Compassion Fatigue among Staff in a Medium Secure Psychiatric Setting: Individual and Environmental Factors

Abstract

Despite a growing interest in compassion fatigue and burnout in mental health staff no study has examined the prevalence and correlates of these occurrences in secure psychiatric settings. Such environments have high levels of violence and disturbed behaviour, and staff care for individuals with treatment-resistant mental illness and personality disorders with whom it is difficult to form a therapeutic alliance. As the potential for the development of compassion fatigue/burnout may be higher than in other settings, issues of staff and patient welfare make it important to understand those factors that can be contributory to the development of such conditions.

1. Introduction

The emotional and psychological risks associated with providing direct mental health services are potentially greater and more serious in secure forensic wards than in other high-risk settings [1] because of the nature of these environments. Previous research has shown that compassion fatigue and professional burnout can have a detrimental impact on the delivery of services and quality of care [2, 3]. In the UK, the investigation of serious incidents in a Mid-Staffordshire National Health Service (NHS) hospital [4] noted that a lack of compassion had led to serious failings in care providing, affecting the quality of the service. Care was not person-centred and the absence of a safety culture had led to bullying, low staff morale, denial, acceptance of poor behaviours and management disengagement. The enquiry led to the Department of Health recommending that compassion should be at the forefront of effective clinical healthcare [5].

Compassion fatigue has emerged in the literature as a general term to describe the overall experience of emotional and physical fatigue that mental health professionals experience when treating their patients [6, 7]. Figley [8] describes compassion fatigue as the “cost of caring” for others in emotional and physical pain. Secondary traumatic stress [whose definition is similar to that of compassion fatigue [9]] is a response that occurs when an individual cannot save or rescue someone from harm, leading to guilt and distress [10]. In contrast, burnout occurs when working individuals cannot achieve their goals, resulting in “frustration, a sense of loss of control, increased efforts and diminished morale” ([10], pp. 17–37).Compassion satisfaction, however, refers to the contentment that an individual draws from his or her work, coupled with the act of helping [11, 12]. Higher levels of compassion satisfaction have been associated with lower levels of compassion fatigue and burnout [11, 13].

It is a widely accepted assumption that work in the caring professions is endemically stressful [14]. Within the mental health professions, studies have indicated that compassion fatigue can occur in a range of professions and settings including psychiatric nurses in forensic units [15], psychologists [16], psychiatrists [17], clinical social workers [18], trauma therapists [19, 20], mental health counsellors [21] and emergency service workers as well as general medical nurses [22, 23] and chaplains [24]. According to the National Survey of the Work and Health of Nurses [25], one-fifth of nurses reported that their mental health had made their workload difficult to handle. In the year before the survey, over 50% of nurses had taken time off work because of a physical illness, and 10% had been away for mental health reasons. Risk factors that may contribute to the development of compassion fatigue include psychological distress, depression and anxiety [26], negative affect and a history of trauma/violence [19]. Secure forensic units have high numbers of female frontline staff who are more at risk of compassion fatigue/burnout and represent settings where regular and appropriate ‘restorative’ supervision for staff is not consistently provided [27, 28]. (See Dolley, this volume, for a summary).

Mental health settings with high levels of patient disturbance and high staff turnover are environments that may particularly predispose individuals to the development of compassion fatigue and burnout [13]. Such settings are characterised by stressful work environments, cynicism and negativity from colleagues, limited resources, heavy workloads and low job satisfaction [12].

In secure forensic psychiatric units [15, 29] the environment is characterised by a relatively high level of violence/disturbed behaviour and the potential for compassion fatigue/burnout is potentially higher. Psychiatric nurses face the highest risk of physical and verbal violence [30, 31]. Other factors that may make compassion fatigue more likely are the nature of the client population and their offending behaviour. These include individuals with treatment-resistant schizophrenia and personality disorder (antisocial and borderline) with whom it is difficult to form a therapeutic alliance [32]. Work-related traumatic events typically take the form of verbal threats or assault, or both [33], such that managing these patients can provoke adverse feelings (including fear and anxiety) and intrusive memories from patient assaults [15]. Fear of assault was found to be a problem in the community [34] and it can be seen as a profound factor in secure settings [35]. Interpersonal conflict is viewed as a causal factor in burnout. In the model proposed by Winstanley and Whittington [36] the most considerable variations in burnout are related to multiple experiences of aggression and how aggressive encounters can have a cumulative effect upon burnout levels in healthcare staff. Burnout factors (emotional exhaustion and depersonalisation, as measured by the Maslach Burnout Inventory (MBI; [37])) were significantly higher in those staff who were more frequently victimised by patients, suggesting that aggressive encounters might lead to an increase in burnout. Conversely, elevated levels of burnout may arguably increase vulnerability to perceived victimisation (actual or real) [38]. Winstanley and Whittington [38] proposed a cyclical model suggesting that elevated levels of burnout from all sources might increase vulnerability to victimisation. Increases in emotional exhaustion may result in an increase in depersonalisation, acting as a coping mechanism, which consequently manifests as a negative behavioural change towards patients. Subsequently, a physical and emotional distancing follows, often resulting in patients being treated more as objects than people [39].

Exposure to aggression is a potentially important variable in the assessment of compassion fatigue and burnout. Research in secure forensic psychiatric wards shows that lower levels of behavioural disturbance, as measured by the Overt Aggression Scale (OAS; [40]), are associated with a more positive social climate (that includes measures of ‘perceived safety’ and ‘therapeutic hold’) and a stronger therapeutic alliance between staff and patients [41]. A positive social climate was significantly associated with lower levels of security when medium secure wards were compared with low secure mental health settings and with higher levels of treatment engagement and patient motivation. It is feasible, therefore, that staff in a more positive ward social climate (as measured by EssenCES subscales of patient cohesion, therapeutic hold and experienced safety) will show lower levels of compassion fatigue and burnout, and higher levels of compassion satisfaction [41].

To date, the historical focus on compassion fatigue/burnout in secure settings research has been on variables that are typically outside the control of the individual who is experiencing the compassion fatigue/burnout (e.g. negative client behaviours and organisational factors; [42]). Individual factors of relevance, however, include gender (female staff in forensic mental health settings show an increased awareness of their own personal safety and show greater burnout than male staff; [43, 44]), years of professional experience in a mental health setting (found to be associated with increased compassion fatigue), and lower levels of compassion satisfaction [15]. In the context of medium secure services for people with developmental disabilities, however, it was found that increased time in employment, particularly when combined with behavioural analysis, intervention, training and support to promote attitudinal change was associated with decreases in MBI emotional exhaustion and depersonalisation and an increase in personal accomplishment [45]. Other studies (e.g. [11, 43]) have also found that professional experience may protect against the negative effects of secondary traumatic exposure.

According to longitudinal studies conducted over four decades, such as the Kauai Study [46] and the Lundby study [47] there are several key features characterising those people who are able to overcome extremely difficult conditions despite long-term stress and adversity or maltreatment. The major factor that accounted for the ability to cope with adversity was found to be resilience. People with higher resilience tendencies rely upon favourable dispositional attitudes and behaviours such as internal locus of control, pro-social behaviour and empathy. Resilience (hardiness) is a personality trait that involves the ability to successfully cope with change or adversity [48, 49]. Predictors of resilience include gender, age, race/ethnicity, education, level of trauma exposure, income change, social support, frequency of chronic disease, and recent and past life stressors [50]. Resilience has been found to correlate with compassion fatigue, burnout and compassion satisfaction [51, 52]. Recent studies have questioned whether resilience is a key variable which moderates the relationship between compassion fatigue and burnout. These findings link to ‘positive psychology’ studies of coping, highlighting the importance of self-efficacy in determining outcomes in working life and in clinical settings [53].

Staff members in mental health forensic settings have a vital role in the process of treatment, and the relationship between staff experiences and their well-being may be complex. Compassion fatigue can be considered as a continuum that is affected by many factors. These factors are both individual and environmental and include resilience, social climate, professional stress and personal circumstances. It is likely that staff working in secure mental health settings will be affected by one or more of these factors over the course of their professional career.

As the concept of compassion fatigue among psychiatric staff in secure settings has not been extensively researched, this study aims to address the following questions:

1. Do staff working in secure forensic mental health settings experience significantly more compassion fatigue compared with other groups of healthcare workers?

2. Is the expression of compassion fatigue, burnout and compassion satisfaction related to the social climate of the ward environment, staff resilience, past experience of violence/aggression, individual staff characteristics and individual differences (age, gender, profession and clinical experience)? Specifically, it is hypothesised that:

   1. Higher levels of compassion satisfaction will be associated with lower levels of burnout and secondary traumatic stress as measured by the Professional Quality of Life (ProQOL; [12]) scales.

   2. Staff with more years of experience in a secure mental health setting will show higher levels of burnout and secondary traumatic stress.

   3. Staff with more self-reported experience of violence/aggression in the workplace will show higher levels of burnout and secondary traumatic stress.

   4. Higher social climate (EssenCES) ratings of therapeutic hold and patient cohesion will be associated with higher levels of compassion satisfaction and lower levels of burnout and secondary traumatic stress. Conversely, lower EssenCES ratings of experienced safety will be associated with higher ratings of burnout and secondary traumatic stress.

   5. Higher resilience levels will be associated with lower levels of burnout and secondary traumatic stress and higher levels of compassion satisfaction.

2. Methodology

2.1 Design

This study used a descriptive correlation survey design to collect data using a sample of mental health professionals in a secure psychiatric setting. Participants were selected by a convenience sampling method.

2.2 Setting

Six medium secure units of the men’s and women’s services of an independent healthcare provider were included in the study. The provider was an independent charitable trust provider of mental health treatment for difficult-to-manage patients cared for in secure settings. All participants were recruited from a single hospital site in Great Britain.

2.3 Participants

All participants were working-age adults (18 years+, with no upper age limit) and the sample included a mix of male and female staff.

2.4 Measures

The questionnaires distributed to staff included the following measures:

• Professional Quality of Life Scale (ProQOL v5, [12]): Compassion satisfaction and compassion fatigue were measured using the 30-item ProQOL version 5 scale [12]. The scale is divided into three 10-item subscales which measure an individual’s potential for compassion satisfaction, risk of burnout and risk of secondary traumatic stress; items are rated on a 5-point Likert scale ranging from 1 (never) to 5 (very often).

• Maslach Burnout Inventory (MBI; [54]): The MBI is a well-validated, self-reported 22-item questionnaire scored on a 7-point scale (ranging from 0/Never to 6/Daily). These are grouped into three ‘dimensions’: emotional exhaustion (EE) – lack of energy, feelings of emotional depletion, frustration and tension; depersonalisation (DEP) – lower personal involvement with people, cynicism and emotional detachment from work; and lack of personal accomplishment (PA) – feelings of lower professional competence and diminished ability to have positive personal interactions at work [54, 55]. High scores on depersonalisation and emotional exhaustion along with low scores on personal accomplishment are indicative of burnout.

• Essen Climate Evaluation Schema: EssenCES [56]: The EssenCES was used to assess the social climate of the work environment. The social climate of a psychiatric ward has been defined as “the interaction of aspects of the material, social and emotional conditions of a ward, which may – over time – influence the mood, behaviour and self-concept of the persons involved” ([56], p. 15). The EssenCES has three 5-item subscales: therapeutic hold (the extent to which the ward climate is seen as supportive of patients’ therapeutic needs); patient cohesion and mutual support (whether the mutual support typical of therapeutic communities is present); and experienced safety (the level of perceived tension and threat of aggression and violence). Items are scored on a 0–4 scale, with high scores indicating a positive social climate.

• Actual Level of Violence Measure [36]: This 3-item questionnaire ascertains previous experience of aggression of staff in terms of frequency of self-reported physical assault or being threatened within the preceding 12 months by patients or patients’ relatives/friends. Physical violence is defined as any aggressive contact, regardless of whether an injury was sustained (e.g. hitting, scratching and biting). Threatening behaviour is detailed as statements indicating an intention to harm or threatening by virtue of overt behaviour, e.g. punching the wall or overturning furniture. Finally, verbal aggression is defined as being sworn at, personally insulted or being called names.

• The 14-Item Resilience Scale for Adults (RS-14; [57]): The Resilience Scale was originally developed by Wagnild and Young [57] as a 25-item self-report questionnaire to measure five resilience themes (perception of self; planned future; social competence; family cohesion; social resources; and structured style) using a 7-point Likert scale. Wagnild [58] developed a shorter 14-item version with items rated on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). The scoring on this scale can be interpreted as follows: scores greater than 90 indicate high resilience; 82–90 moderately high; 65–81 moderately low to moderate; 64–57 low, and scores below 56 indicate very low resilience.

• Demographic and Occupational Data: A short questionnaire gathered information on age, gender, clinical profession and professional experience.

2.5 Procedure

The staff questionnaire, which had a number of components was aimed at staff working in medium secure forensic psychiatric settings for people presenting with challenging behaviours and mental health problems. Questions explored staff opinions, experiences and views about their work. The questionnaire was given directly to staff who were willing to take part, so they could complete it at a convenient time.

Following completion, the questionnaires were sealed in an envelope to maintain confidentiality and put into a designated box for the researcher to collect. Completion of the questionnaires took approximately 30 minutes (plus or minus 15 minutes). Participants were able to contact the researcher with queries about completing the questionnaires.

2.6 Ethical considerations

Ethical review was obtained through the University of Birmingham Research Ethics Committee and was approved by the participating charitable trust. The information form stated that participation was voluntary and that data collected would be anonymised.

3. Results

3.1 Participant demographics and descriptive statistics

Of 200 questionnaires distributed, 163 (81%) were returned. 57 questionnaires were withdrawn due to partial completion. 106 participants were included in this research. Their mean age was 33.6 years (S.D. 11.78 years, range 19–66). There were 51 males and 55 females. The mean employment time of employment within medium secure settings was 6.83 years (S.D. 6.23, range 6 months to 23 years, 4 months). The majority (N = 78; 74%) of participants were of Caucasian origin. Around 11% (N = 12) identified as Black or Black British, 11% (N = 12) as Asian or Asian British, and 4% (N = 4) defined themselves as mixed origin. The majority of participants (92%) were from nursing and psychology backgrounds (health care assistants N = 64, senior staff nurses N = 22 and assistant psychologists N = 12). There were also psychiatrists (N = 3), cognitive behavioural therapists (N = 2) and physiotherapists (N = 3) (see Table 1). The majority of participants (N = 74; 70%) were married, cohabiting or living in civil partnerships.

	ProQOL v5; compassion satisfaction	ProQOL v5; burnout	ProQOL v5; secondary traumatic stress
Standardised sample mean scores*	56	49	50
Bottom quartile (N and %)	N = 12 (11%)	N = 11(10%)	N = 12 (11%)
Mid-point	N = 68 (64%)	N = 63 (59%)	N = 71 (67%)
Top quartile	N = 26 (36%)	N = 32 (31%)	N = 12 (22%)
Sample score	MBI; emotional exhaustion	MBI; depersonalisation	MBI; personal accomplishment
High	≥27; N = 13(12%)	≥10; N = 11(10%)	0–33; N = 11(10%)
Moderate	19–26; N = 71(67%)	6–9; N = 68(64%)	34–39; N = 72(68%)
Low	0–18; N = 22(21%)	0–5; N = 27(26%)	≥40; N = 23(22%)

Table 1.

Professional quality of life scale (ProQOL v5) and Maslach burnout inventory (MBI) scores.

^*

Standardised scores are based on manuals [12, 37].

3.2 Prevalence of compassion fatigue and burnout

This study examined the prevalence of compassion fatigue and burnout among staff in medium secure psychiatric settings using ProQOL and the MBI. A standard score was used by Stamm [12] to indicate relative risk or potential threats for each of the three subscales with cut-off scores at the 25th and 75th percentiles. Thus ProQOL scores below 43 are indicative of risk factors for low compassion satisfaction and protective factors for secondary traumatic stress and burnout, whereas scores of 57 or higher are indicative of risk factors for secondary traumatic stress and burnout and protective factors for compassion satisfaction. Table 1 provides information about measures of ProQOL compassion fatigue and MBI staff burnout.

Level of aggression was identified by using a level of violence measure. Participants reported experiencing aggression from service users on average 10.17 times a month with a range from no incidents to 21 or more incidents over a calendar month. While not based on reported staff experiences, a survey of incidents involving aggression (verbal aggression, physical violence and self-harm) in a UK high secure hospital reported 0.89 incidents per patient per month, although a small number of patients accounted for a high proportion of incidents. The level of violence in this study appears to be exceptionally high compared with the UK high secure hospital rates. The system for recording incidents used in the current study included behaviours that were threatening or verbally abusive, which was not the case in the Uppal and McMurran study.

Table 2 shows EssenCES social climate ratings along with comparative data from a British medium secure hospital sample.

Score	EssenCES; Patient cohesion mean (SD) range	EssenCES; Experienced safety mean (SD) range	EssenCES; Therapeutic hold mean (SD) range
Current sample	13.22 (2.39) 9–18	14.37(2.87) 9–20	12.84 (2.19) 9–16
Milsom et al.	9.72 (3.48) 9–20	9.95 (3.92) 9–20	14.85 (3.23) 9–18

Table 2.

EssenCES mean scores for study sample and comparator British medium secure sample.

It can be seen that sample scores on the patient cohesion and experienced safety subscales are slightly higher than scores found in a similar medium secure sample. Scores on the therapeutic hold subscale are similar to scores obtained previously.

In terms of resilience, Wagnild [58] reported a total (non-psychiatric staff) sample mean as 76.2. In contrast, the current study mean was within the moderately low to moderate range (mean 69.42; SD = 8.86; range 45–86) with 59% (N = 63) of staff in this study scoring below 64 (i.e. low or very low resilience).

3.3 Correlation between measures of compassion fatigue and burnout

There was a significant positive correlation between MBI emotional exhaustion (M = 20.39, SD = 12.44), and both the ProQOL burnout scale (M = 29.91, SD = 5.33, rs (104) = 0.796, p < 0.01) and the ProQOL secondary traumatic stress scale (M = 20.16, SD = 6.46, rs (104) = 0.245, p < 0.01). There was also a significant positive association between the MBI depersonalisation scale (M = 7.86, SD = 4.59) and the ProQOL Burnout scale (M = 29.91, SD = 5.33, rs (104) =0.438, p < 0.01).

Participants’ age was negatively correlated with ProQOL compassion satisfaction (rs (104) = −0.21, $p$ = 0.04). Younger staff reported greater compassion satisfaction as measured by ProQOL. Time employed in a secure psychiatric setting, however, correlated positively with MBI personal accomplishment (rs (104) = 0.21, $p$= 0.03). The results therefore support Hypothesis 2.

Actual level of violence correlated positively with MBI emotional exhaustion (rs (104) = −0.30, p < 0.01), MBI depersonalisation (rs (104) = 0.20, $p$ = 0.05), ProQOL burnout (rs (104) = 0.53, $p$ < 0.01) and negatively with MBI personal accomplishment (rs (104) = −0.47, $p$ < 0.01). The results therefore support Hypothesis 3 which predicted that staff with more experience of violence/aggression in the workplace would show higher levels of burnout and secondary traumatic stress.

In terms of the social climate of the work environment, Hypothesis 4 predicted that lower EssenCES ratings of therapeutic hold and patient cohesion would be associated with higher levels of secondary traumatic stress and burnout while lower experienced safety ratings would be associated with higher burnout and secondary traumatic stress ratings. Therapeutic hold correlated negatively with MBI emotional exhaustion (rs (104) = −0.36, $p$ < 0.01), ProQOL burnout (rs (104) = −0.49, $p$ < 0.01) and ProQOL secondary traumatic stress (rs (104) = −0.33, $p$ < 0.01). However, the patient cohesion domain correlated positively with compassion satisfaction (rs (104) = 0.44, $p$< 0.01). Experienced safety correlated negatively with MBI personal accomplishment (rs (104) = −0.40, $p$ < 0.01). The results are therefore broadly supportive of Hypothesis 4, particularly with regard to therapeutic hold. Interestingly, the construct of compassion satisfaction was only associated with patient cohesion but not with therapeutic hold (rs (104) = 0.13, $p$ = 0.22).

Significant negative correlations were found between individual levels of resilience and MBI emotional exhaustion (rs (104) = 0.-0.41, $p$ < 0.01), MBI depersonalisation (rs (104) = −0.31, $p$ < 0.01) and ProQOL burnout (rs (104) = −0.30, $p$ < 0.01). Hypothesis 5 is therefore supported.

3.4 Relationship between demographic factors and the expression of compassion fatigue, burnout and compassion satisfaction

Relationship between gender and both personal accomplishment (ӽ² = 35.12, p < 0.01) and compassion satisfaction (ӽ² = 28.56, p < 0.01) was statistically significant. Females scored more highly than males on personal accomplishment and compassion satisfaction. There was also a significant correlation between the marital status of participants and the expression of both emotional exhaustion (ӽ² = 54.65, p < 0.01) and burnout (ӽ² = 32.82, p < 0.01). Those participants who were married, in civil partnerships or cohabiting scored lower than those who were single on these two constructs.

3.5 Regression analysis

This section focuses on factors influencing the expression of compassion fatigue, burnout and compassion satisfaction using bootstrap regression analysis. The same four clusters of factors were used as for the correlational analysis: individual characteristics and circumstances, past experience of violence/trauma, the social climate of the work environment, and resilience.

Regression analysis revealed factors associated with the ‘protective’ constructs of compassion satisfaction and personal accomplishment in addition to those associated with burnout and secondary traumatic stress. It was found that both compassion satisfaction and personal accomplishment were positively associated with a better ward social climate and the female gender. Greater experience of reported actual violence was associated with higher levels of burnout and secondary traumatic stress. Higher resilience scores were associated with lower levels of emotional exhaustion and depersonalisation. Other results showed that time in employment in similar environments correlated positively with both burnout and personal accomplishment while staff who were married or in a stable relationship had lower burnout scores, and younger staff had higher compassion satisfaction scores.

4. Discussion

This study explored the relationship between secondary traumatic stress and compassion satisfaction along with other factors influencing the development of adverse psychological reactions among staff in medium secure psychiatric environments. To date, the compassion fatigue/burnout literature has, with notable exceptions (e.g. [15]), not focused on staff in secure environments despite an arguably greater potential for them to be more adversely emotionally affected than those in less disturbed settings. Results revealed that 31% of the current sample (of frontline, mostly nursing staff) scored within the top quartile on ProQOL burnout and 22% scored within the top quartile on ProQOL secondary traumatic stress, scores are consistent with other published findings of burnout in staff in secure settings.

Published studies of the prevalence rates of ProQOL burnout and secondary traumatic stress show much variation across mental health secure settings. For example, it has been found to be very high in therapists working with adult trauma victims in NHS trauma or secondary care services (28% at high risk of burnout and 70% at high risk of secondary traumatic stress; [20]) but low in various professionals identified as disaster behaviour health respondents (0% at high risk of either burnout or secondary traumatic stress). Furthermore, some studies (e.g. [15]) have reported well below average scores on ProQOL burnout and secondary traumatic stress for staff working in institutions with a high frequency of violence. These findings, along with the current study results, suggest that multiple factors, not just settings, determine the prevalence of burnout and secondary traumatic stress in these environments.

Overall, study hypotheses were confirmed with factors such as a more positive social climate negatively correlating with burnout and secondary traumatic stress moderating the constructs of compassion satisfaction and personal accomplishment. Burnout and secondary traumatic stress were associated with higher levels of reported violence, lower ratings on EssenCES social climate scales and resilience, and with more time spent working in secure psychiatric settings.

Hypothesis 2 (i) predicted that higher scores on the ProQOL compassion satisfaction would be associated with lower scores on burnout and secondary traumatic stress while higher scores on the MBI personal accomplishment scale would be associated with lower scores on the MBI emotional exhaustion and depersonalisation scales respectively. Although this relationship was observed for both ProQOL and MBI measures, the association was not statistically significant.

The current study found that MBI scales and ProQOL burnout and secondary traumatic stress were correlated. In particular, MBI emotional exhaustion correlated positively with the ProQOL scale of burnout and secondary traumatic stress, indicating that the concepts of burnout and secondary traumatic stress are related and their definitions share one or more of the following components: indirect exposure to traumatic experiences, PTSD symptoms and negative shifts in therapists’ cognitive schema [59].

The results of regression analysis in the current study highlight both mitigating factors (EssenCES social climate scales) and precipitating factors (time in secure psychiatric environment, actual level of violence and resilience) as contributing to the expression of compassion fatigue and burnout in medium secure psychiatric settings.

In the literature, compassion satisfaction has been found to be inversely related to both burnout and secondary traumatic stress [12]. Likewise, higher scores on MBI personal accomplishment are associated with lower scores on emotional exhaustion and depersonalisation [54]. These findings suggest that they may be protective factors that influence the expression of compassion fatigue and burnout.

Therapeutic hold and patient cohesion were positively correlated with ProQOL compassion satisfaction and with MBI personal accomplishment. This finding is concordant with Hypothesis 4. EssenCES experienced safety also correlated positively with MBI personal accomplishment. This finding supports previous work linking a variety of (staff and patient rated) positive therapeutic factors (treatment engagement, therapeutic alliance and higher level of patient motivation) to a more positive social climate [60]. It is of interest that the patient cohesion and social support (mutual support that characterises therapeutic communities) scale of EssenCES correlated positively with hypothesised protective factors for compassion fatigue but was not negatively correlated with ‘negative’ factors such as burnout and actual violence. In previous research [41] in medium secure settings patient cohesion and social support correlated positively with the therapeutic alliance and with patient motivation. Further, in qualitative research in the same setting, service users identified positive interpersonal relationships as characteristic of an effective therapeutic milieu [61]. To explain the relationship between compassion satisfaction and greater positive emotions using non-parametric bootstrapping, Samios et al. [26] found that it was partially mediated by positive reframing, a measure of meaning-focused coping (e.g. [62]). Positive reframing or “positive meaning finding” is a key component of meaning-making theories and refers to the expansion of an individual’s way of thinking [63, 64]. Positive reframing refers to a particular coping style in which the meaning of an adverse event is reinterpreted in a more positive way [64].

Previously, higher scores on compassion satisfaction have been associated with a greater degree of fit in six areas of person–job match [13]. Overall, the relationship between compassion satisfaction/personal accomplishment and the EssenCES subscales may perhaps best be explained by the observation that the ward social climate is a determinant of staff well-being. In particular, the ward climate plays a key role in staff performance and morale [65], job satisfaction [66, 67] and occupational stress [68].

The results of the current analysis suggest that resilience explains a significant part of the relationship with burnout. Findings support the notion that the effect of workplace violence may be influenced by resilience [69]. Previous findings of a positive correlation between resilience and compassion satisfaction were supported, which in accordance with the notion that compassion satisfaction may be considered as one of the multiple pathways of resilience [70].

In this study, burnout, as measured by the ProQOL and MBI emotional exhaustion and depersonalisation, was positively correlated with actual level of violence and with the amount of time employed in a secure setting. In this regard, employee burnout has been correlated with reduced commitment to the organisation [71] and both absenteeism and staff turnover [72]. In mental health settings staff turnover is correlated with reduced fidelity to evidence-based practices [73] and increases in the cost of recruiting and training new staff. Perhaps not surprisingly, negative correlations were also found between EssenCES experienced safety and both ProQOL burnout and MBI emotional exhaustion.

Hypothesis 3 which predicted higher levels of ProQOL and MBI burnout and secondary traumatic stress in those who reported more frequent exposure to physical aggression was supported in the results. These findings accord with those of Adeyemo et al. who found an association between the experience of violence and secondary traumatic stress, and support the proposal that burnout and secondary traumatic stress may relate to being cumulatively more frequently exposed to aggression [38].

The social climate of a psychiatric setting is also linked to the manifestation of aggression in those settings [74]. In one of the few studies that examined the link between aggression and social climate, Ros, Van der Helm, Wissink, Stams and Schaftenaar [75] found that lower levels of aggression were related to positive perceptions of the social climate. Long, Silaule and Collier [76] also found higher ratings of EssenCES social climate to be related to lower levels of behavioural disturbance in the ward environment.

Secondary traumatic stress in the current study correlated positively with actual level of violence, and negatively with resilience and the social climate ratings of therapeutic hold, patient cohesion and mutual support and experienced safety. Secondary traumatic stress, that results from a deep involvement with traumatised individuals, has been used as a definition of compassion fatigue [8] which includes the negative feelings caused by concerns such as hypervigilance, avoidance, fear and intrusions (post-traumatic stress). Given findings of a positive correlation between burnout and secondary traumatic stress that suggest overlay in one or more components of these phenomena [77] it is perhaps unsurprising that the current study found similar relationships between the variables under study and both burnout and secondary traumatic stress.

Sample characteristics that may have contributed to the results include length of time in secure psychiatric employment, marital status, age and gender. The study Hypothesis 2 stated that staff with more years of secure setting work experience would show higher levels of burnout and secondary traumatic stress. Increased time in secure employment was associated with both higher ratings of burnout as well as higher levels of personal accomplishment. These findings are consistent with both Lauvrud et al. [15], who found that longer periods of nursing experience correlated with lower compassion satisfaction, and Rossi et al. who found that more years of experience correlated with increases in both burnout and compassion fatigue. Other research that indicates apparently contrary findings (e.g. [43]) has found that length of employment can act as a buffer against the detrimental effects of secondary traumatic exposure if appropriate training and support is provided for staff [11, 45]. Craig and Sprang [11] speculate that experience, along with evidence-based practice, may increase confidence in decision-making and create a condition where the care provider feels more equipped to deal with the complexity of psychiatric/trauma work. Younger age levels, in the current study, which correlated with higher levels of compassion satisfaction, would seem to support the observed association between length of service and burnout. However, other studies have found that age becomes an insignificant predictor of compassion satisfaction and compassion fatigue when other variables such as the percentage of PTSD in staff caseloads [20] are factored in.

Finally, the current study findings suggest that gender and marital status may be protective against burnout and secondary traumatic stress. Participants who were married or in civil partnerships or cohabiting were less likely to score highly on burnout and emotional exhaustion. This accords with Rossi et al. and with Adeyemo et al. who found that married participants reported a better professional quality of life. The association between the female gender and higher levels of compassion satisfaction and personal accomplishment is at odds with several studies that have found an enhanced risk of suffering from compassion fatigue and burnout among females. However, results in this area are not consistent (e.g. [20]) and may reflect varied sample characteristics. Accordingly, it is not possible to make any definitive statement about the role of gender in the development of burnout and secondary traumatic stress. Unlike previous research [20] no correlation was found in this study between age and burnout.

5. Limitations and methodological issues

The current study has a number of limitations including a self-selected and possibly non-representative sample and a retrospective cross-sectional design that does not allow for the determination of causality. Burnout, for example, is associated with chronic stress rather than acute stress, and single time-point self-report data may reflect transient feelings of exhaustion and irritability rather than sustained burnout.

Type of profession was not controlled for and there appear to be demographic differences between them such as age, previous experience working in similar settings and level of education.

Other methodological limitations include the use of multiple correlations that increase the risk of false positive findings. One of the potential advantages of regression analysis is that it helps the researcher to examine the relative contribution of different predictor variables. However, an inherit problem in regression analysis relates to collinearity between these predictor variables. Collinearity occurs when a regression model includes multiple predictors that are correlated to each other and therefore the shared variance between the predictors confounds the interpretation of the unique contribution of each of the predictor variables.

These considerations, in the context of research to date, illustrate the multifaceted nature of those individual and environmental variables that potentially impact upon the development of compassion fatigue and burnout in secure psychiatric settings. To ascertain the relative importance of the variables identified further research is needed. Future research could investigate the factors contributing to a good ward climate (e.g. the importance of regular supervision, team meetings, promotion of staff well-being and psychological support to staff members).

6. Implications for practice and conclusions

The findings of this study indicating the importance of perceived level of violence, social climate and resilience as possible determinants of burnout and secondary traumatic stress with secure psychiatric staff has a number of clinical practice implications for medium secure settings. That might include measures to reduce patient violence and aggression, improve social climate and enhance staff resilience.

The first relates to a suite of appropriate measures to reduce the likelihood of extreme behaviours and aggression. These include a clear rationale and structure to underpin a ward’s approach to risk management [78] and one that engages patients in the process [79]. The National Institute for Health Care and Excellence (NICE) Guidelines on violence and aggression recommend the use of de-escalation techniques, noting the importance of prevention rather than reaction [80]. Indeed, recent research has shown that an increase in on-ward training with increased time devoted to prevention and de-escalation is associated with a reduction in risk behaviours and staff injuries in a secure setting [60]. Therapeutic systems that emphasise relational security [81] and which aim for early patient engagement and behavioural stabilisation are a crucial first step in ensuring patient and staff safety [28].

Second, the monitoring and measurement of social climate may support the development and maintenance of a safe and supportive atmosphere for frontline clinical staff. As a dynamic construct, social climate can be influenced by a wide variety of factors, including staff and patient dynamics, changes in mental state as well as aggression. Accordingly, it is viewed as good practice to regularly assess the social climate of a secure facility [82, 83] in order to gain insight into ways of improving the climate, promoting effective engagement, monitoring the impact of treatment programmes and service change. Indeed, during the author’s employment in the study setting, all the data was collected, the results of six-monthly administrations of EssenCES were collated and interpreted with actions discussed and agreed at multidisciplinary team meetings. Initiatives agreed on the basis of results at ward level included an anti-bullying group initiative and a project on overcoming barriers to treatment. In instances where obtained results did not point to specific actions, attempts were made to focus on those aspects of ward functioning that were contributing to a positive social climate.

The practical implications of each social climate review will, accordingly, depend upon the nature of the results obtained. For example, the finding that therapeutic hold ratings differ between staff and patients [41, 84] may prompt a review of the extent to which therapeutic needs are being met and to the need for greater staff attention to therapeutic relationship-building and relational security [81].

A third line of intervention relates to how emotional resilience can be enhanced for clinical staff. There is growing evidence that resilience is not a fixed, innate characteristic but can be developed through carefully targeted interventions [85]. A ‘best practice’ programme of key components includes, among other things, developing protective factors and rebound capabilities that promote self-efficacy [86], nurturing self-care strategies [19, 87], providing access to restorative supervision [60], arranging for post-incidents closure of activities and follow-up support [88], providing access to specialised training and opportunities for skill development [11] and nurturing self-help [87].