Promoting resilience to prevent burnout and secondary traumatic stress among intensive care units’ nurses

Abstract

Objectives:

This study aimed to: (a) determine the levels of burnout, secondary traumatic stress, and compassion satisfaction among intensive care unit nurses at the university hospital in Sfax, Tunisia, and (b) explore the relationship between resilience and the three dimensions of professional quality of life in this nursing specialty.

Design and methods:

This was a descriptive and predictive study using validated self-reporting instruments: Professional Quality of Life Scale version 5 and Brief Resilience Scale. Multiple regression using stepwise solution was employed to explore the relationship between resilience and the three dimensions of professional quality of life (burnout (BO), compassion satisfaction (CS), and secondary traumatic stress (STS)). Statistical significance was set at p < 0.05.

Results:

The results revealed that 61.3%, 63.2%, and 47.2% of ICU nurses were in the moderate range for BO, CS, and STS, respectively. Resilience score was the critical predictor contributing to Professional Quality of Life subscales scores: Burnout (β = −0.26, p = 0.001), secondary traumatic stress (β = −0.23, p = 0.001) scores were negatively predicted by resilience score. However, CS score was positively predicted by resilience score (β = 0.28, p = 0.002).

Conclusion:

The current study’s findings support the argument for the development of training programs to promote psychological resilience among ICU nurses in order to improve the quality of professional life.

Keywords

Resilience burnout secondary traumatic stress compassion satisfaction intensive care units nurses

Introduction

Psychosocial risks are a common and unavoidable problem in intensive care units (ICU).¹ Physical, psychological and environmental factors make working in ICU very stressful for nurses.² In addition, ICU nurses are constantly confronted with traumatized patients and those suffering from serious, disabling and potentially life-threatening illnesses.³

In this nursing specialty, the disparity between the demands of the work environment and the individual’s aptitudes can induce symptoms of stress, BO, and compassion fatigue and interfere with CS. These symptoms are intimately related to professional quality of life.⁴

Resilience is an increasingly recognized protective factor against stress. It is defined as a person’s ability to bounce back in the face of adversity and to view adversity as an opportunity for growth.⁵ The study aimed to assess the quality of professional life of intensive care nurses, by determining levels of burnout (BO), secondary traumatic stress (STS), and compassion satisfaction (CS) and to explore the relationship between these three dimensions and resilience among ICU nurses at the university hospital in Sfax, Tunisia. Speciﬁcally, it is hypothesized (H1) that BO and secondary traumatic stress scores would be negatively predicted by resilience score. It is also hypothesized (H2) that CS score would be positively predicted by the resilience score.

Methods

Study design, Sample, and procedures

This cross-sectional study was performed among nurses at the university hospital in Sfax, Tunisia, from January 2024 to March 2024. The population consists of nurses providing direct care in the ICU.

Measures

A self-assessment questionnaire was used to collect the data. In addition to socio-professional details (age, gender, marital status, seniority, department, types of work shifts. . .), two validated scales were used in this study.

Quality of professional life was assessed with the Professional Quality of Life Scale (ProQOL) version 5 (2009).⁶ It consists of three subscales: Compassion satisfaction (CS), Burnout (BO) and Secondary traumatic stress (STS). The convergence of BO and STS describes compassion fatigue (Figure 1).

Figure 1.

Professional quality of life model.⁶

The score for each subscale can range from 10 to 50. Higher scores indicate higher levels of BO, CS, and STS. The level of each subscale (BO, CS, and STS) may be classified as low (score ⩽22), medium (score between 23 and 41), or high (score ⩾42).

The Brief Resilience Scale (BRS)⁷ was used to measure resilience. This instrument provides a self-assessment of individuals’ ability to bounce back or recover quickly from stress.⁸ It consists of six items, each scored on a five-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). The total score is obtained by adding up the scores for the all six items, then dividing the total sum by six. Higher scores indicate greater resilience.

Data collection

Participants were invited to take part in the study by telephone calls and personal letters. The participation in the survey was voluntary, and after giving informed consent. Participants were asked to complete the survey anonymously. To encourage participation in our research, we had daily reminded participants to complete the survey, and we were available to answer any questions they might have about the survey.

Data analysis

Statistical analyses were performed using SPSS for Windows version 23.0 (SPSS, Chicago, IL). Categorical variables were shown as numbers and percentages, while continuous variables were represented as mean and standard deviation (SD). Bivariate analysis was performed to determine associations between socio-professional characteristics, BO, CS, STS and resilience scores. Hypotheses 1 and 2 were tested through multivariate analysis, using a multiple linear regression model (standardized coefficients beta, standard error, t, p). All Significant variables identified from the bivariate analysis were entered into the regression equation using stepwise selection. Statistical significance was set at p < 0.05.

Results

From the 200 distributed questionnaires, 120 were returned, resulting in a response rate of 60%. Among the returned questionnaires, 14 were excluded due to insufficient answers or missing data. Thus, 106 questionnaires (53%) were used for analysis.

Participant characteristics

The mean age was 36.6 ± 7 years, and 80.1% of nurses were 45 years old or younger. The sex ratio was 1.2. The majority were married (75.5%). Mental diseases were noted in 23.6% of cases (Table 1). Regarding occupational variables, job seniority ranged from 1 to 35 years, with an average of 9.65 ± 6.79 years. More than half of the participants (53.8%) had between 6 and 10 years of service. The majority of nurses (75.5%) worked on a rotating shift schedule (Table 1).

Table 1.

Descriptive data.

Characteristics	Number (n = 106)	Percentage (%)
Gender
Male	58	54.7
Female	48	45.3
Age (years)
25–35	40	37.7
35–45	45	42.4
>45	21	19.9
Marital status
Single	26	24.5
Married	80	75.5
Having children
Yes	76	71.7
No	30	28.3
Chronic comorbidity
No	63	59.4
Somatic diseases	18	17
Mental diseases	25	23.6
Departments of ICU
Pediatric intensive care unit	20	18.8
Neonatal intensive care unit	23	21.8
Psychiatric intensive care unit	10	9.4
Post-anesthesia care unit	10	9.4
Surgical intensive care unit	20	18.8
Critical care unit	23	21.8
Types of work shifts
Fixed day shifts (7 AM→1 PM) or (1 PM→7 PM)	16	15.1
Fixed night shifts (7 PM→7 AM)	10	9.4
Rotating shifts	80	75.5
Job seniority
1–5 years	31	29.2
5–10 years	57	53.8
>10 years	18	17

Professional quality of life scale (ProQOL) and brief resilience scale (BRS)

Descriptive analysis of BO, CS, STS, and resilience were reported in Table 2. ICU nurses were in the moderate range for Bo, CS, and STS, with 61.3%, 63.2%, and 47.2% respectively (Table 2).

Table 2.

Descriptive analysis for the BO, CS, STS, and resilience.

The scale	Mean ± SD	Median (min–max)	Level %
The scale	Mean ± SD	Median (min–max)	Low (score ⩽22)	Medium (score from 23 to 41)	High (score ⩾42)
Professional quality of life scale (ProQOL)
Burnout	30.9 ± 7.1	30 (18–49)	14.2	61.3	24.5
Compassion satisfaction	27.5 ± 9.8	28 (13–50)	27.4	63.2	9.4
Secondary traumatic stress	32.8 ± 8.6	30 (14–45)	17	47.2	35.8
Brief resilience scale	3.3 ± 0.7	3.33 (2–4.5)

Factors associated with professional quality of life and resilience

Bivariate analysis of the study variables showed that the socio-professional factors of our population were associated with BO, CS, and STS, as well as the history of somatic and mental disease (as explained in Table 3). None of the variables examined in this study was significantly associated with resilience.

Table 3.

Determinant factors of BO, CS, STS, and resilience.

Variables	BO	CS	STS	Resilience
BO	1
CS	−0.72**	1
STS	0.84**	−0.78**	1
Resilience	−0.71**	0.68**	−0.71**	1
Age	−0.07	0.13	0.05	0.05
Male gender	−0.05	0.19*	−0.10	0.11
Being married	−0.09	0.17*	−0.05	0.12
Having children	−0.69**	0.01	0.04	−0.09
Somatic diseases	0.25*	−0.24*	0.21*	−0.03
Mental diseases	0.23*	−0.22*	0.25*	0.11
Types of work shifts	−0.39**	−0.38**	0.24*	0.08
Departments (ICU)	0.77**	0.36**	0.45**	0.01
Job seniority	0.37**	0.36**	−0.38**	0.11

p < 0.05; **p < 0.01.

Both BO (r = −0.71, p < 0.01) and STS (r = −0.71, p < 0.01) were negatively correlated with resilience. However, CS was positively correlated with resilience (r = 0.68, p < 0.01; Table 3).

Predictive factors for BO, CS, and STS scores

Multiple regression analysis adjusted to gender, age, and marital status was used to determine which variables could predict BO, CS, and STS. As shown in Table 4, rotating shifts work (β = −0.12, p = 0.01) and working in the critical care unit (β = 0.22, p = 0.005) were identified respectively as a predictive factor for BO and STS. Job seniority (β = 0.12, p = 0.031) was retained as the professional predictive factor of CS. Furthermore, resilience was the most critical predictor contributing to ProQOL subscales: BO (β = −0.26, p = 0.001) and STS (β = −0.23, p = 0.001). However, CS was positively predicted by resilience (β = 0.28, p = 0.002).

Table 4.

Multiple linear regression analysis adjusted to gender, age, and marital status.

Independent factors associated with BO
Model (adjusted R-square = 0.77)	Bêta	t	p	95% confidence interval
Constant		6.37	0.000	(20.07, 38.22)
Rotating shifts work	−0.12	−2.45	0.01	(−3.60, −0.38)
Compassion satisfaction (CS)	−0.24	−3.26	0.001	(−0.58, −0.26)
Secondary traumatic stress (STS)	0.54	6.98	0.000	(0.32, 0.57)
Resilience (BRS)	−0.26	−2.48	0.001	(−2.84, −0.32)
Independent factors associated with CS
Model (adjusted R-square = 0.66)	Bêta	t	p	95% confidence interval
Constant		2.9	0.005	(17.39, 37.33)
Job seniority	0.12	2.18	0.031	(2.03, 4.21)
BO	−0.39	−3.43	0.001	(−1.81, −0.42)
STS	0.17	2.88	0.005	(−2.91, −0.26)
Resilience	0.28	3.21	0.002	(1.87, 3.20)
Independent factors associated with STS
Model (adjusted R-square = 0.78)	Bêta	t	p	95% confidence interval
Constant		3.87	0.000	(9.54, 29.53)
Critical care unit	0.22	2.29	0.005	(2.43, 4.38)
BO	0.59	8.13	0.000	(3.13, 4.02)
CS	−0.29	−4.18	0.000	(−1.81, −0.32)
Resilience	−0.23	−3.19	0.001	(−1.42, −0.62)

Discussion

This study aimed to assess the quality of professional life of intensive care nurses by determining levels of BO, STS, and CS and to explore the relationship between resilience and these three dimensions of professional quality of life among nurses working in ICU.

In the present study, the results indicated moderate levels of BO and STS among 61.3% and 47.2% of ICU nurses, with mean scores respectively 30.9 ± 7.1 and 32.8 ± 8.6. These scores vary among different studies; According to Hunsaker et al., 54.1% of the emergency department nurses were in the average level of burnout, and 65.9% of them were in the low level of STS, with mean scores for BO and STS of 23.66 (SD = 5.87) and 21.57 (SD = 5.44), respectively.⁹

On the contrary, other studies have shown higher levels of these two negative aspects of professional quality of life in this nursing specialty.^10,11 This variability in results could be explained by both the individual and collective dimensions of the populations studied (culture, lifestyle, management support, employment status, etc.).

CS is defined as the amount of pleasure derived from helping others.¹² In this study, a moderate level of CS was noted in 63.2% of respondents, and these findings were consistent with previous studies.^9,13 According to some authors, it is important to carry out more research into the factors that contribute to promoting CS in ICU nurses.^9,14

This present study has also identified certain demographic and professional characteristics that affect the level of BO and STS, as well as the level of CS in ICU nurses.

Rotating shifts work (β = −0.12, p = 0.01) and working in a critical care unit (β = 0.22, p = 0.005) were identified as predictive factors for two negative aspects of professional quality of life (respectively BO and STS scores). Previous researches indicate that critical care nurses have always been at high risk of BO and STS associated with their care-giving activities.^13,14 In addition, shift work characteristics are important factors in job dissatisfaction and BO.¹⁵ For example, rotating shifts work and long working hours are critical BO predictors among healthcare teams. This can be explained by working conditions that make it difficult to reconcile professional and family life, and thus, they are important contributing factors to BO.¹⁶

The only professional characteristic found to predict CS scores was job seniority (β = 0.12, p = 0.031). Although there are conflicting reports in the literature regarding the association between job seniority and CS,¹⁴ some studies showed that the only demographic variable associated with CS was the number of years of experience in nursing.^9,13 Thus, for some authors, in order to promote CS, experienced nurses need to provide a collaborative and supportive environment for new nurses. It might be useful to set up a formal mentoring program in the ICU to pair a more experienced nurse with a new nurse.⁹

The critical modifiable feature related to predicting the level of three dimensions of ProQOL was the resilience score. As hypothesized in H1, burnout (β = −0.26, p = 0.001) and secondary traumatic stress (β = −0.23, p = 0.001) scores were negatively predicted by resilience score. Therefore, it has been proposed that lower levels of BO and STS are linked to a better resilience score. Among the individual characteristics, resilience, a measure of stress coping ability, could buffer the negative impact of traumatic events, BO, and STS.^17–20

Hypothesis H2 indicates that resilience (β = 0.28, p = 0.002) predicts CS. Our findings support previous results that suggest that resilience enhances mindfulness, positive emotions, acceptance, and creates a more positive state of mind.^21–23 Consequently, a high level of CS was strongly linked to a positive effect, such as resilience and was considered as a protective factor against BO and STS.⁴

Resilience is the result of a variety of individual cognitive, affective, and behavioral protective factors, which influence how a person responds to adversity.²⁴ These findings encouraged researchers to establish training programs in order to promote psychological resilience at work.^25,26 Thus, resilience training has been introduced in a different occupational groups, such as healthcare workers and the military.²⁷ The results had shown that specific resilience training can improve positive affect, behavioral control, and stress reactivity.^28,29

Relevance for clinical practice

This research underscores the importance of fostering resilience among intensive care unit nurses to mitigate burnout and secondary traumatic stress. By identifying effective resilience-building strategies, such as peer support and stress management training, practitioners can implement targeted interventions that enhance nurse well-being in intensive care units. This not only improves the mental health of healthcare providers but also positively impacts patient care quality, leading to better outcomes in high-stress environments.²⁹

Limitations and future research

Although the current results were specific to ICU nurses, they may have significant implications for nurses in other hospital units. This study shed some light on the preventative role of resilience in coping with BO and CS. Nevertheless, it has some limitations that need to be clarified. Our study focused on all ICU nurses, and participation was not mandatory; this can cause a volunteer bias (due to the self-selection of participants). Thus, new multicenter studies seem to be necessary to have a larger sample of ICU nurses and improve the representativeness of the study. Additionally, since this study is cross-sectional and correlational, it limits the ability to draw causal conclusions. Therefore, further research may be required to replicate these results using prospective longitudinal data.

Conclusions

The research findings contribute to the understanding of factors that may reduce the risk of burnout and secondary stress and increase compassionate satisfaction in ICU nurses. The current study’s findings support the argument for the development of training programs to promote psychological resilience among ICU nurses in order to improve the quality of professional well-being.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Amel Kchaou

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