Job burnout and secondary traumatic stress (STS) are the crucial negative consequences of work-related stress in health professionals, including nurses (Beck, 2011; Frey, Robinson, Wong, & Gott, 2018). Nursing has been identified as an occupation with a high level of stress (Hingley, 1984; McGrath, Reid, & Boore, 2003; Smith, Brice, Collins, Matthews, & McNamara, 2000). Experiencing of stress by nurses involves providing professional assistance and care of patients with various physical and emotional needs and their families (DeLucia, Ott, & Palmieri, 2009; Peters et al., 2012). It also refers to a group of environmental factors such as long working hours, shift work, implementation of a new medical technology, requirements of the health care system that impose more paperwork and lack of support or high demands of superiors (Pikó, 1999).
Working with terminally ill patients is specific in that the services center on the needs of dying individuals and their relatives contrary to focusing on helping them to recover from acute disease or disability and improving their functioning as in other disciplines of nursing, for example, critical care, rehabilitation nursing (Martens, 2009). A study conducted by Sharma et al. (2014) found that 42% of a studied group of nurses in India suffered from moderate-to-severe stress. Keidel (2002) points to a number of factors that may be a source of severe stress among palliative care nurses including societal influences, institutional problems, problems with the health care system, problems with the nursing system (working with dying individuals and his or her family, visiting patients’ relatives at night, specific relationship with the patient and his or her family, and emotional involvement with patients), problems with the hospice system (identification with ideology of hospice care), and stressors associated with other issues facing the patient and his or her family (addiction, abuse, mental illness, and somatic disease). Job stress not only had a negative influence on nurses’ health, but also on their abilities to cope with the demands of the job.
Job (occupational) burnout is defined as a prolonged response to job stressors, encompassing exhaustion, cynicism, and inefficacy (Maslach, Schaufeli, & Leiter, 2001); however, a more recent definition includes exhaustion and disengagement (Demerouti, Bakker, Vardakou, & Kantas, 2003; Demerouti, Mostert, & Bakker, 2010). Exhaustion, in this sense, refers to being drained of physical, cognitive and emotional energy as a result of exposure to job demands, while disengagement is interpreted as distancing oneself from work and possessing a negative attitude toward work-related objects and tasks. Job burnout is associated with depletion of energy and personal resources, which makes it an important factor in the process of health impairment (Basińska & Gruszczyńska, 2017). Burnout can cause the individual to be susceptible to other negative consequences of experienced stress, including posttraumatic stress disorder (PTSD) or secondary traumatic stress.
STS is a concept similar to PTSD. It is also known as secondary PTSD and is characterized primarily by symptoms of intrusion (returning thoughts, dreams related to trauma), avoidance (an effort to get rid of emotions, thoughts associated with traumatic event) and hyperarousal (increased vigilance, anxiety, and impatience; Bride, Robinson, Yegidis, & Figley, 2004). These consequences have been observed in human services providers and are believed to result from indirect exposure to the traumatic events experienced directly by their patients or clients. STS has a widespread impact on the personal and professional lives of the subjects and has been observed in health care professionals (Cieslak et al., 2014; Manning-Jones, de Terte, & Stephens, 2017). It is important to mention that the consequence of secondary exposure to trauma at work is also called compassion fatigue (Figley, 2002), which indicates that STS bears some similarity to burnoutsyndrome, especially to emotional exhaustion. According to Figley (1995) STS appears as a complex state of dysfunction and exhaustion in which emotional distress and suffering experienced by trauma victims is taken on by the helpers.
The available data confirm that burnout and STS are related (Cieslak et al., 2014), but only to a moderate degree, as the theoretical frameworks are slightly different. Besides, exposure to client reports of traumatic experience, burnout can be caused by structural strains in the workplace and chronic organizational issues. In turn, STS is conceptually linked only to those workplace factors concerning indirect exposure to trauma content.
Psychological Resilience as a Factor Protecting From Negative Outcomes of Work-Related Stress
Resilience is a complex phenomenon. It may be treated as a process, personal characteristic, or resource of the individual, known as psychological resilience. Psychological resilience is defined as effective coping and adaptation in the face of adversity (Tugade & Fredrickson, 2004). It is the ability to “bounce back” or recover from stress. Psychological resilience is manifested as persistence and flexible adaptation to the demands of life, an ability to take remedial actions in difficult situations, and a tolerance of negative emotions and failures (Block & Block, 1980). Individuals with greater resilience display greater capacity to modify ego-control in response to situational opportunities. They are more likely to experience positive emotions, to be self-confident, to cope with stress more effectively, and to be generally better adjusted psychologically (Tugade & Fredrickson, 2004). Positive emotionality suggests possible relation with compassion satisfaction, which is important in health care professionals (Pietrzak, Johnson, Goldstein, Malley, & Southwick, 2009).
Psychological resilience may protect employees from the negative outcomes of experienced stress. In a study conducted in a group of medical rescue workers, resilience was negatively related to intrusion symptoms (Ogińska-Bulik, 2015). Similarly, Duan, Guo, and Gan (2015) found psychological resilience to be a predictor of PTSD and Pietrzak et al. (2009) found a higher level of psychological resilience to be negatively associated with PTSD and depressive symptoms. Ssenyonga, Owens, and Olema (2013) also highlighted the protective role of resilience.
Few studies examine the relationship between resilience, STS, and job burnout. However, one study of New Zealand counselors working with trauma survivors confirmed a negative relationship between resilience and STS symptoms (Termitope, 2014). Another study of female social workers characterized by high resilience found significantly lower levels of emotional exhaustion and depersonalization, and higher professional satisfaction (Ogińska-Bulik, 2011). A third study identified a negative relationship between resilience and job burnout among Japanese psychiatric hospital nurses (Gito, Ihara, & Ogata, 2013).
Aim of the Study
The aim of the present study was to establish the relationship between psychological resilience, job burnout, and STS among nurses working with terminally ill patients, and to determine whether job burnout plays a mediating role in the relationship between resilience and STS. It was assumed that:
* There are positive links between STS and job burnout.
* Resilience is negatively correlated with STS and job burnout.
* Job burnout plays a mediating role in the relationship between resilience and STS.
The adopted research model identified job burnout as a mediator in the relationship between resilience and secondary traumatic stress. It is consistent with data obtained by Shoji et al. (2015) who note that job burnout precedes the occurrence of secondary traumatic stress. It can also be assumed that job burnout may play a more important role in predicting secondary traumatic stress than resilience.
Method
Design and Participants
The study was cross-sectional and carried out in the hospice and the Non-Public Care and Treatment Center for the Chronically Ill in the Świętokrzyskie province (Poland), from September to December 2017. The respondents were 75 nurses working with terminally ill patients; in total, 72 questionnaires were fully completed and taken for analysis. The study was conducted in direct contact with nurses during duty hours. Nurses were informed of voluntary participation and anonymity. The questionnaires were delivered and collected by the researchers. The age of the participants ranged from 22 to 72 years old (M = 46.01, SD = 10.69). The number of years of practice ranged from one to 47 years (M = 23.61, SD = 1.37). Twenty-three of the women (31.9%) had secondary education, 27 (37.5%) had not completed higher education and 22 had completed higher education (30.6%). Thirty-nine (54.2%) nurses were employed in the hospital, and 33 (45.8%) in the hospice.
Measures
The Secondary Traumatic Stress Scale (STSS), the Oldenburg Burnout Inventory (OLBI), the Resilience Measurement Scale were used in the study. The STSS, developed by Bride et al. (2004) is a 17-item instrument to measure of the frequency of intrusion, avoidance and arousal (e.g., “It seems as if I was reliving the trauma(s) experienced by my patients”), together with other STS symptoms associated with indirect exposure to traumatic events, occurring in the previous month. Responses are provided on a 5-point scale ranging from 1 (never) to 5 (very often). Cronbach’s α in the current examined group of nurses was 0.89. The Polish version of the scale, developed by Cieslak (the scale was obtained directly from the author of the Polish version), was used in the study.
The OLBI, developed by Halbesleben and Demerouti (2005) is a 16-item questionnaire used to assess the level of burnout and its two components: exhaustion (e.g., “During my work, I often felt drained”) and disengagement (e.g., “It happens more and more often that I talk about my work in a negative way”). Respondents are asked to rate the degree of agreement for each item on a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). Cronbach’s α was 0.84. The Polish version of the inventory, developed by Cieslak (the scale was obtained directly from the author of the Polish version), was used in the study.
The Resilience Measurement Scale, authored by Ogińska-Bulik and Juczyński (2008), measures the overall level of resilience, treated as a set of personal traits (e.g., “I undertake efforts to cope no matter how difficult the problem is”), and its five component parts: (1) Determination and persistence in action; (2) Openness to new experiences and sense of humor; (3) Competencies to cope and tolerance of negative affect; (4) Tolerance of failures and treating life as a challenge; and (5) Optimistic life attitude and ability to mobilize in difficult situations. The overall result of the scale was given as the sum of the five component factors. Cronbach’s α in the examined group of nurses was 0.90.
Data Analysis
As the distribution of the results was normal, the following parametric tests were used: Student’s t test to determine the differences between means and Pearson’s correlation coefficients to calculate the relationships between variables. The mediating role of job burnout in the relationship between resilience and STS was established by using the bootstrapping method (Preacher & Hayes, 2008). The bootstrapping method is a nonparametric test, similar to model of regression, which can be used for small sample sizes. This approach determines whether a predictor or independent variable is associated with a dependent variable via a third variable known as the mediator; in this case, resilience is the predictor, STS is the dependent variable while job burnout is used as the mediator. When the value of the mediator variable decreases the predictive value of the predictor variable on the dependent variable, it is recognized as having a mediating effect.
Results
The mean scores for resilience, job burnout and STS are presented in the Table 1.
The age of the recipients, number of years of practice, level of education and type of workplace (hospital, hospice) were controlled in this study. No significant correlations were observed between age and intensity of STS (r = −.03) and job burnout (r = −.01). Similarly, no links were observed between number of years of practice and the two variables: STS (r = .02) and job burnout (r = .11). The level of education did not influence the intensity of STS (secondary education: M = 40.39, SD = 11.00; incomplete higher: M = 42.04, SD = 8.64; higher: M = 41.00, SD = 11.05, F = 0.17) or job burnout (secondary education: M = 47.04, SD = 9.61; incomplete higher: M = 48.30, SD = 7.95; higher M = 44.91, SD = 10.20, F = 0.83). The type of workplace influenced the level of STS and job burnout, with the hospital nurses revealing slightly greater severity of STS (M = 44.28, SD = 0.77) and higher mean job burnout scores (M = 50.51, SD = 7.74) than the hospice nurses (STS: M = 37.55, SD = 9.29, t = 2.98, p < .05; job burnout: M = 42.55, SD = 8.00, t = 4.04, p < .001).
The next step of the analysis was to establish the links between resilience, job burnout, and STS (see Table 1). STS symptoms were positively associated with job burnout (r = .62, p < .001). Higher correlation coefficients were identified between exhaustion and STS (r = .59, p < .001) than between STS and disengagement (r = .54, p < .001). These scores are not only associated with overall STS score, but also with two of its components, that is, avoidance and arousal. Intrusion was found to be associated only with exhaustion (r = .25, p < .05). Resilience was negatively correlated with STS (total, r = −.36, p < .01) and two of its symptoms: avoidance (r = −.45, p < .001) and arousal (r = −.33, p < .01). No relationships were observed between resilience and intrusion. With regard to the particular resilience factors, significant and strong associations were found between STS and openness to new experiences and sense of humor (factor 2, r = −.50, p < .001), as well as a tolerance of failure and treating life as a challenge (factor 4, r = −.45, p < .001). Negative links were also identified with all the resilience and job burnout dimensions. Stronger correlation coefficients were found between resilience and job burnout (total, r = −.59, p < .001) than between resilience and STS (total, r = −.36, p < .01).
The next stage of the analysis was to determine whether job burnout acts as a mediator in the relationship between resilience and STS. In total, six models of mediation were obtained in the study (Figures 1-6 (figure 1,
Figure 1. Model of relations between resilience, job burnout and secondary traumatic stress. βa, coefficient between independent variable and mediator (indirect effect); βb, coefficient between mediator and dependent variable (indirect effect); βc, coefficient between dependent and independent variable (total effect); βc’, coefficient between dependent and independent variable (direct effect). * p < 0.05; ** p < 0.01; *** p < 0.001; ns Not significant.
figure 2,
Figure 2. Model of relations between resilience, job burnout and avoidance. Abbreviations as in Figure 1. * p < 0.05; ** p < 0.01; *** p < 0.001; ns Not significant.
figure 3,
Figure 3. Model of relations between resilience, job burnout and arousal. Abbreviations as in Figure 1. * p < 0.05; ** p < 0.01; ***p < 0.001; ns Not significant.
figure 4,
Figure 4. Model of relations between openness to experience, job burnout and secondary traumatic stress. Abbreviations as in Figure 1. * p < 0.05; ** p < 0.01; *** p < 0.001; ns Not significant.
figure 5,
Figure 5. Model of relations between competencies to cope, job burnout and secondary traumatic stress. Abbreviations as in Figure 1. * p < 0.05; ** p < 0.01; *** p < 0.001; ns Not significant.
figure 6)),
Figure 6. Model of relations between tolerance of failures, job burnout and secondary traumatic stress. Abbreviations as in Figure 1. * p < 0.05; ** p < 0.01; *** p < 0.001; ns Not significant.
where βc indicates the predictive value of an independent variable before implementing the mediator and βc‘ refers to an independent variable after implementing the mediator.
Figure 1 represents resilience as a predictor of job burnout and STS. A high level of resilience reduces the negative consequences of experienced stress. Job burnout also predicts STS. This relationship is positive, which indicates that the higher the job burnout, the higher the intensity of STS. The introduction of job burnout as an intermediary variable in the relationship between resilience and STS resulted in this relationship becoming nonsignificant, which indicates full mediation. Job burnout became the only predictor of STS. Similar results were obtained when particular symptoms of STS, that is, avoidance and arousal, were introduced as dependent variables (Figure 2 and 3). The introduction of job burnout as an intermediary variable broke the relationship between resilience and these symptoms.
In the next steps, particular factors of resilience were analyzed as independent variables. Job burnout was found to partially mediate the effect of openness to experience on STS, implying that the buffering effect of openness to experience on STS is reduced in the presence of job burnout (see Figure 4). In turn, the introduction of job burnout as an intermediary variable in the relationship between competencies associated with coping and tolerance of negative affect and STS (see Figure 5), as well as tolerance of failure associated with treating life as a challenge and STS (see Figure 6), resulted in these relationships becoming nonsignificant, which indicates full mediation. In these cases, job burnout became the only predictor of STS.
Discussion
Nurses working with terminally ill patients are exposed to negative consequences of work-related stress in the form of job burnout and STS. The mean result for STS obtained from the respondents was higher than that identified previously in a study of social workers (M = 29.49, SD = 10.76; Bride et al., 2004). The level of job burnout presented by the nurses was also higher than that gained in a previous study of human service workers (Shoji et al., 2015). The mean resilience score is similar to those identified in Polish standardization studies and points to its average level (Ogińska-Bulik & Juczyński, 2008). The obtained results are in accordance with other studies, which indicate high prevalence of job burnout and secondary traumatic stress among palliative care nurses (Beck, 2011; Frey et al., 2018).
STS and job burnout are positively associated with each other, hence a high level of job burnout encourages STS, and conversely, the occurrence of STS may intensify job burnout symptoms. Cieslak et al. (2014) indicate that job burnout and STS are likely to co-occur among professionals exposed indirectly to trauma through their work. Resilience was found to be negatively correlated with both job burnout and STS, indicating that psychological resilience is an important resource that may protect the individual from the negative consequences of work-related stress. Openness to new experiences and a sense of humor, as well as a tolerance of failures and treating life as a challenge, play particularly strong protective roles. The results of mediation analysis indicate that job burnout plays a mediating role in the relationship between resilience and STS, avoidance and arousal in particular. Job burnout is the only predictor of STS for most of the obtained models. It indicates that the occurrence of STS is more closely related to job burnout than to resilience. Job burnout partially explained the association between openness to new experiences and STS. Both variables play a role in predicting STS.
Exposure to secondary trauma experienced by nurses caring for dying patients and the emotional costs they incur providing this care may result in job burnout. Palliative care nurses who experience burnout are more susceptible to patient suffering and have less energy to manage job stress; thus, becoming more vulnerable to the symptoms of STS and compassion fatigue. In that case, job burnout may be treated as a “gateway” outcome enhancing the risk of developing STS. These findings are consistent with those of Rudolph, Stamm, and Stamm (1997) who reveal a positive link between job burnout and STS among nurses and Udipi, Veach, Kao, and LeRoy (2008) who report that burnout was a stronger predictor of compassion fatigue, which is a similar term to STS, in counselors working with trauma victims. The association between job burnout and STS confirms the results obtained by Shoji et al. (2015) in a study of health providers working with U.S. military personnel and Polish health care and social workers.
Stressors experienced by palliative care nurses also affect nurses from other disciplines, for example, emergency care, pediatrics, labor, and delivery. These stressors mainly concern emotional costs of caring, role conflict and work environment (Peters et al., 2012). Exposure to particularly traumatic stress may result in occurrence of job burnout and STS among nurses from other areas.
Our study shows that psychological resilience may protect palliative care nurses from negative consequences of job stress. The results are in accordance with data that showed resilience as a preventative factor for secondary traumatic stress and job burnout among human service professionals (Harker, Pidgeon, Klaassen, & King, 2016) and nurses (Back, Steinhauser, Kamal, & Jackson, 2016; Tseng, Shih, Shen, Ho, & Wu, 2018; Yu, Raphael, Mackay, Smith, & King, 2019). Resilient individuals are more prone to cope with the stress and trauma effectively (Brown, 2018; McCain, McKinley, Dempster, Campbell, & Kirk, 2017; Ogińska-Bulik & Kobylarczyk, 2015). They are more likely to be optimistic and flexible, and have an ability to regulate emotions (New et al., 2009). According to Yu et al. (2019) resilient nurses are able to reduce emotional exhaustion and learn more adaptive strategies for coping with job demands. These factors play an important role in trauma processing and help them face the negative outcomes of work-related stress. Moreover, psychological resilience appeared positively related to the level of positive posttraumatic change in a group of medical rescue workers (Ogińska-Bulik & Kobylarczyk, 2015) and firefighters (Ogińska-Bulik & Kobylarczyk, 2016).
Our findings show that job burnout plays a mediating role in the relationship between resilience and STS. The presence of job burnout makes this relationship disappear. It indicates that the occurrence of STS is more closely related to job burnout than to resilience. Individuals with a low level of job burnout may use their resilience to protect themselves from STS, but when they suffer from burnout at a high level the protective role of resilience becomes less relevant. High levels of job burnout and its long duration can deplete resilience and makes individuals more vulnerable to secondary traumatic stress. However, psychological resilience may serve as an important factor in protecting nurses from the negative consequences of work-related stress, that is, job burnout and secondary traumatic stress, but this protective influence is most likely to be observed when the described negative effects occur separately. It appears that resilience may play a more limited role in situations characterized by a number of combined negative outcomes.
It is worth noting that perceived stress at work and its consequence in the form of job burnout may weaken the individual’s resilience, including the ability to cope with stressors, which results in reduction of the protective properties of resilience against STS. The findings are in line with the Conservation of Resources model (Hobfoll, 1989), which suggests that personal resources are depleted by the excessive expenditure needed to cope with a broad range of stressors and their consequences associated with job burnout. This, in turn, may make health care providers more susceptible to the development of further consequences of stress, including STS. Other studies also indicate that job burnout is related to a decline in personal and social resources (Ito & Brotheridge, 2003). Shoji et al. (2015) emphasize that the loss spiral occurring because of high levels of burnout and limited resources has a strong influence on coping with indirect exposure to traumatic events, and as such it is desirable to protect owned resources and develop new ones: this can be facilitated by participation in prevention and treatment programs. Shoji et al. (2015) also highlight the significance of other resources that may be included in a prevention program that builds resources such as control beliefs and self-efficacy. Organizational factors such as reducing caseload size or diversity are also important to reduce negative outcomes of occupational stress, burnout in particular. The literature review by Vokhlacheva, Shakori, and Farzanehkari (2018) shows that workplace interventions (i.e., team meetings, clinical supervision, and psychoeducation based on teaching of self-care strategies), interventions done by community nurses (i.e., rituals reducing negative emotions after patient’s death, joint activities increasing sense of solidarity), and individual nurse interventions (i.e., changes in nurse’s lifestyle, development of resilience, and empathy and self-awareness), may decrease job burnout among nursing staff. Other authors stress the role of retreats, counseling services and therapy programs focused on building emotional support (Henry, 2014). Nurses participating in prevention programs or who are using other types of interventions that counteract burnout are more satisfied with life, show higher levels of job satisfaction and lower levels of distress and can adequately assess and adjust the level of resources to job demands (Braunschneider, 2013; Magtibay, Chesak, Coughlin, & Sood, 2017). In addition, they are in better physical and mental health and are more prone to use personal resources, like resilience, against negative consequences of stress at work (Back et al., 2016; Salvagioni et al., 2017). Job burnout reduction or prevention may contribute to better psychosocial functioning in nurses.
The study does have some limitations. The study was conducted on a relatively small group of nurses and is of a cross-sectional structure. Also, the impact of personal trauma history was not analyzed. Personal trauma history may influence the negative consequences of work-related stress. Palm, Polusny, and Follette (2004) report that employees who have directly experienced some traumatic events may be more resilient to STS and may reveal a low level of negative trauma effects. The ability to cope with stress and to find social support also appears to be important. Pietrzak et al. (2009) suggest that a combination of social support and resilience reduces the risk of developing the negative consequences of job stress. Wagaman, Geiger, Shockley, and Segal (2015) found empathy as an important factor that may protect from STS and job burnout. Further investigation should examine the relationship between social support, coping strategies, personal resources, accomplishment, empathy, and negative outcomes of work-related stress. The current findings need to be confirmed in studies of other professionals working with trauma survivors, including groups of men. A longitudinal design would be useful to verify the direction of the relationship between resilience and the negative consequences of job stress, and the relationship between burnout and STS.
The findings of the research lead to the conclusion that job burnout is positively associated with STS, whereas resilience is negatively correlated with both job burnout and STS. Job burnout plays a role of mediator in the relationship between resilience and STS. Individuals experiencing job burnout are more susceptible to STS after indirect exposure to trauma. Resilience may protect the individuals, including those suffering from low job burnout, from the negative consequences of work-related stress. The degree of protection afforded by resilience in protecting from STS is limited when job burnout is at a high level. Therefore, professional and nonprofessional interventions for individuals experiencing work-related traumatic stress should both focus on building personal resources, that is, psychological resilience and, above all, on decreasing job burnout to prevent secondary traumatic stress in the future.
Strengths and Implications for Practice
The study represents a new contribution to our understanding of the negative outcomes of job stress. Its findings can be used to ameliorate the negative consequences experienced by health care professionals, particularly job burnout. As burnout is a process that develops over a period of years, early recognition of its development is crucial in reducing the likelihood of occurrences of other negative consequences of job stress, including STS. Moreover, it is important to develop an ability to cope with negative outcomes and the development of personal resources, especially psychological resilience which plays a significant role in that process. Resilience not only increases the effectiveness of coping strategies used to manage stressful situations, but it may also be a source of positive change that contributes to posttraumatic growth (Ogińska-Bulik, 2015). Individuals may improve their resilience by using adaptive coping strategies, seeking emotional support, training in mind and body skills, and engaging themselves in interests and healthy behaviors (Perez et al., 2015). It is also appropriate for institutions and organizations to implement resilience-building programs that focus on building self-efficacy and self-confidence, seeking access to supervision and social support, and developing skills that may protect from negative consequences of work-related stress (Burnett & Wahl, 2015; Vanhove, Herian, Perez, Harms, & Lester, 2015).
Corresponding Author
Correspondence concerning this article should be addressed to Paulina Michalska, Institute of Psychology, Department of Health Psychology, University of Lodz, Łǒdź 91-433, PL
Email: [email protected]
Publication History
Received January 19, 2019
Revision received January 22, 2020
Accepted January 23, 2020
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