The concept of resilience is complex and has many facets. Resilience can be defined as the capacity to adjust effectively to difficult life situations by utilizing cognitive, emotional, and behavioral adaptability to manage both external and internal stressors [1]. Another perspective on resilience suggests a dynamic process characterized by effectively adapting to challenging circumstances [2] [3]. Multiple elements influence resilience, but the primary determinant is an individual's comprehension of the circumstance.
Prior studies [2][3][4] have presented evidence that resilience empowers individuals to overcome life's challenges, regardless of the nature of the difficulty. Therefore, resilience can be defined as an innate characteristic of individuals that can be cultivated, honed, and fostered. However, the utilization of resilience is subjective and individualized for every person. Resilience is linked to negative life events like compassion fatigue (CF), moral injury (MI), and vicarious trauma (VT), according to previous studies [5][6][7][8][9][10].
Charles Figley first proposed the idea of compassion fatigue (CF) in the 1980s. Since its inception, the medical community has accepted the idea of compassion fatigue [7]. Notably absent from the DSM-5 is a distinct diagnostic category for this condition despite its widespread acceptance. Many people mistakenly believe that burnout, the inability to cope with excessive and unmanageable stress on the job, is the same as CF [11]. Compassion fatigue is a more severe psychological phenomenon than burnout. While burnout can be effectively addressed, reducing CF is more challenging [12].
Anxieties over patients' rights and the possibility of nurses quitting their jobs altogether are two of the many negative outcomes that can arise from the complicated and serious issue of MI [6][13]. The frequency and severity of MI spikes during a tragedy or crisis. To maintain the ethical principles and values that nurses hold dear, it is essential to recognize and address MI [14]. The prevalence of MI is higher among women in the Philippines, which is impacted by the diverse and complex nature of their health environment [15]. Nurses in the Netherlands feel left out of the decision-making process regarding life-sustaining measures for patients whose health is worsening [6]. Furthermore, in Korea, MI has been found to originate from issues with ineffective communication, lack of decision-making autonomy, inadequate staffing, and missed nursing care [16].
Amy Marshall's article "Vicarious Trauma: The Cost of Care and Compassion" highlights the negative impact of providing care and support to others on the caregiver's well-being. Marshall argues that VT and CF are similar and often called the "cost of caring." It is important to understand the impact of caregiving on oneself to provide effective support and care to others. According to Marshall (2023), witnessing, learning about, and supporting others through their traumatic experiences can be distressing, even if the person providing support has not personally experienced trauma. VT is a condition that occurs because of prolonged exposure to traumatic events that other people experience. Dr. Parekh's article, "Understanding Vicarious Trauma and Its Path to Resilience," explores the idea of VT and how to overcome it. Vicarious trauma happens when someone experiences trauma indirectly by being exposed to the traumatic experiences of others. Dr. Parekh emphasizes that resilience is crucial in overcoming VT. It is important to note that although experiencing trauma, such as VT, may be an unpleasant and difficult experience, it does not mean that one cannot develop resilience. Sometimes, experiencing trauma is necessary to develop resilience. In response to trauma, vicarious resilience refers to acquiring the knowledge of overcoming adversity by observing and interacting with trauma survivors. This process can lead to positive personal growth, empowerment, and increased empathy and engagement [20].
The three concepts of MI, CF, and VT are related, yet each has its unique impact on individuals. Although the causes of these concepts are complex, nurses experience distinct effects from each one that affect their care delivery. As frontline workers, nurses face various challenges in their day-to-day work, so it is necessary to study the influence of CF, MI, and VT on nursing care and patient safety. To ensure they can address these difficulties effectively, it is crucial that they tap into their inherent resilience. By drawing upon their inner strength, nurses can rise above their challenges, providing the best possible care to their patients. Therefore, it is vital to recognize the importance of nurses' resilience in providing quality healthcare.
The American Counseling Association defines VT as the emotional impact experienced by professionals who are exposed to the traumatic stories and experiences of others through their work. This can include witnessing the fear, pain, and terror that others have gone through and being preoccupied with the distressing stories shared with them [4]. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, the symptoms of VT are very similar to those of post-traumatic stress disorder (PTSD). However, it is worth noting that not everyone who experiences VT meets the criteria for PTSD, just as not everyone who experiences other forms of trauma will develop a trauma-related disorder [11].
Nurses are a crucial part of the healthcare workforce, constituting the largest segment. They play a vital role in providing care to patients. To meet the constantly evolving demands of healthcare, the nursing profession strives to find solutions to increase the number of nurses worldwide [21]. The nursing workforce is in high demand due to the emergence of new diseases such as COVID-19. The COVID-19 pandemic brought both strengths and weaknesses to the forefront of nursing. While the demand for nurses has been rising, there has been a shortage of nurses willing to treat patients with communicable diseases. Despite their hard work, nurses often experience high levels of stress and burnout, which can negatively impact their mental well-being. The workplace can often generate stress, leading to burnout, CF, and MI [22]. The provision of care by nurses, coupled with their exposure to patient suffering, can result in CF. Recognizing that not every approach may produce the desired results, nurses can use their resilience to overcome CF and MI [7][14].
Resilience is extensively studied in psychology and behavioral sciences. Nurses demonstrate resilience in various ways, especially in patient care delivery [23][24]. Resilience is a nurse's ability to adapt and cope with challenging situations. Nurses show resilience in challenging work environments by using critical thinking skills to provide patient care. Various factors influence nurses' resilience, such as their community, culture, and belief systems. To increase their resilience and cope with the challenges of their profession, nurses can practice skills such as positive thinking, effective use of support systems, and perceiving their inherent strength [25].
The nursing workforce in Saudi Arabia includes both Saudi nationals and expatriates. According to the Saudi Commission for Health Specialties (SCFHS), in 2021, the workforce comprised 125,379 nurses. Out of this number, only 12,607 nurses, making up approximately 10% of the entire workforce, were Saudi nationals [26]. The primary sources of expatriate nurses for Saudi Arabia are India (26%) and the Philippines (37%) since these countries have a significant number of nurses willing to work in the Saudi Arabian healthcare system [26] [27].
Aims
While a considerable amount of research is available on the resilience of nurses and its effectiveness in managing stress and burnout, very few studies focus on examining the interconnection between VT, MI, and CF in nurses. It is essential to explore how resilience can help mitigate the negative effects of these issues on nurses' well-being. These concepts are crucial factors that affect nurses' professional competence, growth, and burnout. However, conducting a study to examine the relationship between these factors could provide valuable insights into the most effective ways for nurses to develop resilience and overcome VT, MI, and CF.
This study explored the connection between CF, VT, and MI and how resilience mediates this relationship. It is essential to investigate the potential moderating influence of resilience on the link between CF, MI, and VT, given Saudi Arabia's emphasis on cultivating a skilled and capable nursing workforce. To better understand the relationship between MI, VT, and CF, we developed a structural equation model (SEM) and assessed the mediating role of resilience.