key: cord-0790725-g3uykrbi
authors: Navarro Prados, Ana Belén; Jiménez García‐Tizón, Sara; Meléndez, Juan Carlos
title: Sense of coherence and burnout in nursing home workers during the COVID‐19 pandemic in Spain
date: 2021-04-24
journal: Health Soc Care Community
DOI: 10.1111/hsc.13397
sha: 1e34313911e63d882f0d5a75caca48186930b474
doc_id: 790725
cord_uid: g3uykrbi

Care staff in nursing homes work in a challenging environment, and the COVID‐19 pandemic has exacerbated those challenges in an unprecedented way. On the other hand, the sense of coherence (SOC) is a competence that could help these professionals perceive the situation as understandable, manageable and meaningful. This study aims to analyse the extent to which potential risk and protective factors against burnout have affected nursing home workers during the COVID‐19 pandemic and to assess the contribution of these factors to their burnout. Three hundred forty professionals who worked in nursing homes in Spain completed a survey and reported on their sociodemographic characteristics and their organisational characteristics of the job related to COVID‐19, SOC and burnout. Multiple linear regression analyses were performed. The results showed that the SOC is highly related to the dimensions of burnout and is a protective factor against this. In addition, the increase in hours has a negative effect, facilitating inadequate responses to stressful situations; and whereas perceived social support and availability of resources have a protective effect, the deterioration in mental and physical health is the most important risk factor. This study could help better understand the psychological consequences of the effort that nursing home workers and can also help design mental health prevention and care interventions for workers that provide them with resources and supports that foster their coping skills.

The COVID-19 pandemic has had a negative impact on daily life.

It has threatened people's physical and mental health and put social and economic development at risk (Brooks et al., 2020; Dewey et al., 2020) . Specifically, nursing homes have been particularly dangerous places for the spread of COVID-19, considerably increasing the mortality rate because vulnerable high-risk populations reside in them (Trabucchi & De Leo, 2020; Verity et al., 2020) . As of 10 May 2020, a total of 16.678 people had died in nursing homes in Spain. These deaths represented 52.3% of all confirmed deaths in Spain at that time (Comas-Herrera et al., 2020) . This outbreak has produced a unique and unprecedented scenario for most nursing homes, which are going through a very disruptive period Zhang et al., 2020) . To save lives and minimise transmission of the virus in nursing homes, many professionals have been working while being exposed to a high risk of contracting the disease. All of them have worked under extreme pressure and may have experienced high levels of distress and/or anxiety because, in addition to the great psychological pressure, in some cases, they have had to make difficult decisions, for example, in those cases in which they have had to prioritise which residents infected in the most serious condition went to the hospital or decisions related to the protocols of action, ensuring the maximum safety of the residents, sometimes with insufficient means and resources Martínez et al., 2014; Solanes, Martín, et al., ; Yang et al., 2020) .

The COVID-19 outbreak could be considered an uncontrollable stressful life event that can contribute to the development of or increase in burnout in these workers. Burnout is defined as an inadequate response to chronic work stress. It is a three-dimensional syndrome characterised by emotional exhaustion, depersonalisation and low personal accomplishment (Maslach, 1976; Maslach et al., 1986) . The burnout syndrome dimension emotional exhaustion refers to the worker's feeling of not being able to give more of him/herself to others and depletion of their energy or emotional resources; depersonalisation involves the worker's attempt to distance him/herself from the person receiving the service, which corresponds to the development of negative attitudes, feelings and responses, such as cynicism, towards the people with whom she has direct contact, in this case, the users of the nursing home; lastly, low personal accomplishment is characterised by the professional's tendency to feel unhappy with him/herself and dissatisfied with their work results because their professional achievements fall below personal expectations, resulting in a negative self-evaluation (Gil-Monte, 2003; Martínez et al., 2014; Ortega & López, 2004; Solanes, Martín, et al., ) .

Burnout occurs more often in high-demand, low-resource settings, and it involves a disconnect between workers' expectations and experiences and neglect of individual needs (Kehoe & Barrett, 2020) . In the geriatric field, the risk of suffering from burnout syndrome is higher, mainly in direct care personnel (e.g., nursing assistants or formal caregivers; Reyes & González, 2016) . These positions lead to daily exposure to situations of emotional overload because, for example, in the long term, the workers can become emotionally involved with the users they assist. This causes them to experience significant pain if the user dies, which is not uncommon in nursing homes (Boerner et al., 2015) and home care workers or home health aides in the community (Boerner et al., 2017) .

In addition, these professionals maintain direct contact with disease on a daily basis, which in many cases cannot be solved because it is chronic or degenerative. Thus, these positions entail complexity to face certain pathologies, for example, dementias, and due to the irreversibility and closeness to death, which can bring disappointment and feelings of helplessness and generate suffering in workers (Juthberg et al., 2010; Kandelman et al., 2017) , especially during the current pandemic.

Therefore, burnout syndrome deserves special attention in these workers because it has negative consequences for their biopsychosocial health (Álvarez & Fernández, 1991; Martínez, 2010; Ortega & López, 2004; Reyes & González, 2016) . Burnout also has a negative effect on the organisational level and, indirectly, on the users of the nursing home to whom these workers give their attention and care (Gil-Monte, 2003; Ortega & López, 2004; Reyes & González, 2016; Solanes, Martín, et al., ) . Over time, different burnout risk factors have been found, as well as protective factors or buffers.

Lack of social support has been related to higher levels of burnout (Gil-Monte, 2003; Martínez, 2010) . Support from co-workers and friends or family members has been associated with less emotional exhaustion and higher levels of personal accomplishment (Woodhead et al., 2014) . Therefore, strengthening this aspect in workers could mitigate the effects of work stress on health (Garcia-Rojas et al., 2015; Schmidt, 2013) . During this pandemic, social support may have played an important role. Thus, for example, a study with nurses found that continuously sharing feelings and experiences with colleagues and expressing negative emotions greatly reduced stress and exhaustion levels (Catton, 2020; Mo et al., 2020) .

In addition, ambiguity and role conflict have been considered organisational risk factors for burnout (Chamberlain et al., 2017) .

The former refers to uncertainty about the worker's tasks, duties and responsibilities. The latter would occur when the worker is asked to do tasks that she/he feels are not part of their job or when there is a conflict between the job and their personal beliefs (Gil-Monte & Peiró, 1998). In addition, the presence of deficient • While the increase in hours and the deterioration in mental and physical health are risk factors of burnout, the perceived social support and availability of resources are protectors of it.

• Interventions that develop the sense of coherence are needed to reduce the burnout and improve the biopsychosocial health of nursing home workers.

conditions in the place where the work is carried out (e.g., noise, light, space, ventilation or temperature) is another influential factor (Álvarez & Fernández, 1991) , especially during this pandemic .

Pandemic studies with healthcare workers have shown that an excessive load in terms of working hours, inadequate personal protective equipment, uncertainty about their safety and that of their families and concerns about patient mortality are factors that can trigger this psychological distress called burnout during this critical and novel situation Lai et al., 2020) .

In this pandemic situation, stress and difficulties have been present. To face them, Antonovsky (1987) proposed sense of coherence (SOC) as an important factor for health enhancement based on the results of research in highly motivated and healthy middle-aged and older people under stressful conditions. Sense of coherence is defined as one's ability to understand a particular situation and use the available resources effectively by making use of adaptive coping strategies (Eriksson & Lindstrom, 2007) . According to Antonovsky's conceptualisation, SOC has three components: comprehensibility (cognitive), manageability (instrumental) and meaningfulness (motivational). All this translates into two fundamental elements in stress management: orientation towards accepting and solving problems and the ability to use available resources. For Virués -Ortega et al. (2007) , SOC consists of a general ability to perceive vital experiences that allows the person to act constructively in unfavourable situations.

Sense of coherence has been related to better health and higher quality of life in the general population (López- Martínez et al., 2019; Orgeta & Sterzo, 2013) . It seems to have a protective role against stressors that stem from the work environment and difficulties in balancing work and family (Eriksson & Lindström, 2005 , 2006 ). Thus, for example, people with high SOC show a greater ability to avoid dangerous situations. They tend to incorporate health promoting behaviours more easily and reject harmful ones. However, SOC is associated with a lower risk of health problems, such as burnout or depression (Basińska et al., 2011; Jaracz et al., 2012) , namely, people with low SOC do not have the motivation or cognitive basis for active coping (Antonovsky, 1988) .

Despite the fact that SOC can play a protective role when facing adverse circumstances by reducing levels of emotional overload and anxiety (Antonovsky, 1987; Matsushita et al., 2014) , its relationship with burnout syndrome in nursing home workers during this coronavirus outbreak is still unexplored. The few previous studies, before COVID-19, that established a link between SOC and job burnout, were with samples of pharmacists (Basson & Rothmann, 2002) , health workers (Steinlin et al., 2017) , family caregivers (Matsushita et al., 2014) , teachers (Bracha & Bocos, 2015) and/or university students (Fernández-Martínez et al., 2017) .

Their findings indicate that professionals with a strong SOC are better capable to mobilise resources, appraise stressful situations as challenging and use effective problem-solving approaches in order to manage stress and to experience lower levels of the burnout (Kalimo et al., 2003) . This is so because the stronger the SOC, the greater the tendency to identify the nature of the stressor you are dealing with and select the appropriate resources for the given situation. More specifically, these findings indicate that a weak SOC (and especially manageability) is strongly related to emotional exhaustion.

Therefore, the main objective of this study is to analyse to what extent possible risk factors and protectors against burnout have affected nursing home workers during the COVID-19 pandemic and evaluate the contribution of these factors to their burnout. Because future waves of the pandemic might occur, and this type of problem may also reappear in the future, this information can be useful because it would provide strategies for how to act in future pandemics.

Participants were 340 professionals who worked in nursing homes in Spain during the COVID-19 pandemic, with an age range from 20 to 65 years (M = 42.16, SD = 10.90); 89% were women and 11% men; 21.5% were single, 64.7% were married or lived with a partner, 0.9% were widowers, 8.8% were divorced or separated and 4.1% had another marital status. Regarding the education level, 8.2% had completed elementary school, 40.6% had completed secondary school and 51.2% had attended university. The participants' positions at work were 11.5% direction and/or management, 35.6% technical staff, 39.1% direct care staff and 13.8% other services. Therefore, the inclusion criteria were the following: (a) they had to work in a nursing home, and (b) they had to be occupationally active from the time of first case of COVID-19 in Spain.

The nursing homes were public and private property. Sixty-four per cent of workers reported that the institution where they worked had COVID outbreak, while 36% did not.

We conducted a cross-sectional survey through the Microsoft Office Forms platform. The national quarantine in Spain was declared on Saturday 14 March. This survey was available online from Sunday 17 May (at 15:00 hr) to Wednesday 27 May (23:59 hr), when the COVID-19 pandemic had been present in Spain for more than 2 months, so that its effects on these workers could be observed.

Of a total of 397 participants who initiated the survey, 340 (85.64%) completed the full survey, including all the assessment measures.

Participants were contacted through social networks (WhatsApp, Facebook or LinkedIn) and older people's associations and organisations from different backgrounds and using the snowball sampling technique. Participation was completely voluntary, the survey was anonymous and confidentiality of all information provided was ensured. Before starting the survey, all participants were required to read the instructions and provide informed consent, and they could abandon the survey at any time for any reason. Those participants who agreed to answer the survey had to answer all the questions in order to advance.

Information about sociodemographic and organisational characteristics of the job related to the COVID-19 pandemic were collected.

We asked if there was an increase in working hours due to the pandemic, with 'yes' or 'no' answers. In addition, information was obtained about five characteristics of the work, with answers ranging from 1 'Strongly disagree' to 5 'Strongly agree'. The characteristics

were ( Maslach Burnout Inventory (MBI; Maslach et al., 1986) . This 22item scale was used to measure the professionals' feelings and attitudes in their work and towards clients or users, in this case. It included a 6-point Likert scale ranging from 0 (never) to 6 (every day).

These items measure the three dimensions of burnout syndrome: emotional exhaustion, depersonalisation and personal accomplishment. High scores on the first two dimensions and a low score on the third dimension indicate the presence of the syndrome. The Spanish version (Gil-Monte & Peiró, 1998 , 2000 showed good reliability in our sample for emotional exhaustion (Cronbach's α = 0.89), depersonalisation (Cronbach's α = 0.63) and personal achievement (Cronbach's α = 0.78).

Multiple linear regression analyses were performed to study the association between the dimensions of burnout, SOC, organisational characteristics of the job and aspects related to the COVID-19 pandemic, using the standard method. In addition, zero-order correlations between variables were conducted. All the analyses were carried out with the SPSS 25 program.

The workers who participated in this study showed average levels in 

The main objective of this study was to analyse the contribution of SOC, organisational characteristics of the job and aspects related to the COVID-19 pandemic to burnout in a sample of nursing home workers. The results confirmed that the SOC is highly related to the dimensions of burnout. In addition, the increase in hours had a negative effect that facilitated inadequate responses to stressful situations. Moreover, whereas perceived social support and availability of resources and/or materials have a protective effect, the deterioration in mental and physical health is the most important risk factor. According to Basińska et al. (2011) , high levels of emotional exhaustion and depersonalisation are related to lower levels of personal accomplishment, perceived social support, SOC, availability of necessary resources and clarity in the functions performed. In addition, they are associated with a greater concern about infecting oneself and others, as well as a greater deterioration in physical and/ or emotional health.

Likewise, our results confirm that workers who feel more fulfilled in their work have higher levels of SOC, perceive greater social support, have the necessary resources, seem to have more well-defined functions in performing their work and perceive their physical and/ or mental health to be less deteriorated.

Similar to the findings of Malinauskienė et al. (2009) , we found that SOC is positively related to perceived social support, having the necessary resources available and having defined functions.

Workers who report receiving social support, who have resources and who know the functions associated with their position at work seem to respond appropriately to different life situations, and this facilitates their personal relationships with others. Moreover, studies have shown that when workers have higher SOC, they seem to perceive that their physical and/or mental health is less deteriorated (Eriksson & Lindström, 2006) .

Considering that the SOC is a personal disposition to evaluate life experiences as understandable, manageable and full of meaning, we would expect it to be useful for reducing burnout. After carrying out this study, it seems that being able to manage tension and identify and mobilise resources in order to find solutions and achieve efficient and healthy coping is useful in reducing emotional exhaustion and depersonalisation and increasing personal accomplishment.

Therefore, SOC is a protective factor against burnout (Basińska et al., 2011; Ward et al., 2014) .

In order to reduce the risk of burnout and improve the well- Additionally, managers can help reduce and/or manage stress levels through job redesign, flexible work hours and setting goals, as well as helping workers interpret stressors as challenging stressors and focus on understanding the individual response to workplace characteristics (Le Fevre et al., 2003; Rubino et al., 2012) .

Likewise, having the necessary resources to deal with this situation is another factor that influences burnout. The negative relationship with emotional exhaustion and depersonalisation and the positive relationship with personal accomplishment indicate that the more resources workers have, the less exhaustion, disappointment and loss of interest in the work activity they experience in this situation . Although both factors seem to be important in predicting burnout, workers have less control over the availability of resources. Furthermore, during this pandemic, it has been difficult to obtain resources (e.g., masks or personal protective equipment).

However, the SOC is a variable that can be trained and could act as a predictor of the well-being of nursing homes professionals, and so interventions should be carried out with this population in order to increase SOC and reduce burnout and its negative consequences. It has been described how professionals' resort to stress relief activities such as physical exercise, therapy, yoga, meditation or religious or spirituality-related practices (Kahonen et al., 2012) . Some authors have suggested actions to mitigate the impacts of the pandemic on the mental health of professionals to protect them and promote their psychological well-being during and after the outbreak, among them, remotely delivered psychological therapies and psychoeducation (Fiorillo & Gorwood, 2020; Kisely et al., 2020) .

In line with other studies (e. g., Garrosa et al., 2010; Su & Guo, 2015) , perceived social support seems to function as a predictor of personal accomplishment and emotional exhaustion but not depersonalisation, that is, the development of negative attitudes, feelings or responses towards users. Workers who perceive more social support may also perceive more help in dealing with stressful situations, which would have an impact on feeling more fulfilled at work and having higher energy levels.

In addition, the increase in working hours and the deterioration in physical and/or mental health caused by the COVID-19 pandemic seem to be risk factors in nursing home workers. Therefore, the higher their levels, the greater the emotional exhaustion and depersonalisation will be. This result is consistent with other studies that have attempted to relate stress to workload and perceived health during this pandemic (Lai et al., 2020; Liang et al., 2020) . In spite of these limitations, this study contributes to justifying the need for and relevance of implementing programs that can promote and/or improve the biopsychosocial health of nursing home workers and reduce and/or eliminate burnout levels. There is evidence that burnout experienced by nursing home workers not only affects their well-being but also reduces their abilities to provide valuable help for the older adults and their families. There is a need to foster the well-being of these professionals by empowering your coping resources, within a supportive environment (Del Pino-Casado et al., 2018; Kisely et al., 2020; Stacey, 2020) . This can mainly be achieved through interventions that develop the SOC, aimed at understanding and working on personal strengths and resources that favour better health in workers. That is, programs that promote awareness of available resources and increase people's ability to use these resources can help people manage their responses to stressors and job demands. In addition, they aim for the subject to re-evaluate and restructure stressful or problematic situations so that he can face them more effectively, thus controlling his reaction to stressors. Thus, they seek to improve the perception, interpretation and evaluation of labour disputes, in addition to increasing the personal resources of workers (Gil-Montes, 2003; Martínez, 2010) . The most used are cognitive restructuring, control of dysfunctional or irrational thoughts, systematic desensitisation, stopping of thought and stress inoculation (Jiménez & Navarro, 2020; Kaedin et al., 2017) .

These interventions will have a positive impact not only on the workers themselves but also on the nursing home and the users who live in it.

The authors thank all the participants in the study and the institutions, associations and colleagues from the research team who contributed to the sample recruitment by disseminating the survey.

The authors declare no conflicts of interest associated with this research study.

This study was approved by the Ethics Committee of the University of Salamanca, and all participants provided the informed consent in accordance with the Helsinki Declaration.

The data presented in this study are available on request to the authors. The data are not publicly available due to privacy reasons.

Ana Belén Navarro Prados https://orcid.org/0000-0003-1931-4619

Sara Jiménez García-Tizón https://orcid.org/0000-0003-3960-8665

Juan Carlos Meléndez https://orcid.org/0000-0002-6353-6035

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