Twitter (now X) and LinkedIn were also used to share the invitation to participate in the study. Two Research Ethics Boards provided approval before contact was established with the health care organizations. Online data was collected using Qualtrics. Responses to the study were collected from November 2021 to February 2022, which coincided with the first Omicron wave of the COVID-19 pandemic in Canada (this study occurred within the frame of a larger research initiative supported by the Mental Health Commission of Canada. See³¹ for more information). During this period, we obtained 947 responses from HCWs spanning across multiple professions. However, 87 respondents had excessive missing data (more than 50% of items not answered on one or more variables), resulting in a final sample of 860. Table 1 summarizes the demographic statistics.

Table 1 Demographics

Measures

First, to measure job autonomy, we used the corresponding 3-item sub-scale of the psychological empowerment measure proposed by Spreitzer.³² A sample item is: “I have significant autonomy in determining how I do my job”. Second, to measure psychological self-care, we used an adapted version of a scale proposed by Lichner.⁵ We used only the first six items of the scale as they best encapsulate the creation of a good atmosphere at work. A sample item is: “I create a good atmosphere in the workplace”. Third, we measured resilience using the 6-item scale proposed by Smith et al.²⁰ A sample item is: “I tend to bounce back quickly after hard times”. Fourth, we measured emotional exhaustion using the short 5-item version of the MBI.²³ A sample item is: “I feel emotionally drained from my work”. Fifth, we measured role overload using the 4-item scale proposed by Brown et al.³³ A sample item is: “The amount of work I do interferes with how well my work gets done”. All scales are self-reported and on a 7-point Likert scale, except for emotional exhaustion which is on a 4-point temporal scale (from 1 “never” to 4 “a few times per week”). As for control variables, we collected data regarding age, gender, and tenure.

Results

Before testing the hypotheses, we conducted a confirmatory factor analysis (CFA). As presented in Table 2, the results suggest that the theorized model has a better fit than more parsimonious models, supporting construct validity. Considering that our data collection is self-rated and cross-sectional, we used two tests to estimate if common method bias was problematic.³⁴ First, we used Harman’s single factor, and no general factor was observed in the unrotated factor structure. 27% of variance was explained, below the recommended 50% threshold.³⁵ Second, we observed that the variance inflation factor for each focal construct was 1.213 or less, below the recommended 2.5 threshold.³⁶ Both these results confirm that common method bias is not an issue in our sample. Thus, we proceeded with the analyses and Table 3 presents the descriptive statistics.

Table 2 Comparison of Model Fit Indices

Table 3 Mean, Standard Deviation, Inter-Correlations, and Reliabilities

To test the hypotheses, we used structural equation modeling (SEM) in AMOS 28. The results suggest that the model has a good fit with the data (x²(318) = 762.79, p < 0.001, CMIN/DF = 2.399, CFI = 0.965, SRMR = 0.040, RMSEA = 0.040). For the mediation hypotheses, we used a 5000-bootstrap sample and a 95% bias-corrected confidence interval in AMOS 28. For the moderated mediation hypotheses, we probed the interactions using a 5000-bootstrap sample in SPSS 28 with the PROCESS macro (Model 7³⁷) and identified the conditional effects of mean-centered autonomy at −1 and +1 standard deviation (SD) for role overload (see³⁸). All presented regression weights are standardized to ease the comparison of effect sizes. Regarding the control variables, women scored higher on emotional exhaustion than men (β = −0.116; p < 0.001), a result replicated in many previous studies.³⁹ Furthermore, older individuals (β = 0.105; p = 0.008) scored higher on resilience than younger individuals. This result corresponds to previous findings.⁴⁰ Tenure had no significant relationship.

H1a proposed that PSC mediates the positive relationship between job autonomy and resilience. H1a was supported as the result was significant and in the predicted direction (β = 0.075; LB: 0.048 UB: 0.108; p < 0.001). H1b proposed that PSC mediates the negative relationship between job autonomy and emotional exhaustion. H1b was supported as the result was significant and in the predicted direction (β = −0.047; LB: −0.072 UB: −0.029; p < 0.001). In both instances, the direct effect of job autonomy on resilience and emotional exhaustion remained significant (β = 0.116; p = 0.003, β = −0.154; p < 0.001, respectively). This demonstrates a complementary mediation.³⁶

Regarding the moderated mediations, first, H2a proposed that role overload moderates the relationship between job autonomy and resilience through PSC such that the positive indirect relationship is weaker when role overload is high. The index of moderated mediation was significant and the predicted direction (Index = −0.0095, LB: −0.0187, UB: −0.0010). At both low (b = 0.0666, LB = 0.0441, UB = 0. 0942) and high (b = 0.0373, LB = 0.0198, UB = 0.0578) levels of role overload, job autonomy had a positive indirect relationship with resilience, but the effect size was smaller when role overload was high. Furthermore, the contrast between the conditional indirect effects was significant (−0.0294, LB = −0.0576, UB = −0.0030), granting support for H2a. Second, H2b proposed that role overload moderates the relationship between job autonomy and emotional exhaustion through PSC such that the negative indirect relationship is weaker when role overload is high. The index of moderated mediation was significant and the predicted direction (Index = 0.0060, LB: 0.0005, UB: 0.0117). At both low (b = −0.0418, LB = −0.0581, UB = −0.0274) and high (b = −0.0234, LB = −0.0361, UB = −0.0126) levels of role overload, job autonomy had a negative indirect relationship with emotional exhaustion, but the effect size was smaller when role overload was high. Furthermore, the contrast between the conditional indirect effects was significant (0.0184, LB = 0.0015, UB = 0.0361), granting support for H2b. Table 4 presents all standardized regression weights.

Table 4 Standardized Regression Weights

Discussion

Overview

This study aimed to better understand the impact of job autonomy on PSC, resilience, and emotional exhaustion among HCWs. According to our results, job autonomy has a valuable influence on relevant factors for this population. In essence, health care organizations must acknowledge the importance of job autonomy when organizing work. Nurturing resilience through self-care strategies has become quite popular in health care in the recent years,⁴¹ and we integrated this logic in a more complex nomological network with the aim of identifying valuable contributions for HCWs. In addition, our results indicated that women had higher scores of emotional exhaustion than men and that older individuals had higher scores of resilience than younger individuals. Both results correspond to previous findings^39,40 and highlight the importance of approaching the contributions with demographic data in mind. Furthermore, our study highlights the importance of striking a balance between autonomy and overload. Increasing autonomy is not a panacea for all challenges facing HCWs. Our results indicate that role overload dampens the positive impact of autonomy, meaning that managing HCWs’ perception of workload or better clarify roles and responsibilities of HCWs is critical to allow job autonomy to generate a cascade of beneficial effects.

While data was collected during the COVID-19 pandemic, issues regarding autonomy,⁴² PSC,⁴³ resilience,⁴⁴ emotional exhaustion,² and role overload⁴⁵ remain in health care installations across many professions, and so, around the world. As such, providing resources and ways to invest them efficiently¹⁵ to HCWs are still salient priorities. The following sections provide more details regarding the contributions of our findings to both theory and practice.

Theoretical Contributions

The first theoretical contribution of this article is the innovative exploration of the relationship between job autonomy and PSC for HCWs. While previous research has focused primarily on PSC among patients with chronic illnesses,⁷ our study contributed to our understanding of how to promote PSC among individuals working in a health care setting. Adjacently, our results highlight the role of PSC as an underlying mechanism for the relationships between job autonomy and both resilience and emotional exhaustion.⁴⁶ The second theoretical contribution is the study of autonomy and PSC within the framework of the COR theory. The theorization that the autonomy to manage one’s resources is a resource in itself is an important part of the COR,¹⁵ but one that is not frequently invoked by research teams. Presenting PSC as a resource passageway invites futures research to consider other climate-altering behaviors as forces which can limit or favor resource investments at work. Furthermore, by studying resilience and emotional exhaustion, our model allows us to integrate both resource gain and loss spirals. This highlights how job autonomy can be a resource to support HCWs’ capacity to bounce back and decreases the likelihood of emotional exhaustion.

In addition, we identified role overload as an impactful boundary condition to autonomy, whereas being autonomous, but overwhelmed, yields weaker results. As predicted by the principles of the COR theory,¹⁵ the context in which we invest ourselves matters as perceiving excessive demands alters behavior and attitude. More salient demands are prioritized, leading to dampened investment in PSC, which in turn harms resource acquisition. This addition to the nomological network of PSC, resilience, and emotional exhaustion constitutes a minor yet relevant contribution.

Practical Contributions

In terms of practical contributions, three recommendations emerge. First, job autonomy must be considered when developing human resources management policies. Even though autonomy can be difficult to grant to individuals who provide care due to the nature of their task, HCWs need latitude in how they structure their work. In this line of thought, healthcare and social services managers need to foster autonomy within their team. Concretely, managers must recognize that promoting autonomy does not equate to abdicating responsibility or decision-making. On the contrary, granting autonomy requires proactive management of the organization of work, in addition to providing clear expectations, well-defined roles, and support when demands become intense. For example, managers should engage in discussions with their team members to identify what matters to them in terms of independence of actions while remaining within the boundaries of their work contract and workplace policies. Second, supporting PSC to create a work climate that protects HCWs from exhaustion and promotes resilience is highly important.⁴¹ To generate such a climate, health care organizations must make psychological health and safety a priority by increasing awareness and implementing targeted strategies. They can contribute by providing the necessary resources for HCWs to develop PSC behaviors at work, such as time, material resources, and funding. For example, providing a calm space designed for employee resourcing gives them a chance to catch their breath, so they can then focus on nurturing a psychologically caring environment and helping patients. In addition, providing training regarding PSC can help, either through team communication workshops or individual training regarding the development of soft skills. Support protocols, such as debriefing sessions after difficult events or a crisis, can help teams’ members and team leaders improve PSC. Third, managing role overload is paramount. Demands in health care are high and cannot be eliminated, but organizations and managers can diminish perceptions of overload. For example, reducing understaffing can help alleviate the perception that there is too much to do for any given HCW.⁴⁷ While this has been a massive challenge for health care organizations since before the pandemic, visibility campaigns and valuing the diverse healthcare professions in conjunction with innovative recruitment practices could be potential solutions. Also, having a clear chain of command can help HCWs prioritize tasks by obtaining vital information from relevant sources. Respectful and constructive communication is key to prevent role overload from disrupting the beneficial cascading effects of autonomy.

Limits and Future Research

Despite these contributions, this study is not without limitations. The cross-sectional nature of the data dampened our ability to infer causality in the tested model. Also, our data collection approach prevented us from formulating a response rate, a limit which deserves mention. In addition, as our study builds on self-reported measure, future investigations might consider the use of multi-source data collection, as this could definitively eliminate this risk of common method bias. As a potential solution, future research could involve managers in the completion of the scales relating to autonomy and/or work overload. Furthermore, all our data is confined to Canadian health care and social services installations. While there is a diversity of settings captured within this sector, future research should aim to replicate the results in other countries to support their generalizability. For example, testing the proposed model in the United-States which does not provide universal health care as in Canada could provide new insights. Finally, future research should scrutinize how autonomy is implemented by the leader, as certain empowering working conditions may be ill perceived by HCWs and hinder their health at work. For example, when the leaders’ empowering behaviors do not match the members’ expectations regarding job autonomy, the latter could be perceived as non-involvement or laisser-faire leadership and have dire consequences for all stakeholders. Additionally, other factors should be considered as relevant antecedents to both resilience and emotional exhaustion, such as organizational culture or climate, support networks in organizations, and personality to increase explained variance.

Conclusion

When health care workers (HCWs) experience job autonomy in conjunction with a manageable workload, they are better positioned to engage in psychological self-care (PSC). This self-care process plays a critical role in mitigating emotional exhaustion while enhancing resilience. This process allows HCWs to navigate workplace adversities more effectively. Promoting job autonomy, fostering PSC, and reducing overload through human resource management practices adapted to health care settings can provide robust support for both HCWs and organizations. By prioritizing resilience-building and minimizing emotional exhaustion, organizations help HCWs maintain the psychological resources necessary to confront present and future challenges.

Data Sharing Statement

Data are available upon reasonable request from the correspondence author.

Ethics and Consent Statements

This study involves human participants and was approved by Comité d’éthique de la recherche HEC Montréal (project #: 2022-4467) and by the Queen’s University Health Science Research Board. Informed consent was obtained from all individual participants included in the study. The study complies with the Declaration of Helsinki.

Acknowledgments

The research team would like to thank the Mental Health Commission of Canada for their support throughout this project.

Funding

This research article benefited from the financial support of the Mental Health Commission of Canada and the Social Sciences and Humanities Research Council (SSHRC). Grant Number: 435-2020-1370.

Disclosure

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

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