Professional Quality of Life and Occupational Stress in Healthcare Professionals During the COVID-19 Pandemic in Greece

Toward better prevention of physician burnout: insights from individual participant data using the MD-specific Occupational Stressor Index and organizational interventions

Background

Physician burnout has become a public-health crisis. The need is dire for robust organizational solutions, focusing on reduction of specific stressors. The physician-specific Occupational Stressor Index (OSI) based on cognitive ergonomics can help. Individual-participant data (IPD) from different studies addressing physician burnout are lacking.

Aims

To perform IPD analysis regarding job stressors and their relation to physician burnout and to utilize the IPD results to inform a systematic review of the stressors that show an association with physician burnout, focusing on intervention studies.

Methods

PRISMA guidelines are followed for the IPD analysis and systematic review of intervention studies on the implicated stressors, taking the COVID-19 pandemic into consideration. The IPD analysis is performed on studies using the physician-specific OSI vis-à-vis burnout assessed by the Copenhagen Burnout Inventory (CBI). Odds ratios (OR) ± 95% confidence-intervals (CI) are reported, adjusting for age, gender and caring for patients with suspected COVID-19 infection.

Results

Three studies fulfilled the inclusion criteria, providing complete IPD data for 95 physicians. Thirty-two (33.7%) physicians had total OSI scores >88, for which intervention is urgently needed. Unit-change in the total stressor burden assessed via OSI yielded OR = 1.11 (95%CI: 1.03-1.18) (p = 0.003) for personal burnout, OR = 1.17 (95%CI: 1.08-1.26) (p = 0.0001) for work-related burnout and OR = 1.07 (95%CI: 1.01-1.15) (p = 0.03) for patient-related burnout. Caring for patients with suspected COVID-19 infection showed significant multivariable results (p = 0.04) only for personal burnout. Twenty distinct work stressors revealed multivariable associations with CBI. Systematic examination via PUBMED, CINAHL and OVID Medline yielded 33 publications mitigating those stressors among physicians. Adequate staffing was pivotal. Clerical staff off-loaded administrative burden. Information-technology staff helped diminish interruptions, enhancing workflow. Cross-coverage reduced time constraints, ensured separate periods for non-clinical tasks, and ≥1 work-free day/week. Several interventions impacted physician burnout, as did recognition of physicians' efforts/achievements. Other OSI-identified stressors were insufficiently examined in intervention studies: e.g. vacation; appropriately-timed, cross-covered restbreaks; and counter-measures for emotionally-disturbing aspects of MD's work, particularly during the pandemic.

Conclusions

Further participatory-action research is needed in well-controlled intervention trials to alleviate physician burnout.

Junior doctors' workplace well-being and the determinants based on ability-motivation-opportunity (AMO) theory: Educational and managerial implications from a three-year longitudinal observation after graduation

PURPOSE

Junior doctors function as trainees from an educational perspective and as employees from a human resource management perspective. Employing the ability-motivation-opportunity (AMO) theory as a conceptual framework, this study longitudinally investigated the factors affecting the workplace well-being and career progression of junior doctors over a 3-year period following their graduation from medical schools.

MATERIALS AND METHODS

This 3-year prospective cohort study enrolled junior doctors who graduated from 2 medical schools in June 2019 in Taiwan. This study collected data by implementing web-based, self-administered structured questionnaires at 3-month intervals between September 2019 and July 2022. The collected data encompassed ability indicators (i.e. academic performance and perceived preparedness for clinical practice), motivation indicators (i.e. educational and clinical supervision), opportunity indicators (i.e. clinical unit cultures), and workplace well-being indicators (i.e. burnout, compassion satisfaction, and job performance). A total of 107 junior doctors participated, providing 926 total responses. The data were analysed using univariate analyses and structural equation modelling with path analysis.

RESULTS

Over the 3-year period following graduation, the junior doctors' confidence in their preparedness for clinical practice and the educational and clinical supervision had varying degrees of influence on the junior doctors' workplace well-being. The influence of clinical unit cultures, which can provide opportunities for junior doctors, became evident starting from the second year postgraduation; notably, unit cultures that emphasised flexibility and discretion played positive and critical roles in enhancing the junior doctors' workplace well-being lasted to the third year.

CONCLUSIONS

Our findings provide insights into the distinct critical factors that affect the socialisation of junior doctors within workplace environments over 3 consecutive years. These findings can provide guidance for medical educators and healthcare managers, helping them understand and support the progressive integration of junior doctors into their work environments.

Improving GPs' Emotional Intelligence and Resilience to Better Manage Chronic Respiratory Diseases Through an Experiential Online Training Intervention: A Mixed Methods Study

BACKGROUND/OBJECTIVES

High levels of emotional intelligence (EI) and resilience in primary care physicians (PCPs) can help them communicate better with patients, build stronger relationships with colleagues, and foster a positive and collaborative workplace. However, studies have indicated that primary care physicians (PCPs) often do not focus enough on developing these skills. Consequently, the purpose of this mixed methods study was to evaluate the effectiveness of an experiential online training (EOT) intervention in enhancing the EI and resilience of PCPs who treat patients with chronic respiratory diseases (CRDs).

METHODS

A total of 46 PCPs from Greece participated in a 25-hour EOT program, which focused on counseling skills for lifestyle change and breathing techniques for self-regulation. Quantitative data were collected using the Trait Emotional Intelligence Questionnaire-Short Form (TEIQue-SF) and the Connor-Davidson Resilience Scale (CD-RISC-25) before, immediately after, and three months post-intervention. Additionally, qualitative data were obtained through written reflections from participants regarding their clinical practice.

RESULTS

The results revealed significant improvements in EI and resilience scores immediately after the intervention (ΕΙ: 5.13, SD: 0.65 vs. 5.3, SD: 0.57, p = 0.007; resilience: 76.6, SD: 11.75 vs. 79.83, SD: 10.24, p = 0.029), as well as at the three-month follow-up (ΕΙ: 5.3, SD: 0.57 vs. 5.36, SD: 0.48, p = 0.007; resilience: 79.83, SD: 10.24 vs. 81.03, SD: 7.86, p = 0.029). The thematic analysis of qualitative data identified improvements in five key themes: communication skills, stress management, emotional awareness, resilience, and patient care. Participants reported feeling more confident, empathetic, and effective when interacting with patients, particularly those from diverse backgrounds. The convergence of the quantitative and qualitative findings showed the efficacy of the EOT intervention in enhancing PCPs' EI, resilience, well-being, and, ultimately, their practice.

Impact of Work-Family Balance on Nurses' Perceived Quality of Life During the COVID-19 Pandemic: A Scoping Review

BACKGROUND/OBJECTIVES

The COVID-19 pandemic has put nurses under extreme pressure, especially affecting them by significantly increasing their workload and compromising their well-being. The lack of balance between work and personal life has caused greater stress and burnout in these professionals, deteriorating their quality of life and the care they provide. This study aims to synthesize the scientific evidence on the relationship between work-family balance and the perceived quality of life of nurses during the COVID-19 pandemic.

METHODS

A scoping review was carried out based on the Joanna Briggs Institute methodology, following the PRISMA-ScR guidelines in the PubMed, CINAHL, SCOPUS, WOS, Cochrane Library, and PsycINFO databases. The quality of the articles was assessed using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

Five studies involving 1641 nurses from Spain, India, Jordan, South Korea, and Turkey focused on three key areas: (1) work-life balance, (2) quality of life, and (3) factors associated with quality of life during the COVID-19 pandemic.

CONCLUSIONS

The pandemic exacerbated pre-existing challenges related to work-life balance and quality of life, particularly for nurses with rigid and extended work hours, increasing stress and negatively impacting their well-being. The study emphasizes the need for flexible labor policies, psychological support, and strong social networks to prevent burnout and improve nurses' quality of life.

Towards a Clinically Relevant Appreciation of the Cost of Caring: A Study of Palliative Care Physicians in Malaysia

Background: The cost of caring for patients and their families in the midst of interconnected resource, ethical, moral, legal and practical considerations compromises a physician's emotional and physical well-being and therefore patient care. Whilst the cost of caring is historically best associated with compassion fatigue, data has suggested that this may extend to other related concepts, such as vicarious trauma, secondary traumatic stress and burnout. In particular, palliative care physicians are especially vulnerable as they witness and encounter more cases of death and dying. Methods: This study aims to provide a more clinically relevant notion of the cost of caring amongst palliative care physicians in Malaysia. 11 physicians underwent semi-structured interviews as part of the Systematic Evidence-Based Approach (SEBA) for prospective studies. Results: Analysis of the interview transcripts revealed the following domains: (1) conceiving the costs of caring; (2) risk factors; and (3) support mechanisms. Conclusion: This SEBA-guided study into the cost of caring amongst Malaysian palliative care physicians suggests that the costs of caring extend beyond encapsulating moral distress, compassion fatigue, vicarious trauma, secondary traumatic stress and burnout. Rather, the data suggests a personalized notion that varies with individual and contextual factors which are in flux and change over time. A longitudinal, personalized and holistic mentoring program is therefore proposed to counter this cost.

Work stress and professional quality of life among Chinese nurses during the COVID-19 pandemic: the chain mediating role of self-compassion and benefit finding

BACKGROUND

Since the outbreak of the Coronavirus Disease 2019 (COVID-19), front-line nurses have faced not only daily work stress but also a high risk of infection and excessive workload, leading to unsatisfactory professional quality of life (ProQOL). This study aimed to explore whether self-compassion (SC) and benefit finding (BF) play a chain mediating role between work stress and ProQOL among Chinese nurses during the COVID-19 pandemic.

METHODS

From March to April 2022, a sample of 13,936 Chinese nurses was recruited through snowball sampling. Demographic information, work stress, SC, BF, and ProQOL were assessed. The SPSS 25.0 software and Amos 24.0 software were used for statistical analysis. The bootstrap method was employed to construct and examine the chain mediating structural equation model.

RESULTS

The ProQOL level of Chinese nurses during the COVID-19 pandemic was moderate. The overall fit indices for the compassion satisfaction (CS), burnout (BO), and secondary traumatic stress (STS) models were satisfactory (χ²/df = 2.486, 3.256, 2.553, RMSEA = 0.011, 0.014, 0.011, the GFI, AGFI, NFI, and CFI values were all above 0.90). Work stress had direct effects on CS, BO, and STS (β=-0.171, 0.334, 0.222, P < 0.001), and also indirectly affected these outcomes through SC (point estimate=-0.010, 0.021, 0.024, P < 0.001), BF (point estimate=-0.033, 0.015, - 0.011, P < 0.001), as well as their chain mediating effect (point estimate=-0.015, 0.006, - 0.005, P < 0.001).

CONCLUSIONS

Our study suggests that SC and BF partially mediated the association between work stress and ProQOL in Chinese nurses during the COVID-19 pandemic. Training on SC and BF may be crucial components of interventions aimed at improving ProQOL.

The relationship between job crafting and work engagement among nurses in China: A latent profile analysis

AIM

To identify subtypes of job crafting among Chinese nurses and to explore the characteristics of different subtypes and their relationship with work engagement.

DESIGN

A cross-sectional study.

METHODS

A survey of 350 clinical nurses was conducted between December 2022 and January 2023. Identify profile categories for nurses' job crafting using a latent profile analysis. Logistic regression and ANOVA were used to explore the characteristics of different categories of nurses' job crafting in terms of sociodemographic, work engagement variables.

RESULTS

Ultimately 3 latent profiles are identified: low job crafting (Class 1, N = 177, 50.7%), moderate job crafting (Class 2, N = 136, 38.9%), high job crafting (Class 3, N = 37, 10.5%). Nurses who are female, aged 31 to 40 and married are more likely to be grouped into Class 2. Nurses with a middle level of title are more likely to be grouped as Class 3. Nurses with high levels of work engagement are more likely to be grouped as Class 2 and Class 3 rather than Class 1.

CONCLUSION

The job crafting has a distinctly classified character among Chinese nurses. 89.6% of nurses were at a low to medium level of job crafting, work engagement is an important predictor of nurses' job crafting. Nursing Managers should focus on the low job crafting group and develop targeted interventions to help nurses improve their job crafting and work engagement levels.

PATIENT OR PUBLIC CONTRIBUTION

None.

Caring through crisis: The professional quality of pediatric nurses during the COVID-19 pandemic

PURPOSE

This study described pediatric nurses' professional quality of life during COVID-19 and explored demographic/clinical practice factors independently associated with compassion satisfaction (CS), burnout (BO), and secondary traumatic stress (STS).

DESIGN AND METHODS

The Relational Caring Complexity Theory was used. This study employed a cross-sectional, descriptive, correlational design to describe professional quality of life of pediatric nurses (demographic questionnaire and ProQOL 5 measure) working during the COVID-19 pandemic.

RESULTS

From 150 pediatric nurses, the mean scores were CS 40.8 (± 4.8), BO 22.6 (± 4.7), and STS 22.8 (± 5.8). Results of the multiple regression revealed that two variables, deployed to the same unit versus not deployed (β = 2.424, p = .02) and currently practicing in perioperative/ambulation settings versus intensive care (β = -0.272, p = .03), were independently associated with CS. Deployed to the same unit versus not deployed was found to be independently and significantly associated with BO (β = -0.28, p = .005). The number of patients cared for with COVID-19 (β = 0.196, p = .03) was significantly associated with STS.

CONCLUSIONS

While the overall response was positive, these nurses were more likely to experience BO when deployed to the same area (likely a COVID-19 adult unit) and STS as they cared for more patients with COVID-19.

PRACTICE IMPLICATIONS

Leaders should be aware of the impact of caring in times of crisis. Decentralized staffing may help meet emergent needs on a particular shift, but ensuring deployed nurses are well-supported is vital.

Risk perception and quality of working life of nurses in infectious disease department in China: The chain-mediating effects of psychological resilience and social support

AIM

To determine whether social support and psychological resiliency are significant mediators of the associations between risk perception and quality of working life in Chinese nurses working with infectious diseases.

DESIGN

A cross-sectional study.

METHODS

A cross-sectional survey of 879 nurses in infectious diseases department of specialty or general hospitals in China completed online questionnaires on the nurses' risk perception questionnaire, quality of working life, psychological resilience and the social support rating scale.

RESULTS

Our study observed that risk perception directly negatively influences the quality of working life of infectious disease nurses, while psychological resilience and social support positively chain mediate this relationship.

CONCLUSION

Critical elements impacting the quality of working life of infectious disease nurses are risk perception, psychological resilience and social support. Managers may think about decreasing the level of risk perception and enhancing the quality of working life of infectious disease nurses by enhancing their psychological resilience and providing support.

PUBLIC CONTRIBUTION

The quality of working life of infectious disease nurses should be a priority for nursing management; it is critical to maintain their health and well-being, raise the quality of care and lower turnover. Managers should create resilience-building programmes and support tools to assist nurses properly perceive risks and adopt protective strategies to deal with them to improve the quality of working life for nurses.

Occupational Stress and Professional Quality of Life Among Community Health Nurses During the COVID-19 Pandemic

Purpose: This study aimed to identify the correlation between occupational stress and professional quality of life (Pro-QOL) among community nurses during the pandemic COVID-19. Design: This study was conducted with a correlational design of 120 community health nurses. The research sample was obtained using a nonprobability purposive sampling technique following the research inclusion criteria. Expanded Nursing Stress Scale and Pro-QOL were used in this study. The research hypothesis: there is a correlation between occupational stress and the Pro-QOL of community health nurses. Methods: Pearson's correlation coefficient was used to analyze the correlation between occupational stress and Pro-QOL. Findings: The results of correlation analysis showed that there was a statistically significant positive correlation between occupational stress and Pro-QOL. Despite being in a difficult situation due to the pandemic and vulnerable to occupational stress, nurses significantly had high compassion satisfaction. Conclusions: Occupational stress affects nurses' Pro-QOL, it can be considered for public healthcare organizations to promote healthcare workers' well-being. Mobilizing the existing workforce, changing work patterns, support from colleagues and supervisors, clear communication of directives, and precautionary measures can reduce psychiatric symptoms.

Occupational Stress of Pediatric Emergency Nurses in Greece During the COVID-19 Pandemic

During the COVID-19 pandemic, numerous studies have shown the high prevalence of occupational stress (OS) of health workers, affecting the quality of health care provided. To date, there is no study regarding OS of emergency care pediatric nurses working in Greece. This study aimed to examine the pediatric nurses' OS working in tertiary public hospitals in Greece. In this cross-sectional study, a total of 104 pediatric nurses were recruited randomly from summer 2020 to summer 2021. The Expanded Nursing Stress Scale (ENSS), which consists of 59 items grouped into nine categories, was used to assess nurses OS. The overall OS mean score was 141.04 (SD = 33.48), indicating mild stress. Among nine categories, pediatric nurses were more stressed about patients and families (mean = 22.83, SD = 5.71), as well as death and dying (mean = 19.33, SD = 5.22), whereas they were less stressed about discrimination (mean = 4.21, SD = 4.09) and problems with peer support (mean = 12.11, SD = 4.58). Sex, age, and shifts did not correlate with OS. Borderline correlation was present between age and inadequate emotional preparation for less experienced nurses (p = 0.047), while higher educated pediatric nurses were more stressed because of workload than lower educated pediatric nurses (p = 0.044). Greek pediatric nurses suffered mild OS during the COVID-19 pandemic. There is a great need for further research and implementation of supportive sustainable programs aimed to the minimization of OS and the optimization of health care provided during and after the COVID-19 pandemic.

Anxiety and Health Concerns among Healthcare Personnel Working with COVID-19 Patients: A Self-Assessment Study

BACKGROUND Anxiety disorders are currently among the most common psychiatric diagnoses. This study aimed to analyze self-assessment of anxiety disorders, depression, and quality of life among healthcare personnel working during the COVID-19 pandemic, with a focus on sociodemographic sources and psychological indicators. MATERIAL AND METHODS The study covered a group of 318 healthcare professionals from Poland. The study used a self-created questionnaire, Beck Depression Inventory, WHOQOL-BREF, Generalised Anxiety Disorder Questionnaire (GAD-7), and Leibowitz Social Anxiety Scale. RESULTS In the study group, 71.1% of the respondents had coronavirus infection, and only 3.5% were not vaccinated. Almost half (45.6%) of the respondents in this group made independent decisions about performing work (45.6%), and 93.4% were satisfied with their work. Less than half of respondents (46.5%) felt work-related anxiety during the pandemic, 54.7% of respondents reported symptoms of depression, and 57% had a good quality of life. Nearly half (47.2%) of the respondents rated their health as good, but 53.1% feared deterioration after performing the aforementioned work, while 87.1% constantly or periodically felt anxious about their work. CONCLUSIONS Although the respondents usually made their own decisions about working with coronavirus-infected patients, most of them experienced anxiety related to their work during the pandemic and were afraid of damaging their health and contracting COVID-19. In self-assessment using standardized questionnaires, most respondents did not show an increase in generalized or social anxiety, but to a greater or lesser extent were diagnosed with a depressive episode. The majority of respondents had a good quality of life: the highest aspect regarded physical functioning and the lowest regarded social functioning.

Lessons on the COVID-19 pandemic: who are the most affected

The COVID-19 pandemic has led to significant changes in work and lifestyle, impacting occupational mental health. This study examines the time and individual heterogeneity in the pandemic's effects on occupational mental health using panel data from job stress checks spanning 2018 to 2021. On average, there was an initial alleviation of high-stress risk in 2020, followed by a deterioration in 2021. Based on the job demand-resource theory, we identify the group of employees most affected by the pandemic. The findings highlight that employees in unfavorable workplace conditions are more likely to experience substantial adverse impacts. Adequate workplace support, including factors like interpersonal relationships, managerial support, job meaning, control, and work-life balance, is crucial for mitigating high-stress risk. Additionally, during the early phase of the pandemic, engaged employees experienced a slight decline in occupational mental health, while those lacking job resources at their worksite faced higher levels of occupational stress in the subsequent year. These findings offer practical suggestions for person-centered coping strategies to mitigate the pandemic's adverse impact.

Professional Quality of Life, Work-Related Stress, and Job Satisfaction among Nurses in Saudi Arabia: A Structural Equation Modelling Approach

Objective

To examine the interrelated impacts of work-related stress, compassion satisfaction (CS), and job satisfaction on burnout (BO) and secondary traumatic stress (STS) among nurses using structural equation modelling (SEM).

Methods

A cross-sectional design was used to survey 727 nurses at a teaching hospital in eastern Saudi Arabia. Three scales were used: the Quality of Life (ProQOL) scale, the Nursing Stress Scale (NSS), and the Job Satisfaction Survey (JSS). Data were analysed using SPSS and Analysis of Moment Structures (AMOS), and SEM analysis was conducted to confirm the interrelations among variables.

Results

The final model had a good fit for the obtained data (X ² = 2.726, RMSEA = 0.032). Stress is directly related to BO and STS, and the following variables were directly related to STS: job satisfaction, BO, and CS. Lastly, BO mediated the relationship between stress and STS.

Conclusion

It is crucial to analyze the effect of stress, CS, and job satisfaction which seems to have a positive and negative impact on nurses' BO and STS. Therefore, implementing a management strategy to manage stress and satisfaction can enhance nurses' quality of life, support the maintenance of positive attitudes, and enhance the standard of patient care.

'Caring for the helpers': factors associated with professional quality of life among Hong Kong nurses during the fifth wave of the COVID-19 pandemic

BACKGROUND

Western studies have found that nurses are likely to experience both positive and negative emotions in their job, as a helping profession [professional quality of life (ProQoL)] during the coronavirus disease 2019 (COVID-19) pandemic, and that psychosocial and work-related variables (e.g. pandemic-related stressors, interpersonal and organizational support, coping strategies) are associated with such outcomes. However, relevant studies on nurses in the Asian context are limited.

OBJECTIVE

This study examined the psychosocial correlates of three indicators of ProQoL, i.e. compassion satisfaction, secondary traumatic stress (STS), and burnout, among nurses during the fifth wave of the COVID-19 pandemic in Hong Kong.

METHOD

Nurses in Hong Kong (N = 220) working in hospitals and community settings during the COVID-19 pandemic were recruited between 24 May and 27 June 2022 through nursing associations to complete an online survey measuring the aforementioned psychosocial variables.

RESULTS

Hierarchical regression results found that stressors from clinical work environments, insufficient emotional support, and less positive reframing were associated with poorer ProQoL (i.e. lower compassion satisfaction; higher STS and burnout) (β from 0.16, p > .05, to 0.44, p > .001). In addition, COVID-19-related worries/uncertainties and emotional processing were associated with higher STS (β from 0.21 to 0.23, p < .01), whereas insufficient organizational support for communication with the healthcare system was associated with higher burnout (β = 0.12, p < .05).

CONCLUSIONS

Our findings identified the important psychosocial determinants in ProQoL among nurses in Hong Kong and provide recommendations for services supporting the mental health of these nurses. Providing workshops for nurses to train their skills in coping with COVID-19-related uncertainties, worries, and stressors from the clinical work environment, in using adaptive coping strategies (e.g. positive reframing), and in soliciting emotional support from important others could facilitate their ProQoL. Moreover, the provision of organizational support through timely and transparent communication with the healthcare system could reduce STS in nurses.

Nurses and Respiratory Therapists Lived Experience During COVID-19 Pandemic: A Qualitative Study

Introduction

Nurses and respiratory therapists working on the frontline during the pandemic surge were short-staffed and worked extended hours while adding new tasks to already demanding workloads. As the world watched news covering COVID-19's effect, nurses and respiratory therapists lived through the daily stress of treating each patient with care, dignity, and compassion. Limited studies have focused on this population, which is vital to providing care and saving lives; research is needed to understand nurses' and respiratory therapists' experiences during the COVID-19 pandemic.

Objective

The study aimed to understand nurses' and respiratory therapists' experiences during the COVID-19 pandemic.

Methods

A qualitative descriptive study, informed by naturalistic philosophy, was designed to obtain a detailed account of participants' experiences during the pandemic surge. A purposive sample was recruited and enrolled from the community through professional organizations and snowball sampling from December 2021 to September 2022. Data was analyzed using thematic analysis.

Results

Participants were seven registered nurses and six respiratory therapists employed full-time in an intensive care unit, step-down intensive care unit, emergency department, or medical-surgical unit; seven (53.8%) with an associate degree, and six (46.2%) with a bachelor's degree. Eight (66.7%) self-identified as White, one Asian, one non-Hispanic Black, and two Pacific Islanders. The mean age was 40, and 10 (76.9%) were female. Six primary themes emerged: (a) the work-life experience before the COVID-19 pandemic, (b) the work-life experience during the COVID-19 pandemic, (c) the personal life experience during COVID-19, (d) the coping period, (e) the professional role change, and (f) the work and personal life experiences post COVID-19 surge.

Conclusion

The knowledge gained from this study can help improve understanding of the professional quality of life, the need for organizational and community support, and for healthcare professionals to seek help and practice self-care to prevent burnout and secondary traumatic stress.