Secondary traumatic stress and compassion satisfaction mediate the association between stress and burnout among Korean hospital nurses: a cross-sectional study

Burnout is a syndrome characterized by three dimensions: emotional exhaustion, depersonalization, and reduced personal accomplishment [1]. People who experience burnout are more likely to leave their jobs; in fact, some resign from their jobs without hesitation. Even if they stay in their jobs, their job performance, efficacy, and job satisfaction are significantly decreased. Moreover, burnout adversely affects physical symptoms, like pain, as well as mental health, including depression and anxiety [2, 3]. Indeed, burnout was recently classified as an occupational phenomenon in the 11th Revision of the International Classification of Diseases (ICD-11) [4] indicating that burnout has emerged as a worldwide health problem in workplaces.

Numerous studies have demonstrated an association between work-related or personal stress and burnout [5‐7]. Nurses perform tasks that require professional knowledge and a high level of technical skills; they are also required to cope with patients who have various health needs. Furthermore, nurses experience elevated stress in the course of providing continuous care for patients 24 h a day, as well as contacting and communicating with many medical staff and family members [8‐10]. This results in chronic stress build-up, leading to nurses’ burnout [11]. Stress affects the incidence of burnout, and that burnout eventually negatively affects nurses’ general health [12]. In addition, increased burnout is related to lower quality of nursing care, lower patient satisfaction, and higher healthcare-associated infection rates [13].

Nurses experience secondary traumatic stress (STS), defined as negative behavior and emotion driven by fear and work-related trauma, in the course of caring for patients. STS occurs when nurses are traumatized by their work, and is usually associated with a particular event [14]. However, nurses also experience compassion satisfaction (CS) which is a positive emotion that reflects the rewards of caring for others. CS occurs as a result of working with patients and families and experiencing positive emotional rewards such as fulfillment, joy, and hope [15]. As such, professional quality of life (ProQOL) encompass positive and negative aspects; thus, when discussing work-related quality of life of nurses, it is necessary to consider the influential effects or interactive dynamics between burnout, secondary traumatic stress, and compassion satisfaction.

A study conducted in China indicated that, after adjusting for the covariates, longer working shifts were associated with higher STS [16]. Another study conducted in Israel demonstrated that stress and CS were negatively correlated [17]. Moreover, a number of studies reveal that stress is related to or affects STS and CS [18, 19]. In addition, positive (CS) or negative (STS) feelings experienced by nurses may affect burnout [20‐22]. In a meta-analysis by Zhang et al. [22] which included 11 studies burnout and STS displayed a strong positive correlation (r = 0.59), and burnout and CS was moderately negatively correlated (r = − 0.446). However, there is a limited number of studies confirming the relationship between stress and STS and CS in nurse burnout [23‐25] and it remains unclear what role of STS and CS play in this relationship. Hence, we sought to elucidate how STS and CS function as mediators of burnout.

A high turnover or resignation of nursing staff results in a tremendous nursing shortage [26] and burnout has a major impact on this outcome. According to a report from the National Academies of Science at the end of 2019, 35% of US nurses experience substantial symptoms of burnout [10]. The situation in Korea is more serious, a systematic review of burnout confirmed that Korean nurses had increased burnout compared to nurses in other countries [27]. In addition, the national survey of health workers in Korea reported that physical and psychological burnout was ranked third as the reason for resigning or changing jobs among nursing staff [28]. Although the Korean nurses’ turnover rate is substantially high, no studies have employed national representative sampling and/or factors affecting the burnout of Korean nurses in a clinical setting. Therefore, to reduce burnout among Korean nurses, it is necessary to identify the factors that affect burnout and the relationship between them.

This research followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline [29].

In this study, we evaluated the influence of stress on burnout among Korean nurses and examined the mediating effects of STS and CS. The results from the mediation model indicated that stress had not only a direct effect on burnout among Korean nurses but also an indirect effect on burnout via STS and CS. Additionally, the magnitude of the indirect effects of CS was significantly greater than STS.

Based on a nationwide representative sample, the mean burnout score of Korean nurses was 26.7 (5.2) indicating moderate burnout. In previous studies that used the same measurement tool, the mean burnout score for American nurses was 23.66–25.63 which was lower than for nurses in Korea [23‐25], while the mean burnout score of Chinese nurses was 26, similar to nurses in Korea [38]. The prevalence rate of overtime work in Korean nurses was 88%, which was considerably higher than the rates observed in China (55%) [39] and Europe (27%) [40]. Moreover, the number of patients per nurse was higher than in Thailand, China, the US, and European countries; a higher nurse to patient ratio (1:12.3) is associated with lower quality care and poor patient safety [41]. In fact, the RN-to-population was 3.5:1000, which is less than half of the mean (7.2:1000) of the Organization for Economic Cooperation and Development (OECD) countries [28].

Our study results revealed a strong positive correlation between stress and burnout, consistent with previous research. In particular, work-related stress is considered a major concern, because burnout symptoms are associated with stress due to job demands and lack of organizational support [6, 7]. Although nurses primarily treat patients’ illnesses and enhance their well-being, they are also required to assist with patients’ circumstances such as family dynamics and social support systems. In this process, nurses who provide 24-h care face difficulty with additional tasks, such as handling unexpected system problems or role conflicts with other medical staff [9]. Conflicts between the patient’s circumstance, institutional system/support, and professional responsibilities of nurses often result in increased overtime work and burnout [8, 27, 41].

On the other hand, Khamisa et al. [5] reported that personal stress rather than work-related stress was a better predictor of burnout and general health. Indeed, it has been reported that when there was a problem with their family, nurses were less able to concentrate on work, which increased burnout [42]. However, the results of our regression analysis revealed that married nurses had lower levels of burnout after accounting for other variables (Table 3). This result supports previous findings that work-related stress or compassion fatigue were alleviated by supportive networks from family and community [43, 44]. There are also gender effects on the prevalence of burnout. Most Korean nurses (95.2%) are female [28] and are responsible not only for work but also for family obligations such as childcare at home. Consequently, they may have to endure stressful situations both inside and outside the workplace [45]. Therefore, we should consider family-work conflict (e.g., how personal stress affects burnout) or how much job stress is buffered by personal situations when individuals perceive situations as stressful. However, since this study is a cross-sectional study, it is difficult to be certain whether perceived stress affects burnout or whether burnout affects perceived stress. Therefore, further large-scale longitudinal study is needed to determine the effect on burnout according to stress.

Taken together, the results of these studies suggest that stress assessment and management are an essential approach to prevent burnout. A recent meta-analysis supported the notion that stress management is one of the major effective interventions to prevent and reduce burnout of physicians [46]. However, it is also necessary to consider the relationship between burnout and stress as a whole given the difficulty with categorizing stress into uniquely “job” or “individual” dimensions [44]. To address nurses’ stress management it is necessary to develop a comprehensive plan that encompasses several characteristics, rather than dividing stress into dimensions and presenting partial solutions.

In this study, we confirmed that STS has an indirect effect on the relationship between stress and burnout. Higher stress levels resulted in higher burnout levels and the additional STS further increased burnout. This finding is consistent with those of a previous study in which nurses who had insufficient time to care for patients due to workload experienced high STS [19]. STS progresses rapidly [14] while burnout progresses gradually due to high workload or an unsupportive work environment [27]. Because STS can be prevented and ameliorated [47], medical institutions need to address STS appropriately and take early, preventative measures to ensure that burnout is not exacerbated.

We also confirmed that CS has a partial mediating effect on the relationship between stress and burnout. This was consistent with the results of a previous study investigating the negative correlation between burnout and CS [20]. CS is a positive outcome of working as a nurse, however, its effects are reduced when experiencing significant stressful situations and, consequently, burnout will occur. Conversely, even if there is a stressful situation, a nurse experiencing CS can counterbalance the relationship between stress and burnout. In particular, the indirect effect of CS was greater than the indirect effect by STS (Table 4) resulting in reducing burnout among nurses. Moreover, high empathy reduces a nurse’s burnout [38], which can be interpreted as an additional positive effect experienced by nurses who experience a sense of reward from helping others, even in difficult situations. Therefore, it would be effective to establish a management strategy to reduce the nurses’ burnout in a way that reduces stress and increases CS. Chen et al. (2018) reported that CS was reinforced by workplace support such as regular debriefing with managers and priests for nurse staff, and CS was associated with personality traits (conscientiousness, affability and emotional stability). In addition, an emotional regulation training program that includes psychoeducation, progressive muscle relaxation, and nonjudgmental awareness has been demonstrated to increase CS [48]. Therefore, an improved organizational approach that encourages a dynamic environment, such as group support or coaching, could help nurses engage with CS.

This study was the first investigation of the relationship between stress, STS, CS, and burnout among Korean nurses using a nationwide representative sample. We observed that burnout was associated with nurses’ stress. Comprehensive identification of the causes increasing personal and work-related stress and appropriate interventions will help to reduce nurses’ burnout. We found that STS and CS may exert partial mediating effects on the relationship between stress and burnout in this study, therefore, a multidimensional approach, including reduction of STS and promoting CS within a stress-reducing intervention program will be more effective.