In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
Bu nou , Compassion Fa igue and Psychological Flexibili y
among Ge ia ic Nu ses: A Mul icen e S udy in Spain
Ca men Sa abia-Cobo 1,* , Vic o ia Pé ez 2, Pablo de Lo ena 2,Ángela Fe nández-Rod íguez 1,
JoséRa ael González-López 3and Julia González-Vaca 4
Ci a ion: Sa abia-Cobo, C.; Pé ez, V.;
de Lo ena, P.; Fe nández-Rod íguez,
Á.; González-López, J.R.;
González-Vaca, J. Bu nou ,
Compassion Fa igue and
Psychological Flexibili y among
Ge ia ic Nu ses: A Mul icen e
S udy in Spain. In . J. En i on. Res.
Public Heal h 2021,18, 7560.
h ps://doi.o g/10.3390/ije ph18147560
Academic Edi o : Paul B. Tchounwou
Recei ed: 22 June 2021
Accep ed: 14 July 2021
Published: 15 July 2021
Publishe ’s No e: MDPI s ays neu al
wi h ega d o ju isdic ional claims in
published maps and ins i u ional a il-
ia ions.
Copy igh : © 2021 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and
condi ions o he C ea i e Commons
A ibu ion (CC BY) license (h ps://
c ea i ecommons.o g/licenses/by/
4.0/).
1Facul ad de En e me ía, IDIVAL, Uni e sidad de Can ab ia, A da Valdecilla s/n, 39011 Can ab ia, Spain;
[email p o ec ed]
2CR San a Lucía, 28001 Mad id, Spain; [email p o ec ed] (V.P.); [email p o ec ed] (P.d.L.)
3Depa men o Nu sing, Facul y o Nu sing, Physio he apy and Podia y, Uni e sidad de Se illa,
C/A enzoa nº6, 41009 Se ille, Spain; [email p o ec ed]
4Depa amen D’Ín e me ia Medicoqui u gica, Campus Bell i ge, Uni e sidad de Ba celona,
08907 Ba celona, Spain; [email p o ec ed]
*Co espondence: [email p o ec ed]
Abs ac :
Nu ses wo king a nu sing homes a e one o he mos ulne able popula ions o su e ing
bu nou and compassion a igue. In Spain, he concep o compassion a igue and psychological
lexibili y ela ed o s ess in ge ia ic nu ses has no been ully explo ed un il now. I is impo an
o analyze hei si ua ion in o de o design obus coping and managemen s a egies. The aim
was o analyze he ela ionship be ween bu nou , compassion a igue and psychological lexibili y
in ge ia ic nu ses in Spain. Pa icipan s included 291 nu ses om 97 cen e s in 51 ci ies ac oss
Spain. Psychological lexibili y (AAQ-II), bu nou (MBI) and compassion a igue (P oQOL) we e
e alua ed. Responses we e ecie ced om 281 nu ses (91% women), wi h an a e age o 7.6 yea s
o wo k expe ience. The MBI esul s we e a e age (26.71), and he P oQOL sco es we e a e age
o compassion a igue (40.2%) and high o compassion sa is ac ion (70.3%), whe eas o AAQ-II,
he mean sco e was 37.34 (SD 4.21). The co ela ion was signi ican and nega i e o lexibili y,
bu nou and compassion a igue, and posi i e o compassion sa is ac ion. The ANOVA indica ed a
signi ican associa ion be ween all a iables (p< 0.05). We can conclude ha ge ia ic nu ses su e
om medium le els o bu nou and compassion a igue, oge he wi h high le els o psychological
lexibili y, which appea s o ac as a s ess elie e , suppo ing compassion sa is ac ion.
Keywo ds: nu ses; s ess; psychological; compassion a igue; men al heal h; ge ia ic nu sing
1. In oduc ion
As ea ly as 1970, Louis Da is unde lined he need o o ganiza ions o be conce ned
abou he wel a e and heal h o all employees, o suppo op imal pe o mance o du-
ies [
1
]. Cu en ly, his encompasses aspec s ela ed o he physical, en i onmen al and
psychological aspec s o he wo kplace [2].
In he ield o heal hca e, he in icacy o ca e wo k (wo k shi s, ela ionships wi h
pa ien s and ela i es, di ec con ac wi h illness, pain and dea h, lack o p o essional
ecogni ion) means ha heal hca e p o essionals su e om ch onic s ess, which leads o
a high incidence o bu nou , as shown in li e a u e e iews, such as a epo by D eison
e al., [
3
] analyzing indings o e he las 35 yea s, o a s udy by Hall which analyzed o y-
six s udies [
4
]. In ge ia ics, hese ac o s a e e en mo e p essing [
5
]. Heal h p o essionals
specializing in his ield a e unde g ea p essu e. They mus es ablish links wi h amilies
o gain hei suppo and us , and ha e o deal wi h elde ly people wi h emo ional
and beha io al diso de s. This is especially ue in demen ia, which is cha ac e ized
by ele a ed ca e needs [
6
]. As demen ia is a long- e m neu odegene a i e disease, bo h
p o essionals and ca egi e s a e a isk o being subjec ed o ch onic s ess and high demand,
In . J. En i on. Res. Public Heal h 2021,18, 7560. h ps://doi.o g/10.3390/ije ph18147560 h ps://www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2021,18, 7560 2 o 10
as co obo a ed by he li e a u e [
7
]. O e ime, all o hese d awbacks can de-mo i a e
he p o essional, inc easing wo k s ess, a o ing he appea ance o bu nou , de e io a ing
he quali y o li e and, ine i ably, also he quali y o ca e [
8
,
9
]. I is impo an o emembe
ha bu nou is unde s ood as he psychological discom o ha is mani es ed as dec eased
pe o mance a wo k, as a esul o maladap i e a i udes and beha io s, ep esen ing a
s ong p edic o o wo k dissa is ac ion, and di ec ly ela ed o he de elopmen o heal h
p oblems [
10
,
11
]. Bu nou implies inadequa e pa ien ca e, isks o pa ien sa e y and a
decline in he quali y o ca e [2–14].
Acco ding o Buunk and Schau eli [
15
] ca ing o people who a e su e ing comes
wi h a high pe sonal cos , as i can lead o a decline in wo k, social and amily unc ions.
Some imes, p o essionals may eel ha hei sense o sel is los . In addi ion, Figley [
16
]
emphasizes he impo ance o knowing ha he abili y o de elop empa hy is one o
he keys o wo king well wi h people who su e , howe e , a he same ime, empa hy
can gene a e an emo ional imbalance due o bu nou and psychological a igue, known
as compassion a igue o empa hy a igue. The concep o empa hy a igue (also called
compassion a igue) is a e m ha was bo n in 1995 a he hand o Cha les Figley, coined as
“compassion a igue”. Fo Cha les Figley [
16
], empa hy a i ion o compassion a igue is a
concep ha ela es o he cos o ca e. Acco ding o he Webs e Encyclopedic Unab idged
Dic iona y o he English Language (ci ed by Figley) [
17
], empa hy a igue is “a eeling o
deep empa hy and so ow o someone who is su e ing”. The di e ence be ween a heal hy
p o essional who wo ks wi h human su e ing and one who has he synd ome is no ha
bo h do no su e he symp oms o empa hic bu nou , bu a he he ch onic na u e o he
symp oms, as poin ed ou in ecen li e a u e e iews [
18
–
21
]. Al hough i is a concep
ha was bo n se e al yea s ago in Spain, i s meaning has been poo ly s udied and is o en
con used wi h o he e ms, including he much mo e s udied bu nou synd ome [22,23].
Po e e al., [
24
] s a e ha one o he di e ences be ween empa hy a igue and bu nou
is ha he o me can a ise in a single session, unlike he la e , which is a p ocess. In
con as , empa hy a igue is isola ed, and e en immedia e. Ano he di e ence s a ed by
Figley [
17
] is ha , among o he consequences, bu nou can esul in a change o wo k o
ca ee . Howe e , compassion a igue is highly ea able once p o essionals ecognize i and
ake s eps o add ess i [
25
]. Showal e [
26
] explains ha ano he no able di e ence be ween
bu nou and empa hy a igue is ha , al hough bo h p oduce a s a e o physical, men al and
emo ional exhaus ion p oduced by being in ol ed in si ua ions o high emo ional demand
o e a long pe iod o ime, bu nou a ises independen ly o he empa hy being p o ided
and wi hou he need o speci ic exposu e o a use ’s su e ing.
The li e a u e indica es ha nu ses a e a high isk o de eloping compassion a igue
and s ess [
27
,
28
]. S udies indica e ha imp o ed educa ion and aining can ha e a
bu e ing e ec on compassion a igue and s ess and may imp o e nu ses’ men al heal h
and hus he quali y o ca e p o ided [
29
,
30
]. Cu en ly, much esea ch is being conduc ed
on he applica ion o Accep ance and Commi men The apy (ACT) [
31
], which aims o
inc ease aluable pe sonal beha io s, inc easing he ecogni ion and accep ance o pe sonal
expe iences associa ed wi h discom o ( hough s, emo ions and eelings) and wha his
en ails: le ing go o con ol as a s a egy ha inc eases he po en ial o discom o [
32
].
An impo an concep ha is add essed in his he apy and is closely ela ed o s ess is
psychological lexibili y, which has been de ined as he “abili y o ully con ac wi h he
p esen momen and he hough s and eelings i con ains, wi hou he need o de ense,
and, depending on he si ua ion, o change o pe sis in he beha io , in o de o achie e
aluable goals” [33].
S udies ha e shown ela ionships be ween psychological lexibili y and impo an
wo kplace beha io s. Highe le els o psychological lexibili y appea o p edic be e
men al heal h and job pe o mance [
34
]. Psychological lexibili y, al hough s able o e ime,
is an indi idual cha ac e is ic ha can be imp o ed, and esea ch has shown ha i can, in
u n, imp o e wo k- ela ed beha io ; o example, con olled ials show ha an inc ease
In . J. En i on. Res. Public Heal h 2021,18, 7560 3 o 10
in psychological lexibili y is he mechanism by which ACT in e en ions imp o e o e all
men al heal h [35–37].
In Spain, he concep o compassion a igue and psychological lexibili y ela ed o
s ess in ge ia ic nu ses has no been ully explo ed un il now, unlike o he in e na ional
se ings [38–40].
Conside ing ha nu ses wo king a nu sing homes a e one o he mos ulne able
popula ions o su e ing bu nou and compassion a igue, i is impo an o analyze hei
si ua ion in o de o design obus coping and managemen s a egies, as sugges ed in he
li e a u e [41].
The e o e, he aim o his s udy was o analyze he ela ionship be ween bu nou ,
compassion a igue and psychological lexibili y in ge ia ic nu ses who wo k in nu sing
homes, ia a mul icen e s udy in Spain.
2. Ma e ials and Me hods
A c oss-sec ional online su ey was designed and hos ed using he Su eyMonkey
pla o m. We ollowed he T anspa en Repo ing o E alua ions wi h Non andomized
Designs (TREND). The da a collec ion pe iod ook place du ing Janua y and
Feb ua y 2020
.
2.1. Sample/Pa icipan s
The ques ionnai e was sen o 97 ca e cen e s o olde people belonging o he same
eligious communi y, dis ibu ed among 51 Spanish ci ies h oughou he coun y. In o al,
291 nu ses ecei ed he ques ionnai e. The inclusion c i e ia we e: a leas six mon hs o
expe ience in he cu en job and no being on sick lea e due o dep ession, psychia ic
diso de o anxie y.
2.2. Va iables and Ins umen s
-
Independen a iables: age, gende , numbe o yea s wo king a he cen e , ma i al
s a us, wo k shi .
- Dependen a iables:
Psychological lexibili y was measu ed using he Accep ance and Ac ion Ques ion-
nai e II (AAQ-II) [
42
] in i s e sion adap ed o Spain [
43
]. This ques ionnai e is based on a
7-poin Like scale. The o al sco es ange om 7 o 49. In alignmen wi h o he p ocesses
in his s udy, his scale was sco ed in e sely, whe eby highe sco es indica ed highe le els
o psychological accep ance and lexibili y (i.e., less expe ien ial a oidance).
Bu nou was measu ed using he Maslach Bu nou In en o y MBI Scale. This con-
sis s o 22 i ems ha a e alued on a Like scale (six possible esponses anging om
“ne e ” o “daily”) o de e mine he equency wi h which a se ies o si ua ions a e expe i-
enced. Th ee dimensions a e e alua ed, o ganized in o h ee subscales: emo ional a igue,
depe sonaliza ion and p o essional ul illmen .
Compassion a igue was assessed using he P o essional Quali y o Li e Scale (P o-
QOL) [
44
,
45
]. This scale measu es he isk o compassion a igue and isk o bu nou as
nega i e consequences o helping p o essions, and he le el o compassion sa is ac ion
expe ienced by he assessed subjec . These h ee dimensions a e e alua ed based on 10
i ems o each dimension, which a e sco ed on a 6-poin Like - ype scale anging om 0
(Ne e ) o 5 (Always).
2.3. Da a Collec ion
The s udy was announced o po en ial pa icipan s in all cen e s h ough e-mail
sys ems and he in ane . The link o he ques ionnai e was p o ided o all in e es ed
pe sons by e-mail. They we e also p o ided wi h in o ma ion abou he con en o he
s udy and we e asked o comple e he s udy in a single session, whene e hey wished.
All pa icipan s ga e hei consen be o e opening and comple ing he su ey. On a e age,
pa icipan s comple ed he ques ionnai e (including ins uc ional eading ime) in 12 min
In . J. En i on. Res. Public Heal h 2021,18, 7560 4 o 10
(SD 3.12). Pa icipan s’ esponses we e expo ed o he IBM SPSS .25 da abase and
p epa ed o da a analysis.
2.4. E hical Conside a ions
Au ho iza ion was ob ained om he Founda ion ha managed all he cen e s, as
well as om he cen e s hemsel es. In addi ion, he Bioe hics Commi ee o he manag-
ing Founda ion g an ed e hical pe mission o his s udy (EC 15/2019). All da a we e
anonymous and we e ea ed acco ding o Spain’s cu en legisla ion. All pa icipan s ga e
w i en consen o pa icipa e in he s udy.
2.5. Da a Analysis
IBM SPSS S a is ics 25 so wa e was used o s a is ical analysis. A bila e al con as
and a 95% con idence le el we e adop ed. A desc ip i e analysis o all he a iables col-
lec ed was pe o med o each g oup. Pa ame ic assump ions (linea i y, homoscedas ici y
and ou lie s) we e isually inspec ed, and he no mali y o he dis ibu ion was e i-
ied. Mul i ac o ial ANOVA and he Pea son’s co ela ion we e used o iden i y po en ial
co a ia es. Linea eg ession was used o analyze he ela ionship be ween psychologi-
cal lexibili y (as an ou come a iable) and he emaining a iables (as co a ia es) using
backwa d elimina ion. S a is ical signi icance was se a p< 0.05.
2.6. Validi y and Reliabili y/Rigo
The s udy design ensu es he c i e ia o alidi y and igo : alida ed and eliable
ins umen s and es s ha e been used, wi h good psychome ic p ope ies o in e nal
consis ency and alidi y, app op ia e and adap ed o he s udy popula ion. Likewise,
he design o da a collec ion and i s subsequen s a is ical analysis ha e ollowed he
ele an quali y and obus ness c i e ia ha allow o ob aining eliable, eplicable and
gene alizable esul s.
3. Resul s
O he 291 nu ses who we e sen he link o he ques ionnai e, 281 esponded o he
ques ionnai e (96.6% esponse a e). Table 1shows he main socio-demog aphic a iables.
Table 1. Sociodemog aphic a iables.
Nu ses (n= 281)
Age (M/SD) 36.8 (5.4)
Gende 91% women
Wo k si ua ion
In e n 11.8%
Pe manen employee 72.8%
Tempo a y 15.4%
Yea s o wo k expe ience (M/SD) 7.6 (4.5)
Shi
Fixed 11%
Ro a ional 47%
Spli -shi 42%
Rega ding he indings o bu nou , analyzing he MBI scale o all p o essionals
(
n= 281
) he mean sco e was 26.71 (SD 7.23). In he subscale o emo ional exhaus ion, we
ound ha 37.2% p esen ed high le els and 47.6% p esen ed medium le els o emo ional
exhaus ion, in he subscale o depe sonaliza ion, 21.8% p esen ed high le els and 59.4%
p esen ed low le els o he same, and o he subscale o pe o mance a wo k, 26.6%
p esen ed high le els, 38.6% p esen ed low le els and 34.8% p esen ed medium le els.
Younge people sco ed highe on emo ional exhaus ion and depe sonaliza ion, al hough
he e we e no s a is ically signi ican di e ences ( = 12.34, p= 0.08; p= 0.07). The e we e
no majo di e ences be ween he h ee subscales by employmen s a us, gende o wo k
In . J. En i on. Res. Public Heal h 2021,18, 7560 5 o 10
shi . We explo ed i he e we e di e ences be ween men and women on psychological
lexibili y and i gende mode a es i s ela ionship wi h bu nou and dep ession, bu he e
was no signi ican esul .
In e ms o indings o compassion a igue, acco ding o P oQoL, sco es below 22 in-
dica e low le els, 23–41 a e a e age and hose abo e 42 a e conside ed high o each
subscale. Wi hin ou sample, bu nou and compassion a igue le els we e in he middle
ange (bu nou : low = 24.5%, a e age = 75%, high = 0.5%; compassion a igue: low =
59.8%, a e age = 40.2%). The sco es o le els o compassion sa is ac ion we e compa a-
i ely highe wi hin ou sample (low = 1.4%, a e age = 70.3%, high = 28.3%). S a is ically
signi ican di e ences we e ound o compassion a igue by yea s wo ked, wi h hese
pe cen ages being highe wi h mo e yea s o wo k expe ience ( = 9.25, p= 0.02). No
s a is ically signi ican di e ences we e ound o compassion a igue and compassion
sa is ac ion by age, gende , p o essional ca ego y o shi .
In e ms o psychological lexibili y, measu ed using he AAQ-II, he mean sco e was
37.34 (SD 4.21), which is conside ed a high ange, wi h s a is ically signi ican di e ences
acco ding o age: he olde he pe son, he mo e lexibili y ( = 24.14, p= 0.00), addi ionally,
he mo e yea s wo ked, which also indica es mo e yea s o wo k expe ience, he g ea e
he lexibili y ( = 32.74, p= 0.00). The esul s o he co ela ion s udy be ween a iables a e
shown in Table 2.
Table 2.
Co ela ional s udy be ween psychological lexibili y, bu nou and compassion a igue, and
compassion sa is ac ion a iables.
Mean (SD) 1 2 3 4
1. Bu nou 26.71 (7.23) –
2. Compassion a igue 22.85 (2.35) 0.74 * – – –
3. Compassion sa is ac ion 38.45 (8.41) −0.65 * −0.71 * – –
4. Psychological lexibili y 37.34 (4.21) −0.74 * −0.78 * −0.58 * –
5. Age 36.8 (5.4) 0.47 0.65 0.88 0.87 *
6. Yea s o wo k expe ience 7.6 (4.5) 0.58 0.74 0.25 0.74 *
* = p< 0.001.
This s udy has shown ha high le els o bu nou a e posi i ely co ela ed wi h p e-
sen ing compassion a igue and in e sely co ela ed wi h psychological lexibili y and
compassion sa is ac ion. We also obse ed a signi ican nega i e co ela ion be ween com-
passion a igue and compassion sa is ac ion and lexibili y. Likewise, he la e co ela es
posi i ely and signi ican ly wi h compassion sa is ac ion.
A mul i ac o ial ANOVA, conside ing psychological lexibili y as an independen
a iable and bu nou , compassion a igue and compassion sa is ac ion as dependen
a iables, indica ed a s a is ically signi ican ela ionship be ween lexibili y and bu nou
(F(8, 261) = 12.34, p= 0.02), be ween lexibili y and compassion a igue (F(8, 261)= 23.54,
p= 0.03) and be ween lexibili y and compassion sa is ac ion (F(8, 261)= 9.45, p= 0.01).
A mul iple eg ession analysis (MRA) wi h he o wa d s epwise me hod was used o
in es iga e po en ially p edic i e ac o s o he de elopmen o psychological lexibili y.
The inal coe icien s a e p esen ed in Table 3.
Table 3. Mul iple eg ession analysis (MRA).
Model Bβ p
Bu nou 51.62 – 27.13 <0.001
Compassion
a igue 42.12 – 19.48 <0.001
Compassion
sa is ac ion 46.71 – 18.31 <0.001
All a iables we e en e ed in o he eg ession model a he i s s ep.
In . J. En i on. Res. Public Heal h 2021,18, 7560 6 o 10
4. Discussion
The aim o his s udy was o analyze he ela ionship be ween he psychological
a iable lexibili y wi h a iables ha ha e a majo impac on he men al heal h o nu ses,
such as compassion a igue and bu nou . Ou indings e ealed ha in ou sample o
281 nu ses wo king in di ec ca e o olde people in long- e m ca e acili ies, he anges
o bu nou and compassion a igue we e medium, whe eas he anges o compassion
sa is ac ion and lexibili y we e high. We also ound a signi ican associa ion be ween
lexibili y as a p o ec i e a iable compa ed o compassion a igue and bu nou . Compa ed
o o he esul s, he ange o bu nou and compassion a igue is sligh ly highe o he
alues s udied in pallia i e ca e nu ses, c i ical ca e uni s and o he s, and is gene ally a
medium le els [6,27,46–48].
Likewise, ecen sys ema ic e iews and me a-analyses show ha compassion a igue
is a phenomenon ha has been s udied mo e ecen ly, in compa ison wi h o he phenomena
such as bu nou . This highligh s he impo ance o he psycho-emo ional and beha io al
consequences ha can a ise om con inued exposu e o expe iencing he su e ing and
pain o people who nu ses ca e o du ing hei illness [3,22,49].
The e a e many s udies on he medium and high le els o bu nou in hese g oups.
Bu nou in ol es nega i e a i udes and beha io s in good job pe o mance in nu sing
in esponse o wo k s ess [
50
]. I is common o heal hca e p o essionals who mus ca e
o complex pa ien s who equi e ex ensi e ca e (such as he elde ly wi h demen ia) o
expe ience educed compassion sa is ac ion, inc eased compassion a igue and bu nou .
The e o e, nu ses su e om mo e emo ional bu nou han o he heal hca e p o ession-
als [
51
]. I seems clea ha he cha ac e is ics o he job, lack o ime and he p essu e o
a end o pa ien s, gene a e an impac on he men al heal h o nu ses, which, i no p ope ly
managed, leads o ch onic s ess [
28
]. These ac s, oge he wi h he p o essional’s own
pe sonal a iables, ha e an impac on he appea ance o bu nou and compassion a igue,
as indica ed by a ecen sys ema ic e iew in he USA, in which wen y p ima y sou ce
publica ions be ween he yea s 2010 and 2017 we e analyzed, epo ing ha he ac o s o
compassion a igue and bu nou we e age, yea s wo king as a nu se, wo k en i onmen ,
coping mechanisms and special ies [52].
Ou esul s seem jus i ied and aligned wi h he eali y o ca e p o ided in he ge ia ic
en i onmen o nu sing homes, whe e bu nou and compassion a igue ou comes a e
highe han in o he ca e se ings [
7
,
40
,
53
]. Wo k in long- e m ca e acili ies in ol es
he complex ca e o pa ien s and amilies ha can lead o s ess and emo ional s ain.
Emo ional s ess may be due o epea ed exposu e o su e ing, ailed a emp s o alle ia e
such su e ing, equen dea hs and he con lic ha may a ise be ween he “cu e” s.
“ca e” pa adigm, especially in he con ex o olde people [
54
,
55
]. This could be so because
h ough empa hy, nu ses can come o in e nalize and become eng ossed in he p oblems
o he people hey help [
56
,
57
]. Figley also adds ano he cause o jus i y he g ea e
ulne abili y o his g oup, conside ing ha compassion and empa hy a e undamen al
and indispensable alues in his p o ession [17].
Mo eo e , acco ding o ou esul s, i is in e es ing o no e ha olde and mo e
expe ienced nu ses had signi ican ly highe a es o lexibili y and compassion sa is ac ion
han younge and less expe ienced nu ses. This is co obo a ed in o he s udies, indica ing
ha expe ience and ma u i y o e he yea s inc eases psychological lexibili y and he
capaci y o accep ance de eloped in ad e se si ua ions [
29
]. In his sense, i is impo an
o con inue in es iga ing wha esou ces he wo ke can use o help main ain high s a es
o ene gy and mo i a ion on and o he job, h oughou he yea s o wo king li e. Thus,
he s udy o psychological lexibili y and ull a en ion as pe sonal esou ces in he ield o
nu sing can be e y in e es ing in ligh o he s udies ha ha e ecen ly appea ed in he
li e a u e and ha ela e bo h o he le els o p o essional bu nou and wo k engagemen
wi hin his collec i e.
I seems clea ha psychological lexibili y ac s as an e ec i e modula o o he
con ol o bu nou and compassion a igue, while a he same ime enhancing compassion
In . J. En i on. Res. Public Heal h 2021,18, 7560 7 o 10
sa is ac ion as a p o ec i e a iable [
58
]. The e o e, in ecen yea s, we ha e seen an
inc ease in s udies aimed a imp o ing lexibili y and accep ance h ough in e en ions
based on he heo y o accep ance and commi men , wi h e y good esul s [
32
,
35
,
59
].
Indeed, in e en ions aimed a inc easing psychological lexibili y may e en p e en
he de elopmen o bu nou synd ome [
36
,
37
]. In his sense, he li e a u e indica es
ha wo ke s wi h g ea e psychological lexibili y do no engage in cons an a oidance
s a egies and accep hei emo ions as pa o he pa h hey ha e decided o ake, which is
di ec ed owa ds hei goals and alues.
As a esul , hey a e able o ollow h ough and espond mo e e ec i ely o oppo -
uni ies ela ed o hei goals [
60
]. This is because he p o essional’s a en ion and ene gy
a e no di ec ed a con olling nega i e in e nal expe iences, and he e o e, hey a e mo e
sensi i e o he in o ma ion p o ided by he wo k en i onmen o ini ia e goal-di ec ed
beha io s [
61
]. In addi ion, coping based on psychological accep ance is less esou ce-
in ensi e han coping based on emo ional con ol [
62
]. Thus, psychological lexibili y
has also been shown o be associa ed wi h inc eased pe o mance and p oduc i i y [
60
]
inc eased i ali y [
63
] and dec eased le els o emo ional bu nou [
56
]. All o his seems
jus i ied as, in ou s udy, high le els o psychological lexibili y we e posi i ely associ-
a ed wi h compassion sa is ac ion and nega i ely associa ed wi h compassion a igue and
bu nou . E idence-based in e en ions ha p omo e compassion sa is ac ion and add ess
nega i e s ess ou comes a e essen ial o equip nu ses wi h s ess managemen skills o
p omo e hei p o essional quali y o li e and men al heal h [42,56].
Limi a ions
Finally, his s udy has some limi a ions ha a e wo h no ing. Due o he c oss-
sec ional na u e o he s udy, i is impossible o es ablish causal ela ionships be ween
he a iables, conside ing ha we used a con enience sample. Fu he mo e, al hough all
he cen e s wo k in he same line, he e is also a loca ion bias, as each cen e has i s own
idiosync asy and wo k en i onmen , and he e o e he esul s may no be as homogeneous.
Ou s udy s eng hs a e he la ge sample size, and he ac ha his was a na ionwide
mul icen e s udy, being he i s o his ype ca ied ou in Spain, ocused exclusi ely on
he a ea o nu sing in old people’s homes.
Fu u e lines o esea ch should o e p o essionals he possibili y o inc easing hei
le els o psychological lexibili y and mind ulness h ough s anda dized aining p og ams
ha ha e shown hei e ec i eness in he heal hca e o ganiza ion, such as s ess educ ion
in e en ions based on Accep ance and Commi men The apy and mind ulness. Ano he
in e es ing line o esea ch is o ca y ou longi udinal s udies o obse e he alue and
ela ionship be ween he s udy a iables o e ime. I seems clea ha an in e es ing line o
esea ch will be o eassess all hese pa ame e s du ing he COVID-19 pandemic we a e
cu en ly expe iencing.
5. Conclusions
In ligh o ou esul s, we can conclude ha emo ional exhaus ion a wo k is a pe sonal
s a e in which con ex ual and pe sonal ac o s in e ac , and whe e psychological lexibili y
seems o be a p o ec i e elemen agains bu nou and compassion a igue, which a e
in e mingled and o e lapping in p o essionals, making i di icul o de ec and ac upon
such ac o s. Nu ses who ca e o olde people, who a e in he inal s age o li e, a e exposed
o g ea e emo ional dis ess, nega i ely a ec ing hei men al heal h, compa ed o o he
special ies. Solu ions o inc ease psychological lexibili y and o alle ia e high le els o
bu nou and compassion a igue should begin wi h ea ly de ec ion o enable app op ia e
in e en ions and o p e en a nega i e p og ession. To ac upon hese p oblems, i
is necessa y o s a egies o be a icula ed, s emming om he a ec ed pe son, hei
colleagues and he o ganiza ion whe e hey wo k. P e en i e measu es and men al heal h
p og ams o wo ke s a e a ac o ha mus be conside ed, due o he cos s ha can be
In . J. En i on. Res. Public Heal h 2021,18, 7560 8 o 10
sa ed on an economic and human le el. I is necessa y o combine he implemen a ion o
ce ain aining p og ams and psychological in e en ions wi h heal hca e s a .
Au ho Con ibu ions:
Concep ualiza ion, C.S.-C.; me hodology, C.S.-C. and P.d.L.; so wa e, C.S.-
C.; alida ion, V.P.; o mal analysis, C.S-C.; in es iga ion, V.P. and P.d.L.; da a cu a ion, C.S.-C.;
w i ing—o iginal d a p epa a ion, C.S.-C., V.P. and P.d.L.; w i ing— e iew and edi ing, Á.F.-R.,
J.R.G.-L. and J.G.-V.; supe ision, C.S.-C. All au ho s ha e ead and ag eed o he published e sion
o he manusc ip .
Funding: This esea ch ecei ed no ex e nal unding.
Ins i u ional Re iew Boa d S a emen :
The s udy was conduc ed acco ding o he guidelines o he
Decla a ion o Helsinki, and app o ed by he Ins i u ional Re iew Boa d (o E hics Commi ee) o
CR San a Lucía (p o ocol code EC 15/2019; June 2019).
In o med Consen S a emen :
In o med consen was ob ained om all subjec s in ol ed in
he s udy
.
Da a A ailabili y S a emen : No applicable.
Acknowledgmen s: The au ho s hank all he pa icipan s in ol ed in his s udy.
Con lic s o In e es : The au ho s decla e no con lic o in e es .
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