July 2018 Article of the Month
by John Ehman, Editor, ACPE Research Article-of-the-Month
and Manager for Pastoral Care, Penn Presbyterian Medical Center, Philadelphia PA
Hotchkiss, J. T. and Lesher, R. "Factors predicting burnout among chaplains: compassion satisfaction, organizational factors, and the mediators of mindful self-care and secondary traumatic stress." Journal of Pastoral Care and Counseling 72, no. 2 (June 2018): 86-98.
SUMMARY and COMMENT: This is one of two articles in the June 2018 issue of the Journal of Pastoral Care and Counseling relating to burnout among members of the Association of Professional Chaplains [--for the other article, see Related Items of Interest, §I, below]. Burnout has been a topic of two previous Article-of-the-Month features: October 2013 and October 2011. The present research adds not only new findings to the literature but also a potentially valuable theoretical framework and the use of the just-published Mindful Self-Care Scale. It is the authors' thoughtful method itself that particularly recommends this article.
Jason Hotchkiss, EdD, and Ruth Lesher, MDiv, work at VITAS Healthcare in Walnut Creek, CA, and bring both pastoral understanding and research expertise to this project, "to examine the relationship between self-care practices and the professional quality of life of chaplains" [p. 89]. They introduce well the concepts of Burnout (BO) and Secondary Traumatic Stress (STS) -- constituent elements of compassion fatigue -- along with the concept of Compassion Satisfaction (CS) [--see pp. 86-87]; and link to these two organizational factors (i.e., "overwhelming caseload" and "feeling bogged down by the system") and the idea of mindful self-care. Regarding the latter, the authors turn to the newly-developed Mindful Self-Care Scale (MSCS) [--see Related Items of Interest, §II, below] and propose a theoretical framework pairing the domains of the MSCS (i.e., Physical Care, Mindful Relaxation, Supportive Structure, Supportive Relationships, Self-Compassion & Purpose, and Mindful Awareness, leading to Compassion Satisfaction) with Abraham Maslow's well-known hierarchy of needs:
[reproduction of Figure 1, p. 88, used with permission of the author]
Email invitations to participate in the study were sent to chaplains affiliated with the Association of Professional Chaplains (5,361), with data collected occurring between October 2, 2017 and December 22, 2017* from 534 respondents. Though only 10.1% of the total sample participated, there were responses from all 50 US states, plus Australia, Canada, Hong Kong, and The Netherlands. Measures included the Professional Quality of Life (ProQOL) in addition to the MSCS, and various demographic information was elicited [--see p. 90, and for the ProQOL see Related Items of Interest, §III, below]. Analysis, according to the study's formal hypotheses, yielded the following:
- Hypothesis 1: "Age, years of experience, education, board certification status, practice setting, and employment status would be predictors of Burnout." [p. 89]
- PARTIALLY SUPPORTED: "Only two factors from the demographic and professional variables remain significant in the final model: board certification status and hospital setting. Becoming a Board-Certified Chaplain (BCC) explained a 7.2% increase in Burnout. The most probable explanation for this result is that becoming a BCC increases spiritual care competencies, leading to potential promotion opportunities and increased work responsibilities, which may increase the BCC's risk for Burnout. ...Working in [a] hospital also explained a small (4.2%) increase in the risk of Burnout. The typical medical center, and its associated acute care elements, adds stressors that might increase Burnout risk." [p. 95]
- Hypothesis 2: "Experiencing compassion satisfaction, practicing multiple and frequent self-care strategies would lower Burnout risk among chaplains; secondary traumatic stress would increase Burnout risk." [p. 89]
- SUPPORTED: "Experiencing compassion satisfaction, practicing multiple and frequent self-care strategies lowered Burnout risk; secondary traumatic stress increased Burnout risk. Hypothesis 2a through 2d [--see directly below] were all confirmed. MSCS was strongly correlated with both CS...and negatively correlated with both STS...and BO.... ...This study found: a negative correlation between CS and STS...; a negative correlation between CS and Burnout...; a positive correlation between STS and Burnout.... In addition, CS, MSCS, and STS were predictors of Burnout." [p. 91]
- - Hypothesis 2a: "CS and MSCS [scores] would be positively correlated." [p. 89]
- - Hypothesis 2b: "STS and MSCS will be negatively correlated." [p. 89]
- - Hypothesis 2c: "BO and MSCS would be negatively correlated." [pp. 89-90]
- - Hypothesis 2d: "CS, MSCS and STS would predict Burnout." [p. 90]
- Hypothesis 3: "STS and MSCS practices would mediate a relationship between CS and Burnout." [p. 90]
- SUPPORTED: "...[T]he indirect effect of STS and all self-care practices on Burnout were all significant (p < 0.01).... [p. 91] ...Secondary traumatic stress and all mindful self-care practices mediated the relationship between compassion satisfaction and risk for Burnout. [pp. 91 and 93] ...While all mindful self-care factors mediated between compassion satisfaction and Burnout, self-compassion and purpose, mindful self-awareness, supportive relationships, supportive structure, mindful relaxation were the strongest protective factors, in order of strength, against Burnout." [p. 94]
Among other results:
- Two work-related/organizational factors, "overwhelming caseload" and the frustration of "feeling bogged down by the system" (selected from the ProQOL measure), predicted Burnout. [--see pp. 91 and 95]
- "While chaplains in this study exhibited moderate secondary traumatic stress and Burnout according to...normed data, they were also found to have high levels of compassion satisfaction." [p. 94]
- "Data analysis...revealed an overall pattern of self-care being practiced by study participants. The self-care practices categorized as supportive relationships were the most frequently practiced (4.51 days per week). The categories of mindful self-awareness (3.85 per days week), self-compassion (3.81 days per week), supportive structure (3.69 days per week) were practiced with nearly equal frequency. Mindful relaxation (2.66 days per week) and physical care (2.39 days per week) practices had the lowest frequency of endorsement among participants." [p. 91, and see also p. 94]
Hotchkiss and Lesher hold that their findings "support the theoretical premise, based on Maslow's model, that deficiency motivations [i.e., basic and psychological needs on the lower levels of the pyramidal model] must be met before higher motivations manifest and that compassion satisfaction is an expression of chaplain self-actualization," and "[w]hen chaplains feel a sense of joy and purpose, and have their needs met as conceptualized in the Maslow hierarchy, they can buffer the impact of compassion fatigue (secondary traumatic stress and Burnout)" [pp. 93-94]. One way of understanding this "joy and purpose" is in terms of a chaplains' sense of calling -- "the feeling that a chaplain's work is a calling that they enjoy" [p. 95, and see p. 89] -- which the authors find to be of central importance for reducing burnout risk [--see pp. 93 and 94]. They encourage "[m]indful efforts to celebrate feeling good about doing good" [p. 96], atop addressing practical and organizational issues. "[C]haplains who felt good about helping their clients and worked in a supportive setting tended to take care of themselves better and have lower risk for Burnout" [p. 96].
The article offers a number of suggestions for reducing Burnout, but this reader was especially struck by the observation from their data, made in light of other research, that "Secondary traumatic stress appears less amendable to mindful self-care activities practiced while at work and in the process of everyday life," and so, "necessary interventions may extend beyond individual self-care to include peer or professional counseling" [p. 95]. However, "In contrast, symptoms of Burnout appear to be more amendable to bodily rest, caring for one's self..." [p. 95]. The authors note that Burnout fits a "resource depletion" model of compassion fatigue by which "helpers become worn out, physically and mentally, by exposure to distressed clients and addressing their care needs" [p. 89, and see p. 95]; whereas STS seems to fit a model of "emotional contagion," referring to an "affective process in which a helper, caring for traumatized persons, feel[s] emotional responses parallel to that person's actual or anticipated emotions" [p. 89]. This would seem to underscore the significance of chaplains' utilizing multi-modal strategies for wellbeing.
Addressing the limitations of the study, the authors state that their findings' "generalizability is increased by chaplains participating from all 50 states" [p. 96], yet the "low overall return rate of 10.1%" [p. 96] is certainly problematic. Nevertheless, as this reader has pointed out before in our Article-of-the-Month features, a study can contribute substantially to the literature largely by raising productive questions, and the present work would seem to proffer many leads for future investigation, including further testing of its own theoretical model, along with methodological elements that could be brought to bear on samples that would support greater generalization.
*NOTE: The dates of data collection were supplied to ACPE Research in a communication from Dr. Hotchkiss and are not mentioned in the published article.
CORRECTION: Jason Hotchkiss has communicated that the sentence on p. 96 that begins, "A low overall return rate of 10.1%, may belie selection bias..." should actually read, "A low overall return rate of 10.1%, may suggest selection bias..." [--italics added here for clarification of the change].
Comment to ACPE Research readers from Jason Hotchkiss, EdD, VITAS Healthcare, Walnut Creek, CA, and Psychology Faculty,
Cornerstone University, Grand Rapids, MI (firstname.lastname@example.org):
Studying wellness among helping professionals, and especially in my own discipline, chaplaincy, has been rewarding. This is my third publication, and I am learning to be patient with the process. I have benefited from excellent mentorship from my co-author Rev. Ruth Lesher. Receiving feedback can be challenging, since I have journeyed through my research and writing with dyslexia. Yet, I have felt joy in the challenges of taking a deeper look at sustainable spiritual care. A reflective practice on feeling good about doing good, and on mindful self-care, are vital for that sustainability. Some of my chaplain colleagues have shared that the practice of spiritual care can't be quantified. Indeed, our work is beautiful and mystical. However, it is worth the effort to increase our visibility in healthcare as the field is moving toward a more holistic understanding of health and wellness. Our chaplain voices will be heard in interdisciplinary teams from the large medical center to the local hospice. I invite you to take charge of your wellness by completing the evidence-based, wellness assessment on my website at www.thecompassionatelife.org/assessment (--scrolling down to the Helping Professionals Assessment). The assessment measures your well-being, mindful self-care and provides custom feedback from which you can take action to improve your self-care and well-being. Many blessings to you as you continue in your courageous journey of spiritual care. --JH
Suggestions for Use of the Article for Student Discussion:
The statistics in this article are likely to be challenging to most chaplain readers, but students could be guided to follow the basic narrative of the text, move initially over the technical aspects that they do not understand, and return to the statistical sections once they have the whole picture of the article in mind, to try to appreciate the finer aspects of the methodological process and data analysis. (An explanation of the null hypothesis could be particularly useful.) Figure 2 [p. 93] might also help students see how the statistical details relate to the larger scheme of things. Of course, for any students interested and versed in research, this article contains a rich amount of information.
Discussion could begin by clarifying the crucial concepts of Burnout, Secondary Traumatic Stress, and Compassion Satisfaction, along with the ideas of self-care and organization factors. For most CPE groups, the experience of chaplaincy may be new enough that Burnout and Secondary Traumatic Stress could be relatively abstract concepts, but Compassion Satisfaction may be a dynamic that they can identify early on; so that may be a productive area to focus on first. Also, the theoretical framework and its graphic representation in figure 1 [--see above, plus pp. 88-89] should easily engage the group. Do students understand Maslow's hierarchy in the first place? Talk of the theoretical framework might be aided by reference to the specific items of the Mindful Self-Care Scale, which can be found freely online [--see Related Items of Interest, §II, below]. What do students think of the observation that Burnout was not associated with a hospice setting like it was for a hospital setting? Does the authors' mention of the idea of "calling" [pp. 89, 93, 94, and 95] resonate with students? Does it fit will all students' religious traditions or personal perspectives? Finally, has this research provided insights or raised questions that students see as having practical application for themselves?
Related Items of Interest:
I. Also regarding burnout, in same issue of the journal is:
Oliver, R., Hughes, B. and Weiss, G. "A study of the self-reported resilience of APC chaplains." Journal of Pastoral Care and Counseling 72, no. 2 (June 2018): 99-103. [(Abstract:) Approximately 5000 members of the Association of Professional Chaplains were surveyed using the Professional Quality of Life instrument in order to assess levels of Compassion Satisfaction and Compassion Fatigue and its associated subscales, Burnout and Secondary Traumatic Stress; 1299 surveys were completed. The most significant finding of this study is that Board Certified Chaplains have remarkably low scores of Burnout and Secondary Traumatic Stress and significantly high levels of Compassion Satisfaction.]
II. The Mindful Self-Care Scale (MSCS) may be found in the Appendix (p. 173) of:
Cook-Cottone, C. P. and Guyker, W. M. "The development and validation of the Mindful Self-Care Scale (MSCS): an assessment of practices that support positive embodiment." Mindfulness 9, no. 1 (February 2018): 161-175. [(Abstract:) This study details the development and validation of a measure of mindful self-care, the Mindful Self-Care Scale (MSCS). Based on theory and emerging empirical work, the MSCS items were developed to align with a set of actionable practices that promote positive embodiment and well-being. The extant literature on self-care was reviewed and a set of items developed. Following expert review, the retained items were factor analyzed (N = 448, aged 18–71, 79.7% female, 90.0% Caucasian) resulting in six factors: physical care, supportive relationships, mindful awareness, self-compassion and purpose, mindful relaxation, and supportive structure. Overall, the MSCS was significantly and positively correlated with body esteem and negatively correlated with eating disorder risk. Confirmatory factor analyses were applied to a second independent sample (N = 452, aged 18–78, 69.7% female, 70.8% Caucasian) providing cross-validation of the six-dimensional structure of the MSCS. Internal consistency was upheld for the total scale and subscales. Findings and implications for future research follow along with a review of the limitations of this study.]
The MSCS is also available directly online from the Mindfulness journal site, along with the abstract and references; and the entire article is available in a pre-publication form from the author's website: www.catherinecookcottone.com.
III. Full information on ProQOL may be found on the measure's website at www.proqol.org, including the questionnaire and manual.
IV. Jason Hotchkiss has also just published:
Hotchkiss, J. T. "Mindful self-care and secondary traumatic stress mediate a relationship between compassion satisfaction and burnout risk among hospice care professionals." American Journal of Hospice and Palliative Medicine 35, no. 8 (August 2018): 1099-1108. [(Abstract:) BACKGROUND: Effective self-care in hospice is anecdotally proclaimed to reduce burnout risk. Yet, the topic has received little empirical attention. PURPOSE: This study developed a model for predicting burnout risk from compassion satisfaction (CS), secondary traumatic stress (STS), and mindful self-care. PARTICIPANTS: Hospice care professionals (n = 324). DESIGN: Cross-sectional self-report survey. RESULTS: Mindful self-care was correlated with CS ( r = 0.497, p < .01), Burnout ( r = -0.726, p < .01), and STS ( r = -0.276, p < .01). A multiple regression model indicated that the combined effect of CS, STS, and mindful self-care explained 73.7% of the variance in Burnout. Mindful self-care and STS mediated a relationship between CS and Burnout. Each self-care category was statistically significant protective factors against burnout risk ( p < .01). Associations with Burnout in order of strength were self-compassion and purpose (SC; r = -0.673), supportive structure (SS; r = -0.650), mindful self-awareness (MS; r = -0.642), mindful relaxation (MR; r = -0.531), supportive relationships (SR; r = -0.503), and physical care (PC; r = -0.435). However, for STS, only SS ( r = -0.407, p < .01) and MR ( r = -0.285, p < .05) were statistically significant protective factors. CONCLUSION: Hospice care professional had higher self-care, CS, lower STS, and Burnout compared to published norms. Those who engaged in multiple and frequent self-care strategies experienced higher professional quality of life. Implications for hospice providers and suggestions for future research are discussed.]
V. Other recent articles relating to burnout among chaplains
McCormick, W. H., Carroll, T. D., Slagel, B. A., Drescher, K. D., Nieuwsma, J. A. and Currier, J. M. "Professional quality of life and changes in spirituality among VHA chaplains: a mixed methods investigation." Journal of Health Care Chaplaincy 23, no. 3 (July-September 2017): 113-129. [(Abstract:) A mixed method design was implemented to examine the spirituality and emotional well-being of Veterans Health Administration (VHA) chaplains and how potential changes in spirituality and emotional well-being may affect their professional quality of life. Four distinct categories of changes emerged from the narrative statements of a nationally representative sample of 267 VHA chaplains: (1) positive changes (e.g., increased empathy), (2) negative changes (e.g., dysthymic mood, questioning religious beliefs), (3) combination of positive and negative changes, and (4) no change (e.g., sustenance through spirituality or self-care). Most chaplains reported positive (37%) or no change (30%) in their spirituality and/or emotional well-being. However, quantitative analyses revealed that chaplains who reported negative changes endorsed greater burnout and secondary traumatic stress. Overall, these findings suggest VHA chaplains are predominantly spiritually resilient, but negative changes in the spiritual domain can occur, potentially increasing the risk of adverse changes in professional quality of life.]
O'Mahony, S., Ziadni, M., Hoerger, M., Levine, S., Baron, A. and Gerhart, J. "Compassion fatigue among palliative care clinicians: findings on personality factors and years of service." American Journal of Hospice and Palliative Medicine 35, no. 2 (February 2018): 343-347. [(Abstract:) OBJECTIVES: Palliative medicine is a rewarding field, but providers encounter patient trauma on a routine basis. Compassion fatigue, marked by burnout, secondary traumatic stress, and low satisfaction may result. However, professionals differ markedly in how they respond to patient trauma. The objective of the current study was to determine whether personality traits of neuroticism and agreeableness relate to aspects of compassion fatigue, after accounting for time spent working in the field. METHODS: Sixty-six palliative medicine physicians, nurses, social workers, and chaplains completed validated measures of personality traits, compassion fatigue, and work background. RESULTS: Providers who had worked longer reported higher levels of satisfaction and lower levels of burnout. Neuroticism demonstrated strong significant associations with secondary traumatic stress and burnout (Ps < .001). Agreeableness was significantly and strongly associated with compassion satisfaction (P < .001). These associations held after accounting for years spent working in the field. SIGNIFICANCE OF RESULTS: Personality traits of neuroticism and agreeableness may convey risk and resilience, respectively, for palliative care professionals. More research is needed to determine if assessing personality traits can help identify providers at risk for adverse reactions to patient trauma.]