2016 Volume 58 Issue 1 Pages 66-71
Objective: This study investigated the effects of burnout on the relationship between spirituality and mental health among healthcare workers in Hong Kong. Methods: Using a cross-sectional design, 312 healthcare workers (mean age=38.6, SD=9.9; 77.7% females) in a mental rehabilitation institution completed a self-administered questionnaire on anxiety, depression, burnout, and daily spiritual experiences. Multivariate regressions were used to test the effects of burnout on the relationships between daily spiritual experiences and anxiety and depression. Results: After adjusting for age, education level, marital status, and staff ranking, higher levels of daily spiritual experience were associated with lower levels of burnout (β=−0.22, p<0.01), depression (β=−0.68, p<0.01), and anxiety (β=−0.05, p<0.01). Burnout was found to have a significant partial mediating effect on the relationship between daily spiritual experiences and depression (z=−2.99, p<0.01), accounting for 37.8% of the variation in depression. Burnout also completely mediated the relationship between daily spiritual experiences and anxiety (z=−3.06, p<0.01), accounting for 73.9% of the variation in anxiety. Conclusions: The results suggested that the association between spirituality and mental health is influenced by the level of burnout, thereby supporting the role of burnout as a potential mediator. Moreover, day-to-day spiritual practice was found to be potentially protective against burnout and mental health problems. Future interventions could incorporate spirituality training to reduce burnout so as to improve the well-being of healthcare workers.
(J Occup Health 2016; 58: 66–71)
The health and social service sectors are particularly stressful workplace settings, in which healthcare workers often experience job burnout1). Burnout is a prolonged response to chronic emotional and interpersonal workplace stressors and is defined by exhaustion, cynicism, and inefficacy2). Previous studies have demonstrated the adverse health consequences of burnout. For example, social workers who experienced more intense burnout were found to have higher levels of depression, anxiety, and irritability3). Besides, burnout was also found to be associated with increased risk of cardiovascular disease4), diabetes5), chronic fatigue6), and insomnia7). Given the damaging effects of burnout, it is important to understand the potential factors that could alleviate this phenomenon among healthcare workers.
In recent decades, spirituality and mental health have become the foci of a large body of scientific research. Spirituality is defined as the attempt to find meaning, purpose, and hope in relation to the sacred or significant, on a secular, religious, philosophical, humanist, or personal level8). It is an integrating factor within the individual that manifests through senses of interconnectedness, purpose and meaning in life, inner resources, and transcendence9).
The beneficial effects of spirituality with regard to individual health have been documented in different populations. For instance, spirituality was found to buffer the adverse effects of stress on negative affect and physical symptoms among Korean university students10). Tuck, Alleyne11) also found a negative correlation between perceived stress and spiritual well-being among healthy adults. In addition, spirituality was found to moderate the relationship between stressors and life satisfaction12) and was negatively correlated with anxiety, depression, and other behavioral outcomes such as substance abuse13) and alcohol consumption14). Despite the proven association between spirituality and mental health, the underlying mechanism has yet to be explored.
According to the conservation of resources model15), psychological stress is perceived when individuals are confronted with stress and perceived that there is a net loss of resources. On the other hand, when individuals are not confronted to stress, they try to develop resource surpluses in order to cover the possibility of future loss. While people strive to obtain and protect their personal resources, either instrumental (money or shelter), social (social support), or psychological (self-esteem or sense of autonomy), and minimize loss, personal characteristics such as traits and skills play a significant role in stress resistance15). For example, people who reported higher levels of hardiness, locus of control, optimism, and self-consciousness were less likely to experience stress15).
In fact, one of the core components of spirituality is transcendence, which refers to an individual's capacity to transcend the self and view life from a larger and more objective perspective16). Transcendent individuals could discover meaning or creat meaning from experiences in their lives17). Indeed, Coward17) showed that self-transcendence was associated with a number of positive psychological variables in which transcendent individuals reported significantly higher levels of self-esteem, hope, and emotional well-being. Another study also revealed that self-transcendence views and behaviors were positively correlated with sense of purpose, self-worth, and mental health in women with advanced breast cancer and people with AIDS18, 19). In the healthcare context, this capacity to transcend could be a kind of personal resource that may shift individuals' focus of attention and help lower stress and burnout levels and thus protect healthcare workers from developing mental health-related problems. Rather than assessing the religion-specific beliefs or behaviors of an individual, the daily spiritual experience (DSE) was used to examine the component of spirituality in this study20). DSE refers to the emotional perception of an individual toward the transcendent in daily life. It is regarded as a pragmatic approach to understanding spirituality. Existing measures for spirituality that focus on individuals' spiritual beliefs, behavior, or traits in assessing one's spirituality have often been considered too broad and abstract20). DSE focuses on direct individual encounters with the transcendent in an individual's routine experiences20). Since burnout is an ongoing, daily stress reaction, other daily processes, such as daily spiritual experiences, are likely to be more strongly related to burnout21). Thus the aim of this study was to investigate the relationship between individuals' daily spiritual experiences and mental health among healthcare workers in Hong Kong as well as the role of burnout in the relationship.
A total of 350 healthcare workers from a large mental rehabilitation institution in Hong Kong were invited to participate in this study. Participants were given a self-administered questionnaire that included measures relating to job burnout, spirituality, depression, and anxiety, as well as other demographic information such as the participants' age, gender, marital status, education level, and staff ranking. Informed consent was obtained from the participants, and they were assured that the data would remain confidential and that their personal details would remain anonymous. Participation in the research was entirely voluntary, and no incentives were given to the participants. Ethical approval was obtained from the institutional review board. The questionnaire was completed and returned by 312 healthcare workers, giving a response rate of 89.1%.
Measures1) Burnout
Burnout was measured using the 19-item Copenhagen Burnout Inventory22), the scale consisted of three subdimensions: personal burnout, work-related burnout and client-related burnout. Respondents rated the degree of physical and psychological fatigue and exhaustion associated on a 5-point Likert scale. Sample items included “Do you feel worn out at the end of the working day?” and “Do you feel that every working hour is tiring for you?” The item scores were averaged to compute a global score of burnout, with higher scores denoting higher levels of burnout on a scale of 0–100. The Chinese version of the inventory has been shown to demonstrate acceptable reliability and validity23). The scale also showed good reliability (α=0.92) in this study.
2) Mental health
The mental health of the participants was measured using the 14-item Hospital Anxiety and Depression Scale24), with 7 items on depression and anxiety respectively. Respondents indicated their psychological states in the past week on a 4-point Likert scale. Sample items included “I feel as if I am slowed down” and “I get sudden feelings of panic”. The item scores were summed to produce total scores of anxiety and depression separately, with higher scores denoteing poorer mental health. The Chinese version of the scale has been shown to demonstrate adequate reliability and validity25). In the current study, the scale demonstrated good reliability (α=0.80).
3) Spirituality
The 16-item Daily Spiritual Experience Scale (DSES)14) was used to measure the participants' day-to-day spiritual experiences. This single-factor scale measures some of the common, practical, everyday spiritual experiences, such as awe and joy, that lift the individual out of the mundane and evoke a sense of deep inner peace.
For the first 15 items, the respondents rated the frequency of experiencing a particular spiritual state on a 6-point Likert scale. Sample items included “I feel thankful for my blessings” and “I experience a connection to all life”. The final item asked the respondents to indicate their sense of closeness to God on a 4-point scale. The scores of each item were summed to give a global DSES score, with higher scores indicating higher levels of daily spiritual experiences within the range of 16–94. The Chinese version of the DSES has been shown to demonstrate high reliability and validity20). In this study, the scale demonstrated excellent reliability (α=0.94).
4) Demographic information
Respondents were also asked to provide demographic information, such as: age, gender, education level, and marital status, and information about their job, such as their staff ranking and work unit.
Statistical analysesDescriptive statistics were used to examine sample characteristics. To compare the profile of the participants across gender, independent sample t-tests and chi-square tests were performed to assess the differences in continuous scale scores and categorical proportions such as marital status, education level, and staff ranking, respectively. Demographic variables such as staff ranking, education level, and marital status were coded into dummy variables. Preliminary univariate regression analyses showed that age and the three dummy-coded demographic variables were significantly associated with anxiety and depression. As a result, we controlled these variables in subsequent regression mediation analyses.
The mediation effects of burnout were tested according to the criteria suggested by previous research26). For burnout to be a mediator of daily spiritual experience and anxiety/depression, four criteria should be met: i) daily spiritual experience should be associated with anxiety/depression; ii) burnout should be correlated with anxiety/depression; and iii) controlling for burnout, the relationship between daily spiritual experience and anxiety/depression should be reduced or no longer significant. Sobel tests were computed to examine the significance of the mediation effects. The data analyses were performed using IBM SPSS Statistics 20. The results were calculated with 95% confidence levels, and a p-value of less than 0.05 was considered statistically significant.
Table 1 shows the sociodemographic characteristics of the sample. Of the 312 participants, 77.7% were female and 22.3% were male. About 29.8% were working in a mentally retarded accommodation unit, 37.8% were working in a mentally-ill patient rehabilitation unit, 3.8% were working in a rehabilitation training unit, 5.8% were working in an occupational rehabilitation unit, and 22.1% were working in a general support unit. The mean age of the participants was 38.6 years (SD=9.9). The majority of the participants were married (52.8%), were frontline support staff (82.7%), and had a secondary-level education (71.4%). The mean scores of daily spiritual experiences, burnout, depression, and anxiety were 48.67 (SD=15.66), 28.48 (SD=16.99), 4.61 (SD=3.28), and 5.86 (SD=3.76), respectively, and no gender differences were found. Table 2 shows the summary statistics for the daily spiritual experience scale.
| Entire sample (n=312) | Male (n=69) | Female (n=241) | Tests of differences | ||||
|---|---|---|---|---|---|---|---|
| % | M (SD) | % | M (SD) | % | M (SD) | ||
| Age | 38.6 (9.91) | 36.68 (10.93) | 39.19 (9.53) | −1.85 (ns) | |||
| Marital status | |||||||
| Single | 38 | 53.6 | 33.3 | ||||
| Married | 52.8 | 42 | 56 | ||||
| Divorced/separated/widowed | 9.2 | 4.3 | 10.7 | 10.06 (p<0.01) | |||
| Education level | |||||||
| Primary | 4.9 | 2.9 | 5.4 | ||||
| Secondary | 71.4 | 58.8 | 75 | ||||
| Tertiary | 23.7 | 38.2 | 19.5 | 10.39 (p<0.01) | |||
| Staff ranking | |||||||
| Supporting | 82.7 | 73.9 | 85.1 | ||||
| Professional/management | 17.3 | 926.1 | 14.9 | 4.64 (p<0.05) | |||
| Daily spiritual experience | 48.67 (15.66) | 4.84 (18.10) | 49.23 (14.84) | −0.75 (ns) | |||
| Burnout | 28.48 (16.99) | 31.10 (18.08) | 27.71 (16.64) | 1.22 (ns) | |||
| Depression | 4.61 (3.28) | 5.43 (3.61) | 4.37 (3.15) | 2.00 (ns) | |||
| Anxiety | 5.86 (3.76) | 6.43 (4.33) | 5.70 (3.57) | 1.20 (ns) | |||
Independent t-tests were used for assessing mean differences while chi-square tests were used for proportional differences; M, Mean; SD, standard deviation; ns, nonsignificant.
| Item content | M (SD) |
|---|---|
| 1. I feel God's presence. | 4.00 (1.34) |
| 2. I experience a connection to all life. | 3.80 (1.21) |
| 3. During worship, or at other times when connecting with God, I feel joy, which lifts me out of my daily concerns. | 4.10 (1.19) |
| 4. I find strength in my religion or spirituality. | 4.25 (1.23) |
| 5. I find comfort in my religion or spirituality. | 4.12 (1.28) |
| 6. I feel deep inner peace or harmony. | 3.59 (1.12) |
| 7. I ask for God's help in the midst of daily activities. | 4.23 (1.30) |
| 8. I feel guided by God in the midst of daily activities. | 4.23 (1.36) |
| 9. I feel God's love for me, directly. | 4.21 (1.36) |
| 10. I feel God's love for me, through others. | 4.15 (1.24) |
| 11. I am spiritually touched by the beauty of creation. | 3.91 (1.22) |
| 12. I feel thankful for my blessings. | 3.58 (1.28) |
| 13. I feel a selfless caring for others. | 3.29 (1.09) |
| 14. I accept others even when they do things I think are wrong. | 3.48 (1.00) |
| 15. I desire to be closer to God or in union with Him. | 4.09 (1.37) |
| 16. In general, how close do you feel to God? | 2.00 (0.75) |
For items 1–15, the respondents rated the frequency of experiencing a particular spiritual state on a 6-point Likert scale. For item 16, respondents indicate their sense of closeness to God on a 4-point Likert scale.
As illustrated in Table 3, after controlling for age, education level, marital status, and staff ranking, a significant negative relationship was found between daily spiritual experiences and depression (β=−0.07, p<0.01) as well as burnout (β=−0.22, p<0.01), with increased daily spiritual experiences being related to lower levels of depression and burnout. Increased levels of burnout were also found to be associated with increased levels of depression (β=0.12, p<0.01). The data met the four criteria of mediation suggested by Baron and Kenny26). The standardized beta coefficient was reduced by 0.124 from −0.204 to −0.328, suggesting a partial mediating effect of burnout between daily spiritual experience and depression (z=−2.99, p<0.01), with burnout accounting for 37.8% of the variation in depression.
| Std β | β | SE | 95% CI | p value | |
|---|---|---|---|---|---|
| Daily spiritual experience – depression | −0.328 | −0.068 | 0.014 | −0.095, −0.040 | <0.01 |
| Burnout – depression | 0.624 | 0.122 | 0.011 | 0.100, 0.144 | <0.01 |
| Daily spiritual experience - burnout | −0.216 | −0.221 | 0.071 | −0.361, −0.081 | <0.01 |
| Daily spiritual experience – depression | burnout | −0.204 | −0.042 | 0.012 | −0.065, −0.019 | <0.01 |
| Sobel test | z=−2.99 p< 0.01 R2 change=37.8% | ||||
| Daily spiritual experience – anxiety | −0.211 | −0.050 | 0.016 | −0.082, −0.019 | <0.01 |
| Burnout – anxiety | 0.736 | 0.165 | 0.010 | 0.144, 0.185 | <0.01 |
| Daily spiritual experience - burnout | −0.216 | −0.221 | 0.071 | −0.361, −0.081 | <0.01 |
| Daily spiritual experience – anxiety | burnout | −0.055 | −0.013 | 0.011 | −0.035, 0.009 | ns |
| Sobel test | z=−3.06 p< 0.01 R2 change=73.9% | ||||
Age, education level, marital status, and staff ranking were controlled in all analyses. Std β, standardized beta coefficient; SE, standard error; CI, confidence interval; ns, nonsignificant.
Table 3 also shows that, after controlling for the sociodemographic variables, increased daily spiritual experiences was significantly associated with decreased levels of anxiety (β=−0.05, p<0.01) and burnout (β=−0.22, p<0.01). Elevated levels of burnout were also associated with higher levels of anxiety (β=0.17, p<0.01). The effect of daily spiritual experiences on anxiety became nonsignificant when burnout was included in the regression, suggesting that burnout had a significant complete mediating effect (z=−3.06, p<0.01) on the daily spiritual experiences-anxiety relationship, with burnout accounting for 73.9% of the variance in anxiety.
This study investigated the relationships between daily spiritual experiences, burnout, and mental health using a Chinese sample of healthcare workers in Hong Kong. The results supported the hypothesis that daily spiritual experience is negatively associated with depression, anxiety, and burnout. Individuals who regularly experience feelings of blessedness, connectedness, and transcendence are less likely to experience depression, anxiety, and burnout, suggesting that day-to-day spiritual practice can serve as a potential protective factor against mental health-related problems. These results are consistent with a number of previous studies that found support for the beneficial effects of spiritualty on both physical and mental well-being10, 11, 14).
The results of the current study also supported that burnout mediates the relationship between daily spiritual experience and mental health. Burnout was found to partially mediate the link between daily spiritual experience and depression, and to completely mediate the relationship between daily spiritual experience and anxiety. The results of the Sobel tests revealed that about 37.8% and 73.9% of the variance in depression and anxiety, respectively, may be due to changes in the levels of burnout. A possible explanation for this finding is that daily spiritual activities provide a release from fear and worry, cultivate meaning and purpose, and enable individuals to focus on the small joys of everyday life27), which may help lessen their distress and reduce their risk of developing mental health problems. For example, prayers, meditation, or similar rituals can be used as emotion-focused coping strategies28) to help reduce and manage the intensity of the negative and distressing emotions brought about by the daily work encounters of healthcare workers. In addition, spirituality can provide a broader meaning structure29), helping workers to understand their situation, gain a sense of meaning in their work, and regain cognitive mastery over their situation. As already mentioned, the capacity to view life from different and more objective perspectives may facilitate appraisal-focused coping. All of these factors contribute to more effective coping and lower levels of psychological distress, thus, protecting individuals from developing depression or anxiety21).
Due to the cross-sectional design of this study, caution is warranted in attributing a causal relationship between daily spiritual experience and mental health. In addition, biases may be caused by common method variance, resulting in overestimated impact of the predictors. Besides, the current study did not obtain information about participants' religious beliefs, so it is unclear whether religious beliefs contribute to the differences in spirituality levels among the participants.
Future studies should adopt longitudinal or experimental designs to better ascertain the relationships between daily spiritual experience, burnout, and mental health. Organizational factors, such as the nature of the job, shift work, organizational support, and workloads, and other personal attributes, such as personality and positive and negative affect, also affect the psychological health of healthcare workers. These factors may moderate the relationship between daily spiritual experience and mental health and should be addressed in future studies.
The results of this study offer initial insights suggesting that day-to-day spiritual practice has a significant influence on the mental health of healthcare workers and support burnout as a potential mediator of the relationship between spirituality and mental health. Efforts should be made to increase workers' awareness of spirituality and promote their spiritual growth. A spirituality component could be included in stress reduction intervention programs to reduce the levels of burnout among workers and improve their mental well-being.
Acknowledgment: We would like to thank the Providence Garden for Rehab of Hong Kong Sheng Kung Hui Welfare Council Limited for their help in data collection and the organizational newcomers for their participation in the study. We would like to thank Mr. Ryder Chan for his support and help in this study.
