Burnout and related concepts: a systematic review exploring moral injury and burnout and an investigation into the role of individual psychological factors in the development of burnout in mental health nurses
BACKGROUND: It has been demonstrated that those working in “helping” roles, such as mental health professionals, are at increased risk of experiencing forms of occupational distress, including burnout, due to the emotional and cognitive demands of their work. More recently, there has been a shift in understandings of occupational distress and consequently the construct of burnout has drawn criticism for its limited validity and narrow conceptualisation. Alternative descriptions of occupational distress have been suggested in the literature, including that of moral injury. This thesis presents a systematic review of the literature quantifying both moral injury and burnout as well as an empirical paper exploring the role of psychological factors in the development of burnout in mental health nurses. PURPOSE: The systematic review aimed to explore the presence and strength of conceptual overlap between burnout and moral injury constructs in the existing empirical literature. The empirical study aimed to explore relationships between job demands, cognitive fusion, self-compassion, coping style, engaged living, demographic variables and burnout. It aimed to determine which variables were predictive of burnout, whether coping styles and values-based processes indirectly effect the relationship between job demands and burnout, and to explore whether levels of self-compassion and cognitive fusion strengthen or weaken these relationships. METHODS: For the systematic review, specified search terms were used to search multiple electronic databases to identify existing research which used quantitative measures of burnout and moral injury in occupational contexts. Findings were synthesised using a narrative approach. The empirical study utilised a cross-sectional survey of 214 mental health nurses to collect demographic information alongside scores on measures of self-compassion, burnout, engaged living, cognitive fusion, job demands and coping styles. Regression analyses and conditional process analyses were utilised to explore hypothesised relationships between these variables. RESULTS: Ten cross-sectional studies met the criteria specified for inclusion in the systematic review. All studies reported a significant correlation between burnout and moral injury scores. However, preliminary findings suggest the two constructs are distinct. Measurement and assumed core experiences of the two constructs varied considerably. Findings from the empirical paper demonstrated that job demands and engaged living predicted burnout in opposing directions. Conditional process analysis showed that job demands exerted direct and indirect effects on burnout via avoidant coping and a less engaged response style. Self-compassion moderated the relationship between job demands and avoidant coping but did not moderate the overall indirect effect. Cognitive fusion moderated the direct effect between job demands and burnout but not the indirect effect via avoidant coping and engaged living. CONCLUSIONS: There appears to be a significant relationship between moral injury and burnout which warrants further exploration, particularly by using high-quality, longitudinal designs. Both constructs would benefit from efforts to further empirical validation and the development of a measurement standard. Third wave interventions targeted at facilitating engaged living and adaptive coping may be effective in reducing burnout in mental health nurses. Such interventions may also benefit from a self-compassion component.