Accepted Manuscript

Understanding the influence of resilience on psychological

outcomes — Comparing results from acute care nurses in Canada
and Singapore

Shin Yuh Ang, David Hemsworth, Thendral Uthaman, Tracy

Carol Ayre, Siti Zubaidah Mordiffi, Emily Ang, Violeta Lopez

PII: S0897-1897(17)30530-X
DOI: doi:10.1016/j.apnr.2018.07.007
Reference: YAPNR 51091
To appear in: Applied Nursing Research
Received date: 19 September 2017
Revised date: 10 July 2018
Accepted date: 25 July 2018

Please cite this article as: Shin Yuh Ang, David Hemsworth, Thendral Uthaman, Tracy
Carol Ayre, Siti Zubaidah Mordiffi, Emily Ang, Violeta Lopez , Understanding the
influence of resilience on psychological outcomes — Comparing results from acute care
nurses in Canada and Singapore. Yapnr (2018), doi:10.1016/j.apnr.2018.07.007

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TITLE: UNDERSTANDING THE INFLUENCE OF RESILIENCE ON PSYCHOLOGICAL

OUTCOMES — COMPARING RESULTS FROM ACUTE CARE NURSES IN CANADA AND
SINGAPORE

Authors: Shin Yuh Ang1, David Hemsworth2, Thendral Uthaman1, Tracy Carol Ayre1, Siti
Zubaidah Mordiffi3, Emily Ang4, Violeta Lopez4
1
Division of Nursing Administration, Singapore General Hospital, Singapore
2
Faculty of Applied and Professional Studies, Nipissing University, Canada

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3
Nursing Administration, National University Health System, Singapore

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4
Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore

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Corresponding Author: Ang Shin Yuh
Singapore General Hospital, Bowyer Block B, 11 Third Hospital Ave,
Singapore 168751

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Office: (+65) 65762458
Email: ang.shin.yuh@sgh.com.sg
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Acknowledgement:
The International Collaboration Workforce Resilience - 1 (ICWR-1) team: Australia: Mark
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Craigie, Janie Brown, Rebecca Osseiran-Moisson, Susan Slatyer (Curtin University), Lesley
Siegloff (Flinders University), Allison Williams (Monash University), Karen Francis (Charles Sturt
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University); Hong Kong: Aggi Tiwari (Hong Kong University), Kin Cheung, Shirley Ching, Mak
Shuk Yan, Polly Chan, Yobie Lam, Alex Molasiotis (Hong Kong Polytechnic University).

Funding:
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This study is also supported in funding from SingHealth Foundation (The SingHealth Foundation
is a not-for-profit grantmaking organisation that awards grants to support programmes which
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improve the healthcare standards for Singapore's future generations) and the National
University of Singapore, Alice Lee Centre for Nursing Studies Departmental Research Grant
and the Internal research grant, Nipissing University.
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Acknowledgement:
The International Collaboration Workforce Resilience - 1 (ICWR-1) team: Australia: Mark
Craigie, Janie Brown, Rebecca Osseiran-Moisson, Susan Slatyer (Curtin University), Lesley
Siegloff (Flinders University), Allison Williams (Monash University), Karen Francis (Charles Sturt
University); Hong Kong: Aggi Tiwari (Hong Kong University), Kin Cheung, Shirley Ching, Mak
Shuk Yan, Polly Chan, Yobie Lam, Alex Molasiotis (Hong Kong Polytechnic University).

Conflict of Interest: None to declare

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TITLE: UNDERSTANDING THE INFLUENCE OF RESILIENCE ON PSYCHOLOGICAL

OUTCOMES — COMPARING RESULTS FROM ACUTE CARE NURSES IN CANADA AND
SINGAPORE

ABSTRACT

Background

Building resilience among nurses is one of the ways to support and retain nurses in the profession.
Prior literature which evaluated influence of resilience on psychological outcomes, were

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conducted in relatively homogeneous populations. It is of interest to evaluate whether

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relationships between resilience and psychological outcomes remain consistent across nations
and among different nursing populations.

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Aim

To evaluate a theoretical model of the impact of resilience on burnout (BO), secondary traumatic

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stress (STS) and compassion satisfaction (CS) by comparing results between nurses in Canada
and Singapore.

Method
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A self-reported questionnaire consisting of questions on demographics, resilience (Connor-
Davidson Resilience Scale), and psychological adjustment (Professional Quality of Life) was
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administered via an online survey. One thousand three hundred and thirty-eight nurses working
in two Academic Medical Centres in Singapore responded to the online survey. Similar data was
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also collected from 329 nurses in Canada. Hypotheses were tested using structural equation
modelling.

Results
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Resilience exerts a significant negative direct impact on STS, and a significant negative direct
impact on BO. Additionally, resilience has a positive direct impact on compassion satisfaction.
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STS exerts a positive direct impact on BO while CS has a negative direct impact on BO.

Conclusion
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Current study affirmed significant associations between resilience and professional quality of life.
Knowledge on resilience is key in informing design and implementation of resilience-building
strategies that include professional development, and strengthening of interpersonal skills. A
resilience-based approach will help reduce nurses’ BO and STS while caring for their patients,
and in turn reduce turnover.

Keywords: Burnout; Canada; Nurses; Resilience; Singapore.

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Contribution of the paper

What is already known about the topic:

 Resilience is an important trait for nurses to have to thrive in this challenging field

What this paper adds:

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

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This paper has compared and identified differences in resilience among nurses from two
different cultures, Canada and Singapore


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The paper also discussed the reasons for such differences, such as a lower level of
empathy among Singaporean nurses
 The study has reiterated the role of resilience in burnout

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ED
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TITLE: UNDERSTANDING THE INFLUENCE OF RESILIENCE ON PSYCHOLOGICAL

OUTCOMES — COMPARING RESULTS FROM ACUTE CARE NURSES IN CANADA AND
SINGAPORE

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BACKGROUND

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Internationally, there is concern about the rising nursing workforce shortage which could be
attributed to both recruitment and retention issues (Drury, Francis & Chapman, 2008). As the
population rapidly ages in Singapore, there is an increased demand by health care services for
more trained nurses to staff new facilities (Chan, 2016). In Canada, there is also a looming nursing

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shortage with a larger number of nurses leaving the profession than entering it ("Nursing shortage
tipped to hit Canada", 2015).
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Building resilience among nurses has been postulated as one of the ways to support and retain
nurses in the profession (Hart, Brannan & De Chesnay, 2014). Previous studies reported that
resilient nurses having more protective factors, are less likely to burnout (Garcia, 2011) and have
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higher levels of job satisfaction (Matos, Neushotz, Griffin & Fitzpatrick, 2010). Additionally, nurses
who had passion or pride in their work and their profession are more likely to be resilient (Cameron
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& Brownie, 2010; Zander, Hutton & King, 2010). On the contrary, nurses with lower resilience
have higher levels of anxiety, depression and post-traumatic stress disorder (Mealer et al., 2012).

Prior literature which evaluated the influence of resilience on psychological outcomes, were
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conducted in relatively homogeneous populations. It is of interest to evaluate whether the impact

of resilience on psychological outcomes remains consistent across nations and among different
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nursing populations. This study aimed to evaluate a theoretical model of the impact of resilience
on psychological outcomes of burnout (BO), secondary traumatic stress (STS) and compassion
satisfaction (CS) by comparing the results between nurses in Canada and Singapore.
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THEORETICAL MODEL AND LITERATURE REVIEW

This study was based on a theoretical model of individual resilience in the workplace (Figure 1)
(Rees, Breen, Cusack & Hegney, 2015). The model illustrates that resilience is influenced by
intrapersonal traits of neuroticism, mindfulness and self-efficacy; and in turn impacts on one’s
psychological adjustment. This paper focused on the impact of resilience on psychological
outcomes of BO, STS and CS.
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Figure 1
Resilience Scale

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Ability to detach/Be self-
aware Resilience

Mindfulness Measure

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Psychological Adjustment
(Outcomes)

Self-efficacy/intention
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Burnout
Compassion Satisfaction
Self-efficacy Scale
Secondary traumatic stress
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Neuroticism/Affect
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Positive and Negative

Affect
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Coping
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Our hypotheses in this study were illustrated in Figure 2. Based on the association between
resilience and psychological adjustment outcomes as highlighted in Figure 1, we hypothesized
that resilience has a negative direct impact on secondary traumatic stress and burnout. The third
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relationship involves the positive direct impact of resilience on compassion satisfaction. In the
fourth and fifth relationships, we hypothesized that secondary traumatic stress has a positive
direct impact on burnout while compassion satisfaction has a negative direct impact on burnout.

Figure 2
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H1 asserts that resilience has a negative direct impact on secondary traumatic

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stress.
H2 asserts that resilience has a negative direct impact on burnout.
H3 asserts that resilience has a positive direct impact on compassion satisfaction.

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H4 asserts that secondary traumatic stress has a positive direct impact on burnout.
H5 asserts that compassion satisfaction has a negative direct impact on burnout.
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Resilience

According to Luther et al. (2000), resilience refers to a “dynamic process encompassing positive
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adaptation within the context of significant adversity.” (p.? for direct quote) The notion of resilience
is dependent on two conditions, the presence of adverse circumstances as well as being able to
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recover and adapt (Luthar, Cicchetti, & Becker, 2000). Among Chinese nurses, the notion of
resilience comprises of four facets; namely, Determination, Endurance, Adaptability and
Recuperability (Wei & Taormina, 2014).
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In recent years, there is a renewed interest in the study of resilience among nurses. Nurses are
generally perceived to be resilient given that they work in stressful environments and under poor
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working conditions (Koen, Van Eeden & Wissing, 2011). However, in a survey among operating
room nurses (Gillespie, Chaboyer, & Wallis, 2009), it was reported that the resilience level of
nurses, as measured using the Connor-Davidson Resilience Scale, was lower than that of the
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general population in the United States. Challenging workplaces, psychological emptiness,

reduced inner balance and disagreements at work are key factors influencing resilience among
nurses (Hart et al., 2014). Other scholars advocated that determinants of resilience may differ
depending on context (Ungar, 2008) and specific challenges and may also vary depending on
one’s age and maturity (Southwick, Bonanno, Masten, Panter-Brick & Yehuda, 2014).

Burnout

Burnout is commonly defined as a syndrome of feelings of hopelessness and difficulties in dealing

with work or in being ineffective at work (Stamm, 2010); and is known to make up of feelings of
emotional exhaustion, depersonalization and reduced personal accomplishment (Maslach, 1981).
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The burnout syndrome has been widely studied as it is deemed to be a major modifiable factor in
improving the working conditions of professional staff involved in human service. Burnout can be
associated with a very high workload or a non-supportive work environment (Stamm, 2010).
Although burnout has been widely studied among nurses, with most studies using the Maslach
Burnout Inventory, it was challenging to compare prevalence rates across studies due to use of
different cut-off points. In a previous study on nurses in Singapore, it was reported that they
experienced comparable levels of emotional exhaustion; higher levels of depersonalization and
personal accomplishment than nurses in China; but when compared to nurses from United
Kingdom, nurses in Singapore experienced lower levels of emotional exhaustion,

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depersonalisation and higher levels of personal accomplishment (Ang et al., 2016).

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Secondary Traumatic Stress

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Secondary Traumatic Stress (STS) refers to a part of compassion fatigue whereby the individual
is exposed to people who have experienced extremely or traumatically stressful events (Stamm,
2010). The adverse effects include sleep difficulties, intrusive images, or avoiding reminders of

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the person’s traumatic experiences (Stamm, 2010). STS symptoms were reported among nurses
working with different patient populations, including forensic nurses, emergency department
nurses, oncology nurses, pediatric nurses and hospice nurses (Beck, 2011). Nurses are at risk of
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STS, as they tend to empathize with the traumatized during the caring process (Figley, 1995).

Compassion Satisfaction
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Compassion Satisfaction (CS) refers to the positive aspects of helping others. It is the pleasure
that one derives from being able to perform well at work and contributing to the greater good of
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society (Stamm, 2010). Previous study on nurses revealed that inpatient staff had significantly
lower level of compassion satisfaction as compared to their colleagues working in outpatient
settings (Potter et al., 2010) or aged care (Hegney, Rees, Eley, Osseiran-Moisson, & Francis,
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2015). This was attributed to a higher patient acuity, more death episodes, and more severe
clinical symptoms among inpatients (Potter et al., 2010).

Effect of Resilience on Psychological Outcomes

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We first hypothesized that resilience has a negative direct impact on secondary traumatic stress
and burnout, and a positive direct impact on compassion satisfaction. Few recent studies have
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explored the mediating role that resilience play in outcome measures such as burnout and
compassion satisfaction. In a survey on nurses working in high-intensity units, a higher level of
resilience protected nurses from emotional exhaustion, increased experience of personal
accomplishment (elements of burnout); and was associated with a higher level of hope and
reduced stress (Rushton, Batcheller, Schroeder, & Donohue, 2015). Hegney et al (2015) reported
a positive correlation value of r=0.628 between resilience and CS; a negative correlation value of
r=-0.625 between resilience and BO; and a negative correlation value of r=-0.354 between
resilience and STS (Hegney et al., 2015). The authors also concluded that resilience acts as a
partial mediator of the relationship between trait negative affect and compassion satisfaction; the
relationship between the two constructs changes from a large effect (0.53) to a relatively small
effect (0.20) when resilience is being accounted for (Hegney et al., 2015). In another study of
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ambulance personnel (Treglown, Palaiou, Zarola, & Furnham, 2016), resilience was found to
mediate the relationship between dark side traits (excitable, skeptical, cautious, reserved, bold,
mischievous, diligence) and burnout. More specifically, the trait was a negative predictor of
burnout but the influence was no longer significant once resilience was added in the equation.
Similarly, the researchers found that diligence is only effective in reducing an individual’s risk of
burnout if the person also possesses high levels of resilience.

Secondly, we hypothesized that secondary traumatic stress has a positive direct impact on
burnout. In two longitudinal studies among healthcare providers, it was reported that a higher level
of job burnout at time 1 led to a higher level of STS at time 2; while the reverse did not hold true

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(Shoji et al., 2015). A probable explanation being burnout is associated with depletion in personal

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and environmental resources. This depletion leaves an individual with few resources to cope with
further perpetual exposure to indirect trauma; hence leaving the individual more susceptible to

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development of STS (Shoji et al., 2015). Other cross-sectional studies reported association or
significant positive correlation between BO and STS (Sodeke-Gregson, Holttum & Billings, 2013),
indicating that these two syndromes may be exacerbated by each other (Malkina-Pykh, 2017).

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Thirdly, we hypothesized that compassion satisfaction has a negative direct impact on burnout.
CS, and BO are known to co-exist given that the negative impact of working with trauma clients
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can be balanced by the potential for a positive outcome from the work itself (Sodeke-Gregson et
al., 2013). Previous studies have also consistently demonstrated the negative relationship
between CS and BO. To illustrate, in a study among therapists working for the UK National Health
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Service, a negative correlation value of -0.697 was reported between CS and BO (Sodeke-
Gregson et al., 2013). Similar negative correlation values (-0.686) were also reported among a
cohort of nurses in Australia (Hegney et al., 2015).
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SIGNIFICANCE OF STUDY
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Although there is some existing literature on the influence of resilience on psychological outcomes,
there is a lack of a universal theoretical model which is applicable across different settings. To
date, most of the studies on resilience were conducted among populations in largely homogenous
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Western countries. Given the potential influence of culture on the development of resilience, it is
timely to study the phenomenon among nurses in a multi-cultural South East Asian country like
Singapore and compare the results with nurses in Canada. As stated in Ungar (2008), cultural
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factors contextualize how resilience is defined by different populations and manifested. Moreover,
different practice settings and work ethics may demand different resilient behaviors or strategies
for the nurses to remain resilient within their work settings (Hart et al., 2014).

AIM

The primary aim of this study was to evaluate the theoretical model presented in Figure 2 of the
impact of resilience on psychological outcomes of burnout (BO), secondary traumatic stress (STS)
and compassion satisfaction (CS). Involving nurses from Canada and Singapore allow us to
confirm that the model is generalizable to more than a single population as well as examine
differences and similarities between the two countries.
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METHODS

A cross-sectional survey design with a population-based approach was adopted.

Setting and Sample

Singapore

Staff nurses and enrolled nurses from two academic medical centers; namely Singapore General
Hospital (SGH) and National University Hospital (NUH), were approached to participate in the

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survey. All staff nurses in Singapore had a minimum diploma qualification, while enrolled nurses
received vocational training and assisted the staff nurses in patient care and management.

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Canada

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All part time and full time nurses at the North Bay Regional Health Centre (NBHRC) were invited
to take part in the study. The survey was directed towards registered and enrolled nurses at
NBRHC in Ontario, Canada.

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Data collection
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Singapore

Potential participants were informed of the study via internal emails. The survey was administered
online using the REDCap® software in SGH and Qualtrix® software in NUH. To enhance the
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response rate, email reminders were sent out two weeks after the commencement of data
collection for both SGH and NUH participants.
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This study was approved by the SingHealth Centralised Institutional Review Board in Singapore
(CIRB Ref no: 2014/557/A) as well as the National University Hospital Institutional Review Board
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(NUS-IRB Ref No: B-14-152/Approval No: NUS-2371) in Singapore.

Canada
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Invitation posters to take part in the study were posted around the hospital and in the hospitals
newsletter. Participants were provided with two options to take part; hard copy and online.
Hardcopy questionnaires with envelopes were available to pick up on the units or the cafeteria,
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and upon completion, respondents were directed to seal and drop the questionnaire envelopes
at designated sealed boxes in the units and cafeteria; they could also use internal mail to pass
the survey to the research team. As for the online mode, the questionnaire was developed on
SurveyGizmo®, and a link to it was posted on invitation posters and on the hospital newsletter.
Respondents were provided with a $5 card designated to hospitals cafeteria as
compensation/motivation.

Ethics approval from both Nipissing University (REB Protocol #13-01-01) and North Bay Regional
Health Centre’s (NBRHC) Research Ethics Board (1303-005) was obtained.

Measurement tools
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In both Singapore and Canada’s study sites, the survey consisted of the following questionnaires.

The Connor-Davison Resilience Scale (CD-RISC10) was used to measure resilience. It consisted
of ten Likert type additive scale item with five response options (0=never; 4=almost
always)(Campbell-Sills & Stein, 2007). The final score was the sum of the responses on each
item and a higher score reflect a higher level of resilience. Previous study had reported a
Cronbach alpha coefficient of 0.85 and test-retest correlation coefficient of 0.71 for the scale
(Notario-Pacheco et al., 2011), as well as good construct validity(Campbell-Sills & Stein, 2007).
In our study the internal consistency reliability was 0.91 (Cronbach alpha).

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The Professional Quality of Life Scale (ProQol) was used to measure psychological adjustment,

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and was made up of the components of compassion satisfaction (CS) and compassion fatigue
(CF). The latter construct is composed of Burnout (BO) and Secondary Traumatic Stress (STS)

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(Stamm, 2010). It consisted of thirty, five-point Likert scale (1-never to 5-very often) items to
measure the three subscales. It is a widely used scale with good construct validity; and reported
Cronbach alpha reliability of 0.75 (BO scale), 0.81 (STS scale) and 0.88 (CS scale). A higher

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score in each subscale indicates a greater presence of CS, BO or STS (Stamm, 2010). In our
study the internal consistency reliability was 0.92 for CS scale, 0.70 for BO scale and 0.80 for
STS scale.
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Data analysis

Data were entered into Microsoft Excel 2016 for pre-processing, data cleansing, and
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determination of scale composites. IBM SPSS Version 24 was used for the statistical analyses
and Lisrel 8.8 was used for the confirmatory factor analyses (CFA) and structural equation
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modeling (SEM). CFA were conducted on all scales and subscales. All tests were two-tailed, and
the level of significance was set at 0.05, so p-values α=0.05 were reported as statistically
significant unless otherwise specified. The model and hypotheses were tested using SEM. SEM
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is an appropriate statistical technique when assessing the relationships among latent constructs
that are measured by multiple scale items, where at least one construct is both a dependent and
an independent variable (Hair, Anderson, Tatham & Black, 1995)
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RESULTS

Demographics
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In Singapore, a total of 1338 nurses responded to the survey (response rate of 28%) (Table 1).
The majority (93%) were female. Most of them were staff nurses (64%), with a fairly equal
proportion being single (47%) and married (50%). Staff nurses in Singapore have at least a
diploma qualification and are in charge of direct nursing care. Enrolled nurses received vocational
training and support staff nurses in the delivery of care. Respondents were mostly nurses equal
or below 40 years of age (75%). Although the response rate was low, the demographic profile of
nurses was similar to that reported Singapore as a whole (Annual Report 2015).

In total 329 completed questionnaires were collected from Canada’s study site, of which 34 were
completed online, the respondents who missed more than 10% of the questionnaire were
eliminated, hence only 303 completed questionnaire (30% response rate) were included in the
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analysis (Table 1). The majority (86.5%) were female and 69% were married (or equivalent). The
average age was 41 years and the average time working as a nurse was 16 years.

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Table 1 Sample Demographics (Singapore, n = 1338; Canada, n = 303)

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Variables Category Singapore Canada

n (%) n (%)
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Gender Male 88 (7%) 41 (13.5%)
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Female 1250 (93%) 262 (86.5%)

Marital Single 630 (47%) 59 (19.5%)
Status Married 666 (50%) 201 (66.5%)
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Separated/divorced/widowed 42 (3%) 42 (13.9)

Dependents No 527 (39%)
Yes 789 (59%)
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Age group Young less than or equal 27 years 393 (29%) Mean=40.82
(SD=11.96)
Middle age 27.1-40 years 615 (46%)
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older 40.1 and above 326 (24%)

Years of Less than 10 years 810 (61%) Mean=16.2
experience (SD=11.6)
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in Nursing 11-20 years 277 (31%)

More than 20 years 240 (18%)
Highest General nursing certificate 197 (15%)
qualification Diploma in nursing/accelerated diploma 381 (29%) 162 (53.5)
and advanced diploma
Bachelor Degree 687 (51%) 90 (29.7)
Postgraduate 73 (6%) 46 (15.2)
Residential Citizen of the country 868 (65%) 288 (95.4)
Status Permanent Resident 201 (15%) 14 (4.6)
Visas / Work Pass 269 (20%)
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Measurement of constructs

Four constructs were measured in the study: Resilience, secondary trauma stress, compassion
fatigue and burnout. Table 2 provides the means and standard deviations of each of the
measurement variables that make up the constructs. Of particular interest were the comparisons
between the means estimated from the Singapore and Canadian nursing datasets.

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Table 2 Means, Construct Reliability Estimates, and Measurement Loadings

Singapore Canada
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Code Mean SD Std Loadings Mean SD Std Loadings
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Resil Resilience (Singapore: Reliability α = .91) (Canada: Reliability α =.89)

Resil_1 3.78 0.72 .74* 4.13 0.78 .67*
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Resil_2 3.69 0.73 .81* 4.02 0.77 .74*

Resil_3 3.51 0.82 .69* 3.95 0.93 .56*
Resil_4 3.58 0.84 .73* 3.51 0.97 .63*
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Resil_5 3.41 0.88 .58* 3.83 0.88 .70*

Resil_6 3.73 0.76 .81* 3.85 0.75 .73*
Resil_7 3.43 0.83 .79* 3.72 0.84 .83*
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Resil_8 3.50 0.84 .78* 3.32 0.94 .78*

Resil_9 3.69 0.81 .87* 3.92 0.89 .80*
Resil_10 3.53 0.82 .83* 3.66 0.90 .79*
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STS Secondary Trauma Stress (Singapore: Reliability α = .80) (Canada: Reliability α = .85)
STS 2 3.73 0.81 .31* 3.14 1.12 .38*
STS 5 2.83 0.89 -.06 2.57 1.11 .48*
STS 7 2.56 0.97 .52* 2.61 1.51 .58*
STS 9 2.34 0.85 .76* 2.34 1.07 .78*
STS 11 2.49 0.85 .72* 2.15 1.08 .77*
STS 13 2.26 0.85 .85* 1.96 1.01 .77*
STS 14 2.29 0.87 .81* 1.70 0.89 .77*
STS 23 2.28 0.88 .61* 1.64 0.90 .72*
STS 25 2.12 0.88 .71* 1.51 0.80 .77*
STS 28 2.37 0.86 .46* 1.76 0.89 .54*
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CS Compassion Satisfaction (Singapore: Reliability α =.92) (Canada: Reliability α = .91)

CS 3 4.07 0.76 .78* 4.19 0.80 .80*
CS 6 3.69 0.76 .71* 3.37 1.02 .60*
CS 12 3.88 0.83 .88* 3.89 0.94 .66*
CS 16 3.74 0.76 .69* 3.41 0.93 .67*
CS 18 3.63 0.83 .84* 3.51 0.93 .84*
CS 20 3.76 0.76 .79* 3.51 0.91 .79*
CS 22 3.71 0.76 .76* 3.60 0.97 .80*
CS 24 3.97 0.80 .86* 3.95 0.84 .84*

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CS 27 3.33 0.89 .68* 3.40 0.92 .68*

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CS 30 3.83 0.87 .86* 3.99 0.90 .78*
BO Burnout (Singapore: Reliability α = .78) (Canada: Reliability α = .75)

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BO 1 2.28 0.76 .73* 2.15 0.88 .59*
BO 4 2.27 0.76 .73* 2.27 0.87 .45*
BO 8 2.09 0.86 .48* 1.87 0.94 .61*
BO 10 2.35 0.98 .56* 2.05 1.13 .68*

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BO 15 2.40 1.01 .38* 2.84 1.30 .22*
BO 17 2.36 0.83 .74* 2.60 0.93 .68*
BO 19 3.09 0.97 .44* 3.18 1.06 .47*
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BO 21 3.19 0.30 .31* 3.16 1.10 .41*
BO 26 2.67 1.01 .42* 3.27 1.21 .52*
BO 29 2.07 0.74 .65* 1.69 0.76 .52*
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Note: *All coefficients were significant p < .05 and are the
loadings from Figure 2.
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Common Source Bias (CSB)

One potential concern with using a self-reporting method is common source bias which is an error
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resulting from self-reports, that may introduce a bias/error and be contained in multiple measures
which can lead to spurious relationships among variables. Harman’s single factor tests to see if
the majority of the variance can be explained by a single factor (Podsakoff, MacKenzie, Lee &
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Podsakoff, 2003). For Singapore and Canadian CSB, the first component accounted for 31% and
26% of the variance respectively. These values were less than the cut-off of 50%, indicating that
CSB was not a serious concern.
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Scale Reliability
Scale reliability provides a measure of the internal consistency and homogeneity of the items
comprising a scale (Churchill, 1979) and was calculated using Cronbach’s alpha. As presented
on Table 1, for the Singapore data the reliability ranged from α=.78 to α=.92; and α=.75 to α=.91
for the Canadian sample. Thus, four scales for both datasets displayed reliability values in excess
of the 0.70 recommended threshold (Churchill, 1979), providing strong evidence of the reliability
of the scales used.

Model and Hypotheses Testing

The theoretical model was estimated using the Singapore and Canadian datasets. Prior to
assessing the study’s hypotheses, the model’s overall fit had to be established (Bollen & Long,
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1993). The following sections presented the two models along with the results from the
hypotheses tests conducted.

Singapore resilience model fit. The chi-square statistic was significant (χ2 = 1937, df = 735,
p = 0.00). With respect to the fit indices, RMSEA = 0.074, below the 0.08 cutoff. The CFI, NNFI,
and IFI indices were all at the minimum acceptable 0.95 level, with values of 0.95, 0.95 and 0.95,
respectively (Chau, 1997). Thus, the model appeared to fit reasonably well. The results of the
structural model estimation were shown in Figure 2.

Canadian resilience model fit. The chi-square statistic was significant (χ2 = 4671, df = 735,

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p = 0.00). With respect to the fit indices, RMSEA = 0.063, below the 0.08 cut-off. The CFI, NNFI,

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and IFI indices were all above the minimum acceptable 0.95 level, with values of 0.97, 0.97 and
0.97, respectively (Chau, 1997). Thus, the model appeared to fit reasonably well. The results of

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the structural model estimation were shown in Figure 2.

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Figure 3. Resilience model. (S: results from Singapore cohort; C: results from Canada cohort)
Hypothesis testing

The test of the proposed hypotheses was based on the direct and indirect effects of the structural
model presented in Figure 2. The LISREL coefficients between latent variables gave an indication
of the relative strength of each relationship (Jöreskog & Sörbom, 1993). All of the five hypotheses
for both data sets were tested at the significance level of p < 0.05.

With respect to the Canadian dataset, all 40 measurement variables loaded significantly on their
respective constructs. In the Singapore data set 39/40 measurement variables loaded significantly
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with only the second STS measurement variable being non-significant. The parameter coefficients
were shown in Table 3.

Table 3 Parameter coefficients

Singapore Canada
Hypothesis Hypothesis supported
Loading t-value Loading t-value
H1: Resil-STS -.35 -7.30 -.36 -4.64 Yes, Both
H2: Resil-BO -.15 -4.98 -.12 -2.22 Yes, Both
H3: Resil-CS .64 15.5 .46 7.09 Yes, Both
H4: STS-BO .25 7.13 .53 5.63 Yes, Both

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H5: CS-BO -.79 -16.0 -.67 9.87 Yes, Both

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Indirect effects
Resil->STS->BO (-.35 * .25) = -.09 (-.36 * .53) = -.19

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Resil->CS->BO (.64 * -.79) = -.51 (.46 * -.67) = .31

The first hypothesis (H1) asserted that resilience had a negative direct impact on secondary

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traumatic stress. As demonstrated in Figure 2 and Table 2, the path relating these two constructs
was negative and significant (Singapore: standardized 1 coefficient = -0.35; t-value = -7.30, p <
0.05; Canada: standardized 1 coefficient = -0.36; t-value = -4.64, p < 0.05), thus providing strong
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evidence supporting hypothesis 1. This indicated that in both countries, a higher level of resilience
was associated with lower levels of secondary traumatic stress.
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The second hypothesis (H2) asserted that resilience had a negative direct impact on Burnout.
The path relating these two constructs was negative and significant (Singapore: standardized 2
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coefficient = -0.15; t-value = -4.98, p < 0.05; Canada: standardized 2 coefficient = -0.32; t-value
= -2.22, p < 0.05), thus providing strong evidence supporting hypothesis 2. This indicated that in
both countries, a higher level of resilience was associated with lower levels of Burnout.
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The third hypothesis (H3) asserted that resilience had a positive direct impact on compassion
satisfaction. The path relating these two constructs was positive and significant (Singapore:
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standardized 3 coefficient = 0.64; t-value = 15.5, p < 0.05; Canada: standardized 3 coefficient =
0.46; t-value = 7.09, p < 0.05), thus providing strong evidence supporting hypothesis 3. This
indicated that in both countries, a higher level of resilience was associated with higher levels of
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compassion satisfaction.

The fourth hypothesis (H4) asserted that secondary traumatic stress had a positive direct impact
on burnout. The path relating these two constructs was positive and significant (Singapore:
standardized β1 coefficient = 0.25; t-value = 7.13, p < 0.05; Canada: standardized β1 coefficient =
0.53; t-value = 5.63, p < 0.05), thus providing strong evidence supporting hypothesis 4. This
indicates that in both countries, a higher level of secondary traumatic stress is associated with
higher levels of burnout.

The final hypothesis (H5) asserted that compassion satisfaction had a negative direct impact on
burnout. The path relating these two constructs was negative and significant (Singapore:
standardized β2 coefficient = -0.79; t-value = -16.0, p < 0.05; Canada: standardized β2 coefficient
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= -0.67; t-value = -9.87, p < 0.05), thus providing strong evidence supporting hypothesis 5. This
indicated that in both countries, a higher level of compassion satisfaction was associated with
lower levels of burnout.

In Table 3, there were strong similarities and differences observed between the parameters
estimated in the model. The impact of resilience on STS and BO was similar between the two
countries. However, the impact of resilience on CS, STS’s impact on BO and CS’s impact on BO
were quite different in magnitude. Thus, although the model fits for both countries, there were
some differences in the magnitude of relationships among constructs, between both countries.

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DISCUSSION

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In this study, we aimed to evaluate a theoretical model that simultaneously estimates the impact
of resilience on psychological outcomes of BO, STS and CS across two countries/population

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samples. Our study affirmed that resilience has a negative direct impact on STS and BO; and a
positive direct impact on CS; among nurses in Canada and Singapore. The results concurred with
that of previous studies which reported that resilient nurses are less likely to experience burnout

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(Garcia, 2011). Our results are also similar to study conducted among Australian nurses whereby,
significant positive relationships were found between resilience, BO and STS; and individual
resilience accounted for a significant variance in scores on CS (Hegney et al., 2015). Consistency
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in findings across study samples in Australia, Canada and Singapore strengthened the
generalizability and applicability of this model.
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Interestingly, nurses in Singapore reported lower resilience levels than their counterparts in
Canada. This could be attributed to differences in demographic profiles between the two samples,
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with nurses in Singapore being younger and a higher proportion being single. Previous studies
have indicated that younger people tend to react more intensely following loss or potential trauma
(Brewin, Andrews, & Valentine, 2000). Since the Canadian sample had a higher age than the
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Singaporean sample on average, and had more married respondents, the difference in resilience
levels could also be ascribed to the fact older nurses have greater and closer spiritual
relationships as well as friendships with others in the workplace and beyond; and such
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relationships provide a sense of emotional security (Southwick et al., 2014). It is also likely that
being married connects individuals to other individuals and social groups which provided support
to deal with stressful situations (Waite, 1995).
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As expected, we also found that STS has a positive direct impact on BO; while CS has a negative
direct impact on BO. The results concurred with previous literatures which also reported on
significant positive associations between STS and BO (Shoji et al., 2015; Sodeke-Gregson et al.,
2013), and significant negative associations between CS and BO (Ray, Wong, White & Kimberly,
2013; Sodeke-Gregson et al., 2013). This is unsurprising given that STS relates to behaviors and
emotions which arise from engaging in an empathic relationship with individuals suffering from
traumatic experience. The chronic use of empathy when treating patients who are suffering in
some way, then lead to an overall experience of emotional and physical fatigue; commonly
defined as professional BO (Newell & MacNeil, 2010). On the contrary, CS is made up of job
satisfaction, how well one thinks one is doing in the job (competency and level of control) as well
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as positive collegiate support (Stamm, 2010). These positive experiences in turn mitigate against
the risk of BO (Wee & Myers, 2003).

One other interesting finding to note is that the indirect effect of resilience -> STS -> BO is:
Singapore = -.09 and Canada = -.19. Conversely, the indirect effect of resilience -> CS -> Burnout
is: Singapore = -.51 and Canada = .31. Although the magnitudes of these indirect effects are
different between the countries they show a similar pattern. In both cases the impact of resilience
through secondary trauma is much lower than the effect of resilience through compassion
satisfaction on burnout. It seems that the effect of resilience through compassion satisfaction has
a much greater impact on burnout than through secondary trauma (both are partial mediation

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models). Also, the indirect effect of resilience through compassion satisfaction on burnout is much

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larger in magnitude than the direct effect of resilience on burnout in both countries. Thus, to
manage the impacts of resilience through STS and CS to reduce burnout, it would be more

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prudent (in addition to increasing resilience) to focus resources on increasing the compassion
satisfaction that nurses enjoy than trying to reduce the secondary trauma to which they are
exposed.

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Interestingly, although the model fits for both countries, there are some differences in the
magnitude of relationships among constructs, between the two countries. More specifically, the
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relationship between resilience and CS; and between CS and BO were stronger among the
Singapore cohort as compared to the Canadian cohort. This difference could be attributed to
differences in practice status of the two cohorts; the Canadian cohort involved both part time and
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full time nurses while those in Singapore were all working full time (Slocum-Gori, Hemsworth,
Chan, Carson, & Kazanjian, 2013); respondents in Singapore also came from more diverse
practice settings (two tertiary medical centres) than respondents in Canada (one acute care
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hospital).

Conversely, the relationship between STS and BO was stronger among the Canadian cohort as
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compared to the Singapore cohort. This could be influenced by the second STS measurement
variable being non-significant in the data from Singapore. The variable reflected responses to the
statement “I am preoccupied with more than one person I help” (Stamm, 2010)(pg 26). It was
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probable that the word ‘preoccupied’ was interpreted differently by nurses in Singapore as
compared to their counter parts in Canada. Another probable reason could be nurses in
Singapore may have lower level of empathy as found from an international survey (World Vision
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International, 2014) as compared to the Canadian cohort, and hence their vulnerability to STS
also decreases (Malkina-Pykh, 2017). This is based on the notion that a caregiver’s level of
empathy with the traumatized individual plays a significant part in the transmission of traumatic
stress from one individual to another (Malkina-Pykh, 2017).

Limitations of current study

Limitations of this study reflect the use of cross-sectional surveys. We could only establish
associations among the variables and not causality. We did not follow up on the participants
longitudinally to evaluate if participants who were less resilient develop burnout at a later time.
Thus, without longitudinal data, it is not possible to establish true cause and effect relationships
of the variables.
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Implications for future research

The findings of this study affirmed the relationships between resilience, CS, STS and BO.
However, as this study had only used cross-sectional data, it will be important for future studies
to examine how relationships between these constructs change or remain constant over time.
Future studies should also explore individual and environmental factors that influence the
development of resilience and how these factors interact to determine one’s professional quality
of life. Another study could be conducted with regards to the level of empathy among the two
populations in Singapore and Canada as to whether this could have an effect on their level of
resilience, CS, STS and BO.

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CONCLUSION

The present study affirmed significant associations between resilience and professional quality of

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life. Knowledge on resilience is the key in informing the design and implementation of resilience-
building strategies that may include professional development, and strengthening of interpersonal
skills A resilience-based approach will help in reducing nurses’ BO and STS while caring for their

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patients, and in turn reduce turnover. AN
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Highlights

 Building resilience among nurses is essential to support and retain nurses.

 Resilience exerts significant negative impact on burnout and secondary traumatic

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stress.

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 Resilience has a positive direct impact on compassion satisfaction.
 Resilience-building strategies include professional development, and

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strengthening of interpersonal skills.
 A resilience-based approach reduces nurses’ burnout and secondary traumatic
stress.

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