key: cord-1037106-c64r5kwg
authors: Ruiz‐Fernández, María D.; Ramos‐Pichardo, Juan D.; Ibáñez‐Masero, Olivia; Carmona‐Rega, María I.; Sánchez‐Ruiz, Máximo J.; Ortega‐Galán, Ángela M.
title: Professional quality of life, self‐compassion, resilience, and empathy in healthcare professionals during COVID‐19 crisis in Spain
date: 2021-05-25
journal: Res Nurs Health
DOI: 10.1002/nur.22158
sha: a6ad76f003539551df8bf792376bfd10f4fae24a
doc_id: 1037106
cord_uid: c64r5kwg

The coronavirus pandemic has exposed healthcare professionals to suffering and stressful working conditions. The aim of this study was to analyze professional quality of life among healthcare professionals and its relationship with empathy, resilience, and self‐compassion during the COVID‐19 crisis in Spain. A cross‐sectional study was conducted with 506 healthcare professionals, who participated by completing an online questionnaire. A descriptive correlational analysis was performed. A multivariate regression analysis and a decision tree were used to identify the variables associated with professional quality of life. Empathy, resilience, and mindfulness were the main predictors of compassion fatigue, compassion satisfaction, and burnout, respectively.

Spain has been one of the countries most affected by the coronavirus in the world, with very high daily mortality and infection rates (Ceylan, 2020) . Healthcare professionals have faced a wide range of specific challenges arising from the pandemic (Shanafelt et al., 2020) , including working without sufficient personal protective equipment, fear of contagion, acting as intermediaries between isolated patients and family members, witnessing a large number of deaths, assisting dying patients, facing rationing decisions, poor work environments with insufficient staff, hostile working relationships, and ineffective leadership (Halcomb et al., 2020; Shanafelt et al., 2020) .

Compassion and self-compassion are potential protective factors against the psychological consequences of these situations for healthcare professionals (Duarte et al., 2016) . Compassion may be defined as sensitivity to others' suffering coupled with the motivation to alleviate and prevent this suffering (Sinclair et al., 2017) . Compassion involves sensitivity, recognition, understanding, emotional resonance, empathic concern, and tolerance for the distress generated by the suffering of others, coupled with the relational actions to alleviate and prevent it (Faqihi et al., 2017; Lown et al., 2015; Mills et al., 2017; Sinclair et al., 2017) . Self-compassion, on the other hand, is understood as providing ourselves with the care, comfort, and reassurance that we provide to those we care for when they are suffering (Stuntzner, 2015) . To be self-compassionate, one must be kind to oneself rather than judging or criticizing oneself (self-kindness), recognize that suffering is part of human nature (common humanity), and experience the present without overidentifying oneself with one's emotions (over-identification; Neff, 2003) .

The continuous contact with patients' suffering to which healthcare professionals are exposed can have negative consequences for them, although there may be some positive consequences as well. Professional quality of life is a three-dimensional concept that is understood as the degree to which the members of a group are able to fulfill their personal needs through their experiences in the organizational context in which they work (Roney & Acri, 2018; Stamm, 2005) . The three dimensions of professional quality of life are compassion fatigue (CF), burnout (BO; negative consequences), and compassion satisfaction (CS; positive consequence of professional caregiving). Compassion fatigue is defined as the cost of caring for others or caring about their emotional pain (Figley, 2004) . Compassion fatigue may cause a communication deficit with patients, family members, and other colleagues (Nolte et al., 2017) , and is considered to be an avoidance mechanism adopted in response to the suffering of patients and their families (Babineau et al., 2019) . In turn, BO is a syndrome characterized by emotional exhaustion, depersonalization (Lahana et al., 2017) , and lack of personal fulfillment at work appearing as a consequence of continuous exposure to occupational stress Maslach & Jackson, 1981) .

Among the risk factors for BO, factors related to the environment and working conditions have been described, such as work overload, multiple employment, or working shifts, especially at night (Molina-Praena et al., 2018) . In addition, some studies indicate that among the stressors that can influence the occurrence of BO in health professionals is the continuous contact with the suffering of the people they care for (Duarte & Pinto-Gouveia, 2017) . In contrast, CS, that is, the feeling of accomplishment derived from efforts made to help someone else (Mooney et al., 2017; Roney & Acri, 2018) , is a positive aspect of a healthcare professional's work (Craigie et al., 2016) .

There is evidence to suggest that internal resources such as empathy, self-compassion, or resilience can help prevent CF or BO in healthcare professionals (Delgado et al., 2017; Duarte et al., 2016) .

Empathy may be defined as the affective and cognitive attunement that facilitates the understanding of the inner world of others (Hunt et al., 2019) . Empathy has been described in terms of two dimensions: cognitive empathy, which refers to the ability to understand others, and affective empathy, which refers to the ability to share feelings in consonance with others' emotional states (Ge et al., 2016).

In turn, resilience involves enduring stress, tolerating pressure in adverse situations, and reacting by deploying strategies to overcome negative or traumatic experiences (Cooper et al., 2020; Henshall et al., 2020; Terry et al., 2019) . Self-compassion training, meanwhile, has been shown to increase resilience and decrease CF and BO among healthcare professionals (Conversano et al., 2020; Delaney, 2018) . However, studies exploring the relationship of these emotional variables with professional quality of life in health crisis situations are scarce. Therefore, the aim of this study was to analyze professional quality of life and its relationship with empathy, resilience, and self-compassion in healthcare professionals in response to the COVID-19 healthcare crisis in Spain.

A descriptive cross-sectional study was conducted with a sample of 108 physicians and 398 nurses (n = 506) working in primary care, inpatient care, nursing homes, and specific COVID-19 units in 16 regions of Spain. The inclusion criterion was to currently be working as a professional in care services involving direct contact with patients. Professionals working in management or in positions in which they did not have direct contact with patients were excluded.

Professional quality of life was assessed using the Spanish version of the Professional Quality of Life Scale (ProQoL; Morante-Benadero et al., 2006; Stamm, 2005) . It is a self-report questionnaire consisting of 30 items rated on a 6-point Likert scale, divided into three subscales: CF (10 items), CS (10 items), and BO (10 items). On all subscales, higher scores indicate higher levels of CF, CS, or BO respectively. In each case, scores can be categorized as low, moderate, or high: CF (<8 = low; 9-17 = moderate; >17 = high); CS (<33 = low; 34-41 = moderate; >42 = high), and BO (<18 = low; 19-26 = moderate; >27 = high). The Spanish version of ProQoL has a Cronbach's α of 0.782 for CF, 0.774 for CS, and 0.537 for BO, respectively (Galiana et al., 2017) .

The Spanish version of the Basic Empathy Scale (BES; Jolliffe & Farrington, 2006; Oliva Delgado et al., 2011) was used to assess empathy. The scale consists of 9 items rated from 1 (strongly disagree) to 5 (strongly agree), and is divided into two dimensions: affective empathy (4 items), with scores ranging from 4 to 20 points, and cognitive empathy (5 items), with scores ranging from 5 to 25 points. Higher scores indicate higher levels of empathy. Τhe internal consistency of the total scale was 0.84, with 0.85 for the cognitive empathy subscale and 0.84 for the affective empathy subscale (Oliva Delgado et al., 2011) .

Resilience, which is considered to be a positive personal characteristic allowing the individual to adapt to adverse situations, was measured using the Spanish version of the 14-item Resilience Scale Self-compassion, defined as how individuals behave toward themselves at the most difficult times, was measured using the Spanish version of the Self-Compassion Scale (SCS; Garcia-Campayo et al., 2014; Neff, 2003) . This is a 12-item questionnaire with responses rated on a 5point ordinal Likert scale from 1 (almost never) to 5 (almost always). The scale has six subdimensions, each containing two items: self-kindness, common humanity, mindfulness, and their opposites: self-judgment, isolation, and over-identification, which are calculated by reversing the scores. To calculate the subscale scores and total values, it is first necessary to calculate the reverse scores for the items in the negative subscales (self-judgment, isolation, and over-identification). The psychometric properties were adequate, with a Cronbach's α of .89 for the total scale score and ranging between 0.79 and 0.91 for the six subscales 

An online questionnaire was designed for data collection due to the lockdown restrictions in place during the pandemic. Social media pages and the research group's website (http://cuidadoscompasion. T A B L E 1 Sociodemographic and work-related characteristics of the participants and differences in means based on the Professional Quality of Life questionnaire (n = 506) 

Participation through the online questionnaire was voluntary. Before answering the questionnaire, participants had to read a pop-up window with information on the study objectives and give their consent to participate and have their data processed. The confidentiality of the data and the anonymity of the participants were preserved at all times in compliance with Spanish regulations and the ethical principles enshrined in the Declaration of Helsinki. The study was approved by an institutional research ethics committee. was used for data processing.

3 | RESULTS Table 1 shows sociodemographic and work-related data from the sample. A total of 506 healthcare professionals participated in the study, with an average age of 46.7 (SD = 10.2), of whom the majority were nurses with a stable employment status, female, over 46 years old, and married. Mean CS scores were significantly higher in nurses than in physicians, whereas mean BO and CF scores were significantly higher in physicians than in nurses. Table 2) . Table 3 (Table 4 ). For every 1-unit increased in affective empathy and cognitive empathy, CF increased 5.96 and 3.01 points, respectively. Figure 1 shows the decision tree for the dimension of CS. Resilience was found to be the greatest predictor of CS, followed by mindfulness. Participants with higher resilience (>83.5) scores were those with higher mean scores for CS (M = 42.75). As per node 4, 37.4% (n = 189) of the participants were categorized within this node ( Figure 1 ).

In turn, over-identification, resilience, isolation, and mindfulness were the main predictors of BO. The highest mean score for BO (M = 29.45) was observed in node 3, with low mean scores for overidentification (≤6.5) and resilience (≤67.5). This node included 15.6% (n = 79) of the participants (Figure 2) . Over-identification, affective empathy, resilience, and isolation were the main predictors of CF.

Node 4 shows the highest mean values for CF (M = 25.78), with 22.5% (n = 114) of healthcare professionals. Participants in this node had a lower over-identification score (≤6.5) and a higher affective empathy score (>16.5). In addition, the mean score for CF was found to be the lowest in node 5 (M = 13.41), where over-identification (> 6.5) and affective empathy were lower (≤13.5; Figure 3 ).

The aim of this study was to analyze professional quality of life among healthcare professionals and its relationship with empathy, resilience, and self-compassion in an unusual situation for the Spanish health system that has been generated by the COVID-19 pandemic. We found high levels of CF, BO, and CS in the midst of this health crisis. These data are consistent with those obtained in other countries with a serious COVID-19 crisis situation, such as China (Lai et al., 2020; Li et al., 2020) , and with studies conducted before the pandemic showing that continuous contact with patients' suffering can increase CF-as well as CS-among healthcare professionals (Craige et al., 2016; Ruiz-Fernández et al., 2020) .

However, other authors state that, despite the emotional and psychological exhaustion experienced by professionals, the satisfaction they obtain from helping others is very pronounced and could act as a protector against CF and BO (Cummings et al., 2018) .

Resilience has been shown to be the main predictor of CS in this study. The components of resilience include, on the one hand, the acceptance of impermanence and suffering, and on the other hand, equanimity and kindness toward one's own suffering (Southwick et al., 2014 ). Resilience appears to be related to compassion and a variety of studies suggest that having experienced adversity in the past may predispose individuals toward compassion (Lim & DeSteno, 2016) ,

while other studies point out that cultivating acceptance of death and suffering not as a failure but as a natural part of human existence fosters personal growth (Edo-Gual et al., 2015) . Thus, if CS is understood as a sense of achievement or gratification felt by healthcare professionals as a result of their contributions to the wellbeing of patients and their families (Roney & Acri, 2018; Sacco & Copel, 2018) that is achieved through the provision of compassionate care (Coetzee & Laschinger, 2018) , resilience is a personal resource necessary for achieving CS, as it enables healthcare professionals to adjust to the constantly stressful environments that care settings often are (Coetzee & Laschinger, 2018; Sacco & Copel, 2018) .

Interestingly, our results show that occupation (being a nurse or a physician) appears among the variables influencing CS. Nurses have significantly higher CS scores, although they carry out their work under the same difficult conditions generated by the pandemic in terms of workload, uncertainty, and availability of resources and protective measures. Furthermore, the levels of CS obtained among the nurses in our study are also higher than those reported among Spanish nurses in recent studies conducted before the pandemic (Galiana et al., 2017; Ruiz-Fernández et al., 2020) . We believe that the special circumstances generated by the pandemic have given nurses the opportunity to rediscover their own intrinsic motivation to provide care, which had prompted them to choose the nursing profession, through their unconditional effort and commitment to alleviating the suffering of patients in a situation of extreme hardship and uncertainty. The pandemic has also increased the visibility of the work of nurses, showing society the need for highly qualified, specialized professionals, elements that have been considered necessary to improve the social image of the nursing profession (Hoeve et al., 2014) . Thus, in line with Schwartz et al. (2003) , nurses derive satisfaction from working hard and seeing others benefit from their own efforts. This, which could be applicable to physicians, may have been attenuated in their case for two reasons. First, the social image of physicians was already good before the pandemic, so they might have not perceived a significant change in this respect. Second, in the healthcare context in Spain, the final decision on the administration of treatment rests with physicians. During the data collection period of this study, many physicians had to treat critically ill patients with high mortality rates, had to deliver bad news to family members more frequently, or had to prioritize some cases over others due to a lack of resources such as ventilators or ICU beds. It is highly likely that physicians as a whole were not prepared for these situations, causing them to experience moral injury (Greenberg et al., 2020) and

contributing to the development of CF and BO (Winner & Knight, 2019) .

Regarding BO, our regression analysis shows that the mindfulness subdimension of self-compassion is the main negative predictor of BO.

Nonetheless, the decision tree shows that over-identification also has a significant influence on BO, which is consistent with overidentification being conceptualized as the opposite of mindfulness in the construction of the scale used to measure self-compassion in our study (Neff, 2003) . This negative relationship between mindfulness and BO is to be expected, as mindfulness is a state of balance in which individuals are aware of their thoughts and feelings without judging them and without running away from them (Neff, 2003) , whereas BO is characterized by, among other things, a lack of professional fulfilment resulting in low self-esteem and negative assessments of one's own work (Nabizadeh-Gharghozar et al., 2020).

Empathy, especially affective empathy, is the greatest predictor of CF, as reported in other studies (Duarte et al., 2016; Hayuni et al., 2019) .

Compassion fatigue has been defined as a progressive, cumulative pro- (Figley, 2004) . Although empathy has been described as a necessary skill for the development of compassion, other skills such as friendliness, distress tolerance, sensitivity, courage, and generosity are also necessary (Gilbert, 2015) . As a result, a number of authors propose that the negative consequences of exposure to the suffering of others could be termed empathic distress (Klimecki & Singer, 2012) or secondary traumatic stress (Cummings et al., 2018) , instead of CF.

Additionally, over-identification, as a subdimension of selfcompassion, refers to becoming so immersed in one's own emotional reactions that it becomes difficult to connect with others.

According to our results, over-identification was associated with CF, which is consistent with the fact that a high use of self constitutes one of the main antecedents of CF (Coetzee & Klopper, 2010; Jenkins & Warren, 2012) . 

The results of this study show that levels of CF, BO, and CS in health crisis situations caused by COVID-19 are high. Individual factors such as resilience, empathy, or self-compassion influence whether the care work will be positive (CS) or negative (CF and BO) for healthcare professionals. However, situational or environmental factors such as the workload, work organization, or social environment (the recognition of their professional work) may also be influential, although these variables have not been taken into account in this study.

In response to this situation, a series of intervention programs are needed to enhance certain emotion management resources and help prevent the onset of these syndromes. Resilience and the cultivation of compassion must be encouraged among healthcare professionals to prevent CF and BO and increase CS. Being equable and accepting of suffering will enable professionals to make sense of the experiences they face on a daily basis. In addition, cultivating compassion will foster resilience and selfcompassion, and ultimately enable professionals to cope with suffering and death without CF and with CS (Duarte et al., 2016) .

The presence of compassion will permit professionals to remain present in the face of suffering. For this reason, mindfulness should be included in intervention programs for cultivating compassion. Health institutions must take responsibility for the care that their healthcare workers require. The implementation of evidence-based programs that foster compassion will have an impact on the wellbeing of professionals and on the quality of care received by patients. In addition to individual interventions, interventions are needed that involve healthcare institutions and organizations (Crawford et al., 2014) such as offering support services to their own healthcare workers, ethical counseling or psychological support, providing sufficient material and human resources for adequate patient care, and promoting a healthcare system that is safe for both patients and professionals, even in exceptional circumstances such as those generated by the COVID-

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