Defense Styles Mediate the Association Between Empathy And

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” 555 the feelings of emotion work “ models describe www.jonmd.com rience and share individual is feeling without an nstruct. Recent , the theory of compassion fatigue; ng the relationship with them, based e.g. , Lamothe et al., 2014). e.g. A third hypothesis posits that empathy may protect ” Exploring the impact of empathy is important because many Although there is an increasing amount of data suggesting po- RTICLE empathy killer. requires staff to display expected organizationally emotions; thus, when health policies and recommendationsin are empathetic advocating skills. Empathy for is anrelationships; however, the a pathway indicating increase that central empathy component is of ative protec- nurse-patient factor of burnout ishave unclear shown and that requires emotional further demands, attention.tribute Studies or significantly patient to stressors, burnout do (Duquette not2001). et Instead, con- emotional al., dissonance 1994; has Maslach beencontributor et found (Zapf, al., to 2002). be According the to largest Zapf (2002), Duarte et al.,an 2016), whereas indirect other cause modelsdissonance suggest of that proposes burnout. empathyempathic is For that capacities instance, (Tei“ burnout the et theory al., is of 2014). In emotional associated other with words, burnout diminished is an others (Mehrabian andthe Epstein, ability 1972), to whereas identify cognitive what empathy another is affective responseexamined (Fehr the andempathy relationship Fischbacher, on burnout. between 2003). Inwith affective 1999, Researchers Omdahl greater empathy and have cognitive O'Donnell andpatients, empathy found whereas that were cognitive the nurses less oppositelevels pattern likely of affective was to empathy found (Omdahl depersonalize andLee for O'Donnell, et their nurses 1999). al. Similarly, (2003) with found higher thatpredictor cognitive empathy of was the low most important levelspersonal of accomplishment. depersonalization Researchburnout and has shown a are that greater associated lower(cognitive sense empathy) levels of with ( of a higher level of perspective-taking countries, including Ireland,reported found high that emotional onedepersonalization, exhaustion, (27%) 10% in andaccomplishment were four (Dall'Ora experiencing et 17% nurses al., high similar 2015). Other findings had previous studies (Patricksignificant reported and implications a for Lavery, the 2007).et well-being low and These health al., of experiences senseinvestigated nurses 2010; have nurse (Lim burnout Nolan of and itsshown and effect that personal on Smojkis, burnout patientincreased outcomes. can 2003). risk Studies of lead have failure Previous to to2001; recognize research poor patients Poghosyan in et quality has distress of al., (Aikendepersonalization. et 2010). care Depersonalization al., One on asobjectifying reason units a patients for and result and this of dehumanizi on may defense burnout be and may due protection(Brazeau mechanisms, lead to et which to al., consequently 2010; alter Shanafelt empathy et al., 2012; Zenasnitential direct et links al., between 2012). empathy andrelationship has burnout, been met the with direction debate. Some of modelsthy suggest this that is empa- a direct cause of burnout ( health providerssatisfaction from and burnout, jobfound as meaning that an (Halpern, it increaseamong 2003). in may medical empathy Thomas had students. be etrelated a The protective al. associated role to conflicting (2007) against effectsempathy with burnout its as of job consisting empathy multidimensional(Decety of may co and an be affective Jackson,empathy trait, 2004; refers a Eisenberg to cognitive and the trait, Eggum, and ability 2009). both to Affective expe A emotional RIGINAL — O Volume 206, Number 7, July 2018 • have been found to interfere Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. — bout the role of defense styles in nurse f working in the health service can Empathy and Burnout Among Nurses 561) – 0555 – Defense Styles Mediate the Association Between , Vedsted and Heje, 2008) and changes in symptoms 2018;206: 555 e.g. Burnout, nurses, defense mechanisms, empathy, Research has extensively identified empathic skills as essential in Studies have shown that nurses have the highest levels of burn- ver the past decade,concept there of has been empathy a within growing the emphasis health on care the profession. Studies mail: [email protected]. [email protected]; Natasha BA, Fitzgerald-Yau, MSc, PsyD and Jonathan Egan, BA, MA, MPsychSc, PsyD, PGCTLHE

‐ Clinical Psychology, National University of Ireland, Galway, ArtsBuilding, Millennium University Road, Galway, Ireland. E

JNervMentDis care environment. The three dimensions of burnout impact on one's ability to preserve and maintain empathy in a health (Decety and Lamm, 2009). Burnout has been shown to have a negative prevalence rates. A recent study that surveyed nurses in 12 European perspective-taking (Shamay-Tsoory, 2011), and emotion regulation 2006; Poncet et al., 2007). There has been little change in these satisfaction ( macro components: emotional simulation (Decety and Lamm, 2009), clinical levels of burnout (Aiken et al., 2002; Gelsema et al., have shown that practitioner empathy is highly correlated with patient pinnings. There is a growing consensus that empathy consists of three Research has shown that between 30% and 50% of nurses reach tensively studied in an effort to further understand its neurological under- patient care in nursing homes and hospitals (McHugh et al., 2011). (Mercer et al., 2008). The biological basis of empathy has also been ex- It appears that the rates are highest among nurses who provide direct 2002; Dominguez-Gomez and Rutledge, 2009; Sermeus et al., 2011). out when compared with other health care professionals (Aiken et al., (Maslach and Jackson, 1981a, 1981b) regulation. It is essential that staf social world of health care successfully. exhaustion, depersonalization, and reduced personalwith accomplishment cognitive processes and perspective-takinginfer as both well the as affective and emotion cognitive states of others to navigate the ( emotional exhaustion Key Words: burnout and empathy. The study provides further knowledge a empathy and emotional exhaustion and between empathy and depersonalization. fense style. In addition, immature defense styles mediated the association between the nursing staff. The nurses in this study endorsed a predominantly immature de- reflected very high levels of emotional exhaustion and depersonalization among mechanisms as part of a large-scale research study on nurse burnout. Findings of 442 nurses completed questionnaire measures of empathy, burnout, and defense whether defense styles mediate associations between empathy and burnout. A total to a diminished capacity to empathize. To date, studies have not yet explored pathy serves a protective role, whereas other studies have shown that burnout leads flicting views of the impact of empathy on burnout. Some studies contend that em- health trainings, policies, and recommendations. However, there have been con- The Journal of Nervous and Mental Disease Copyright © 2018 Wolters Kluwer Health, Inc.ISSN: All 0022-3018/18/20607 rights reserved. DOI: 10.1097/NMD.0000000000000837 Department of ClinicalSend Psychology, reprint National requests University to of Natasha Ireland, BA, Fitzgerald-Yau, Galway, MSc, Galway, Ireland. PsyD, Department of

Abstract: O

Downloaded from https://journals.lww.com/jonmd by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3jmg6KbmzDt7VD3l1G27d7CpWGxcu1NX9kUEHyUBUth70pScsQJFRJQ== on 07/26/2018 Downloaded from https://journals.lww.com/jonmd by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3jmg6KbmzDt7VD3l1G27d7CpWGxcu1NX9kUEHyUBUth70pScsQJFRJQ== on 07/26/2018 Fitzgerald-Yau and Egan The Journal of Nervous and Mental Disease • Volume 206, Number 7, July 2018

conflict arises between one's inner emotions and the emotions that are surveymonkey.com portal. Participants were broadly categorized as required from them, feelings are suppressed and “emotional disso- “nurses” and self-identified as either employed in general nursing, pae- nance” occurs. Emotional suppression is a form of defense style used diatrics, gerontology, intellectual disability nursing, accident and emer- by the ego to shield the conscious mind from unpleasurable affects gency, surgery, or psychiatric nursing. Full ethical approval was granted (Blackman, 2004) and from the awareness of internal or external through the National University of Ireland, Galway's research ethics stressors. Malan's (1995) “triangle of conflict” has become a useful frame- committee before beginning recruitment to the study. Participants were work for understanding the defensive system. According to Malan (1995), invited to partake in the study via press release, social media, organiza- impulses, wishes, images, and “hidden feelings” that are distressing or as- tion mailing lists, and the contact details provided on organization Web sociated with conflict enter our consciousness, and awareness of this in- sites. On request, participants were provided with a leaflet describing duces anxiety, which in turn activates our defense mechanisms. The the study aims, the benefits of participation, and the limits of confiden- solution or goal is to avoid conscious acknowledgement of this conflict tiality. In line with the ethical requirements, it was also emphasized that to restore psychic equilibrium. It appears then that nurses may be their participation was voluntary and that their data would only be used experiencing anxiety because of a conflict between their own empathy for research purposes. All participants were invited to complete an online and the organization's required emotions and so use defense styles to cope; survey, using the surveymonkey.com portal. Participants were required to this may explain why empathetic processes are altered. provide informed consent online before anonymously commencing the Although defense profiles are for the most part stable, they can survey, which was then followed by a debriefing form. The online survey vary in accordance with the emotional demands of a situation (Bond, was designed in such a way that participants could not access the next on- 2004). Defense styles can be either adaptive or maladaptive depending line page of the survey unless they had answered all the questions. The on the circumstance and their severity. In addition, defense styles exist survey took on average 30 minutes to complete. Contact details for sup- within a hierarchy of maturity. Mature defense styles attenuate anxieties port services were provided at the end of the survey. See Table 1 for sam- and moderate distressing emotions. They gradually increase awareness of ple characteristics. Inclusion criteria for the study were as follows: the sources of anxiety so that the individual can think about them and prob- a) 18 years and older; b) qualified, registered nurses; and c) a minimum lem solve appropriately (Cohen, 2003) through, for instance, the use of hu- of 1 year of work experience after qualification. mor, sublimation, or seeking social support. In contrast, immature defenses hinder the conscious processing necessary for the resolution of anxiety. They tend to distort the importance and scale of the source of stress or Measures stressful event. According to Huprich (2008), a blurring between the self Quantitative data were gathered over 3 months (January 2017 to and the external world can occur. One effect of immature defenses is a lack March 2017). Cronbach's alpha statistics were calculated to provide an of awareness; another effect is ineffective actions. Falling in the middle of indication of each scale's internal consistency, a measure of the extent to this continuum of mature to immature defenses are the neurotic defense which items within the scale are measuring the same latent construct. mechanisms (Bond, 2004). These defense mechanisms attempt to moder- Alpha values of .6 to .7 are considered acceptable, and values of .7 to ate stress by distorting the meaning or effect of the threat source .9, ideal (Bland and Altman, 1997). (Vaillant, 1971; Vaillant et al., 1986). Bria et al. (2012) demonstrated in their systematic review that Demographic Information health care workers with greater levels of burnout were more likely to Participants completed a demographic questionnaire to gather in- use neurotic defenses and defensive strategies such as denial, humor, formation regarding their age, sex, ethnicity, nationality, relationship status, and withdrawal. Research has shown that nurses use avoidance of their number of children, education, employment status (full-time/part-time), own emotions, emotional detachment, masochism, passive aggression, nursing field, and job tenure (number of years after registration). and introjection (Bruneau and Ellison, 2004; Pompili et al., 2006; Skogstad, 1997). However, immature defense mechanisms may Burnout be shielding nurses from conscious awareness of work-related anxiety, placing them at higher risk of becoming “burned-out.” One study found The Maslach Burnout Inventory for Human Services (MBI; that immature defenses (i.e., introjection, masochism) were associated Maslach et al., 1996) is a 22-item instrument designed to measure “ with emotional exhaustion among a sample of 120 nurses (Pompili three domains of burnout: emotional exhaustion (9 items; e.g., Ifeel ” et al., 2006). Similar findings have been reported by Regan et al. emotionally drained by my work ), depersonalization (5 items; e.g., “ ” (2009). Despite evidence linking empathy to burnout and the proposal I really don't care about what happens to some of my patients ), and “ that individual differences in burnout levels may be related to defense personal accomplishment (8 items; e.g., I accomplish many worth- ” styles, the mediating role of defense styles in the relationship between burn- while things in this job ). In this study, the human services version out and empathy has not yet been directly examined. The aims of the pres- (MBI-HSS) was administered. Respondents were invited to rate the fre- ent study were as follows: a) to identify Irish nurses' level of empathy, b) to quency with which they experience each item on a 7-point Likert scale “ ” “ ” examine the association between burnout (emotional exhaustion, deperson- ranging from never to everyday. A subscale score is obtained by alization, and low sense of personal achievement) and empathy, and c) to summing the items in each subscale. A high degree of burnout is one examine whether immature defense styles mediate the relationship between in which a respondent has high scores on the emotional exhaustion and empathy and emotional exhaustion/depersonalization. depersonalization subscales, and a low score on the personal accomplishment subscale. The MBI has good reliability for the three subscales with Cronbach's alphas of .90 for emotional exhaustion, .79 for depersonaliza- METHODS tion, and .71 for personal accomplishment, with test-retest reliability coefficients of .82, .60, and .80, respectively (Maslach and Jackson, 1981a; Design Maslach et al., 1996). In this study, the Cronbach's alpha coefficients for A cross-sectional design was used. Data were collected online the three dimensions of MBI were .93, .77, and .77, respectively. through the completion of self-report measures. Defense Style Participants Participant's defense mechanisms were measured using the Defense A total of 442 nurses working in Ireland (mean age = 41.1 years, Style Questionnaire (DSQ-40; Andrews et al., 1993). The DSQ-40 is a age range = 23–63 years) completed an online survey via the 40-item inventory designed to assess conscious expressions of defense

9-point Likert scale (from 1 to 9). Items include “I get satisfaction from TABLE 1. Demographic and Work-Related Characteristics of Nurses helping others and if this were taken away from me, I would get de- (N =442) pressed,” and “I often act impulsively when something is bothering me.” Individual defense scores were calculated as the mean between Variable n % the two items corresponding to each defense mechanism, and the scores Age, mean (SD) 442 41.1 (9.8) for each category were calculated as the mean between all scores of the Sex defense mechanism belonging to that category. The DSQ-40 does not Male 30 6.8 provide a total score but elicits scores for each of the three defense styles. Female 412 93.2 However, it is the relative strength with which one style is endorsed com- Nationality pared with another that is of interest. Watson and Sinha (1998) found an average item-scale correlation of r = 0.78 for the 20 scales. Test-retest Irish 423 95.7 correlations have been reported with an average of r =0.66forthe British 9 2.0 20 scales using a 4-week period (Andrews et al, 1993). Cronbach's alpha European 3 0.7 values are dependent on the number of items in the scale. As the mature Asian 3 0.7 and neurotic scales consist of a small number of items (less than 10), the American 3 0.7 mean inter-item correlation value was reported instead. Optimal mean Relationship status inter-item correlation values range from .2 to .4 (Briggs and Cheek Married 241 54.5 1986). In this study, the mean inter-item correlation was .21 for the ma- In a relationship 84 19.0 ture factor, .18 for the neurotic factor, and .22 for the immature factor. Divorced or separated 21 4.8 Single, never married 92 20.8 Empathy Widowed 4 0.9 To assess the participants' levels of empathy toward their pa- Children tients, a five-item empathy scale adapted from the Barrett-Lennard Re- No children 205 46.4 lationship Inventory (Ganley, 1989) was administered. In 1989, Ganley identified five items relating to empathy, and these items were adapted One child 50 11.3 and reworded to be stated from a nurse's point of view. Answers to items Two children 82 18.6 such as “Do you usually sense or realise what your patients are feeling? Three or more 105 23.8 Do you nearly always know how they feel?” were recorded on a 5-point Education level Likert scale ranging from never to always. The original scale has good PhD 8 1.8 levels of internal consistency (Cronbach's α = .84) and good test-retest Master's 79 17.9 reliability (.83) (Gurman, 1977). The shorter scale demonstrated good Postgrad diploma/cert 163 36.8 reliability (Ganley, 1989). The internal consistency for the empathy Degree 138 31.2 measure was .69 in this sample. Diploma 54 12.2 Nursing experience, mean (SD) 17.5 10.7 Data Analysis Employment status The data were transferred from the surveymonkey.com portal Full-time 346 78.3 into the IBM Statistical Package for the Social Sciences (SPSS) version Part-time 89 20.1 24 software for analysis. Data was assessed for normal distribution by an- alyzing histograms, stem and leaf plots and employing Kolmogorov- Locum/bank 7 1.6 Smirnov analysis. Descriptive statistics of the variables in the study Nursing discipline included means, standard deviations (SDs), frequency counts, per- General 118 26.7 centages and skewness and kurtosis values. A series of t-tests, one-way Community/PHN 32 7.2 analysis of variance (ANOVA) and Pearson r correlation were performed Older age 70 15.8 to examine the associations between socio-demographics, work-related Emergency/A&E 33 7.5 characteristics, and level of burnout. Mediation analyses were performed Intensive care 18 4.1 using the SPSS PROCESS (Hayes, 2013; www.afhayes.com) macro 2.16 Surgery/surgical ward 31 7.0 (Hayes, Columbus, OH) (model 4). The confidence intervals of the Oncology 24 5.4 indirect effect were created by bootstrapping 5,000 samples. Mediation Mental health 28 6.3 existed if the confidence interval of the indirect effect did not include 0. Disability 6 1.4 a Other 82 18.5 RESULTS aSpecialized nursing field, that is, chronic pain, rehabilitation, renal clinic, etc. Demographic Synopsis The demographic and professional characteristics of the nurse mechanisms. The defense mechanisms are divided onto three catego- participants are shown in Table 1. The nurses in the study were primar- ries: mature (8 items), neurotic (8 items), and immature (24 items). ily women (n = 412, 93.2%), Irish (n = 423, 95.7%), married (n =241, The mature style factor consists of items measuring anticipation, humor, 54.5%), had no children (n = 205, 46.4%), and had completed a post- sublimation, and suppression. The neurotic style factor includes idealiza- graduate certificate or diploma (n = 163, 36.8%). The mean age was tion, pseudoaltruism, reaction formation, and undoing. The immature 41 (SD = 9.8), ranging from 23 to 63 years. Years working as a nurse style factor assesses acting out, autistic fantasy, denial, devaluation, dis- ranged from 1 to 45 years (mean = 17.5, SD = 10.7), with the majority placement, dissociation, isolation, passive-aggression, projection, ratio- in a full-time post (n = 346, 78.3%). Over a quarter of the participants nalization, somatization, and splitting. Participants were asked to rate were working in general nursing (n = 118, 26.7%). The prevalence of the extent to which they agree with statements about themselves on a burnout in the following study was very high. Among the participants,

associated with low personal accomplishment and immature defense TABLE 2. Means and Standard Deviations for Key Variables (N =442) style (see Table 3). Outcome measure Mean SD Mediating Role of Immature Defense Style MBI A mediation analysis was conducted to test the proposed indirect Emotional exhaustion 37.60 10.76 effects model suggesting that the association between empathy and Depersonalization 14.04 5.96 burnout may be due, at least in part, to an immature defense style. A Low personal accomplishment 37.94 6.51 graphical depiction is provided in Figure 1. Results revealed a signifi- Empathy scale cant indirect effect of empathy on emotional exhaustion through imma- − − − Total score 3.90 0.44 ture defense styles, ab = 1.97, BCa CI [ 3.17, 1.03] (see Table 4). DSQ-40 Immature defense style could account for three quarters of the total effect, P = 0.71. The results of the bootstrapping procedure showed that the con- Mature 4.18 1.08 M fidence interval of the indirect effect did not contain zero, which supports Neurotic 4.82 1.12 the significance of the mediation effect. In addition, there was a smaller Immature 6.06 0.99 but significant indirect effect of empathy on depersonalization through immature defense styles, ab = −1.13, BCa CI [−1.76, −.55], accounting for 359 (81.2%) were above the cutoff point for high levels of emotional approximately one third of the total effect, PM = 0.33 (see Table 4). exhaustion, 254 (57.5%) reported high levels of depersonalization, and 75 (17%) scored above the cutoff point for high levels of a low sense of personal accomplishment. Mean MBI scores in this study are DISCUSSION above the normative sample (e.g., Maslach et al., 1996). The mean The present study investigated associations between empathy score for empathy was 3.90 and for immature defense style was 6.06 and burnout and whether the use of immature defense style mediated (see Table 2). the association between empathy and emotional exhaustion and deper- In general, the three burnout subscales were unrelated to demo- sonalization. Within this study, the average score for both emotional ex- graphic features in the nursing samples, with a few small exceptions. haustion and depersonalization was above the cutoff threshold to be Emotional exhaustion was slightly but significantly negatively corre- considered at risk of burnout. In fact, 81% of nurses reported a high lated with age (r = −0.13, p = 0.005), as was depersonalization level of emotional exhaustion and 58% reported high levels of deper- (r = −0.30, p = 0.000). Low personal accomplishment was slightly pos- sonalization. The prevalence rates are higher than Dall'Ora et al.'s itively associated with age (r =0.15,p = 0.001). There were no signif- (2015) recent European study; however, the percentage for low personal icant differences between the three dimensions of burnout and sex, accomplishment was the same (17%). Our findings also revealed that nationality, or relationship status. The difference in depersonalization most of the nurses had a moderate score of empathy and a high score mean scores between no children and having three or more was small, of immature defense styles. Findings showed that older and more expe- with an effect size of 0.03. Nurses with a postgraduate qualification rienced nurses had a higher empathy score. Empathy or burnout was not scored significantly lower on emotional exhaustion (mean = 36.54, associated with sex, educational level, and marital status. In this study, SD = 10.87; t [440] = 2.37, p = 0.02) but higher on low personal accom- the most influential demographic on empathy and burnout was age and plishment (mean = 38.7, SD = 6.85; t[440] = −2.91, p = 0.004); effect work experience. It is interesting to note that nearly half of the nursing sizes were small. Higher mean scores for emotional exhaustion were participants did not have any children. Attachment styles are important noticeable among nurses working in the surgery (mean = 41.7, SD = 8.4) in developing and maintaining effective social relationships. The major- and emergency (mean = 41.4, SD = 9.3) departments. One-way ity of work in health care settings frequently requires interactions with ANOVArevealed that nurses in the above fields had higher mean scores patients and their families. Studies have shown that attachment style than those in mental health (mean = 31.95, SD = 13.51). In addition, can influence individual functioning in the work environment, with emergency nurses had the highest mean scores for depersonaliza- links between secure attachment and higher levels of overall work satis- tion, and their levels were significantly higher than public health faction, confidence, and perceptions of others as viewing them favor- nurses, nurses working in older-age services and those who work in in- ably (Hazan and Shaver, 1990; Mikulincer and Shaver, 2007). Studies tellectual disability services. Nursing experience was negatively correlated have found that attachment styles are significant predictors of nursing with emotional exhaustion (r = −0.13, p = 0.005) and depersonalization staff's abilities to cope with difficult circumstances and in using (r = −0.25, p < 0.0005), but positively correlated with low personal better-coping methods to manage stress (Franczak, 2012). Hawkins accomplishment (r = −0.13, p < 0.01). Empathy was significantly positively associated with age (r =0.16,p < 0.005) and nursing expe- TABLE 3. Correlation Coefficient Values Between Key Variables rience (r = 0.16, p < 0.005). There were no significant differences in (N =442) scores with regard to sex and other demographic variables. Variable 1 2 3 4 5 6 7 Associations Between Burnout, Empathy, and 1. EE – .62** −.38** −.11* .13** −.16** −.41** Defense Styles 2. D – −.36** −.25** .10* −.13** −.45* Examination of bivariate correlations revealed a significant rela- 3. PA – .35** −.36** −.01 .28** tionship between emotional exhaustion and all the outcome variables, 4. Empathy – −.17** .02 .20** with large effect sizes for depersonalization (r = 0.62) and with medium – effect sizes for immature defense style (r = −0.41) and personal accom- 5. Mature DS .26** .02 – plishment (r = −0.38). Depersonalization significantly inversely corre- 6. Neurotic DS .50** lated with immature defense style (r = −0.45) with a medium effect 7. Immature DS – size. There was a significant negative association between low personal *p < 0.05 (two tailed), **p < 0.01 (two tailed). accomplishment and a mature defense style (r = −0.36). Empathy EE indicates emotional exhaustion; D, depersonalization; DS, defense style; was significantly negatively correlated with emotional exhaustion, PA, personal accomplishment. depersonalization, and a mature defense style but positively

FIGURE 1. Analysis of immature defense styles as a mediator of the relation between empathy and emotional exhaustion. et al. (2007) found partial support for the hypothesis that nurses with in- (2003) and does not support the hypothesis that empathy prevents burn- secure attachment styles experience more stress than securely attached out because it generates greater professional satisfaction (Halpern, nurses. It has been proposed that the relationships formed in organiza- 2003). According to Vaillant (1971), ego defenses can alter a person's tions between individuals and groups may mirror the attachments perception of internal and external realities. This might also explain formed between infants and parents and between adults (Popper and why the use of immature defense styles has led nurses to perceive them- Mayseless, 2002). Attachment styles have also been linked to defense selves as less accomplished than their peers. mechanisms. Besharat et al. (2001) demonstrated that participants with Immature defenses are normative in young children (Cramer, secure attachment styles were more likely to use mature defense mech- 1991). However, adults who maintain an immature defense style expe- anisms, whereas those with insecure or ambivalent attachment styles rience greater psychopathology and maladjustment (Perry and Cooper, were more likely to use neurotic and immature defense mechanisms. 1989; Vaillant, 1994), length of marriage, income level, and objective The majority of studies have focused on examining the association be- physical health (Vaillant and Schnurr, 1988). Studies have shown that tween burnout and early attachment relationships, but there is limited immature defense styles act as a moderator in the link between negative at- research on whether burnout is related to current attachment style in tributional style and depressive symptoms (Kwon and Lemon, 2000) and adulthood. Future research could examine the protective role of parent- between low hope and depression (Reff et al., 2005). Kwon and Olson ing and current attachment styles in burnout and nurse empathy. (2007) also found that rumination was associated with depressive symp- This study found that empathy was negatively associated with toms primarily when accompanied by an overuse of immature defenses. emotional exhaustion and depersonalization but positively associated This has important clinical implications for nurses, who, through the over- with a low sense of personal accomplishment. In addition, nurses with reliance of immature defenses, are increasing their risk for further burnout, higher levels of empathy were more likely to use immature defense anxiety, depressive symptoms, and other mental health disorders. styles. Mediational analyses revealed that immature defense style mediated the relationship between empathy and emotional exhaustion, accounting for three quarters of the total effect. In addition, immature Implications and Future Directions defense styles mediated the relationship between empathy and deper- The findings from this study demonstrate that the rate of nurse sonalization, accounting for one third of the total effect. burnout in Ireland is significantly high. Furthermore, from this study, These findings suggest that although empathy may serve a pro- it appears that the majority of nurses with high levels of empathy are tective role, nurses with higher levels of empathy are using immature using immature defense styles to further reduce their levels of emo- defense styles. One reason may be the occurrence of emotional disso- tional exhaustion and depersonalization. The increasing emphasis on nance, that is, the emotion work one must engage in when their organi- productivity within the health care system may lead to a perpetual state zationally required emotions conflict with their true internal emotions of “fight or flight.” It is essential that health care policies advocate for (Zapf, 2002). It may be that nurses are emotionally conflicted. To carry more clearly defined boundaries so that nurses are not at risk of out the demanding role of nursing, they must resort to immature de- overstretching themselves. Defense styles are dynamic and can, there- fense styles to block this conflict from conscious awareness and to in- fore, be altered; thus, it seems important for senior management teams crease their emotional reserves in the short-term. Interestingly, nurses to consider ways to reduce the impact of emotional dissonance. For inwith higher empathy scores reported a reduced sense of personal ac- stance, the organizational rules regarding emotional display of frontline complishment. This is consistent with findings reported by Lee et al. employees and the style of supervision may need revision. Nurses

TABLE 4. Mediational Analyses Testing the Influence of Immature Defense Styles on the Relationship Between Empathy and Emotional Exhaustion/Depersonalization

Confidence Intervals Predictor Outcome Mediator Patha Pathb Direct Effectc Total Effectc Indirect Effectab (Lower to Upper) Empathy Emotional exhaustion Immature DS 0.45*** −4.36*** −0.81 −2.79* −1.97 −3.15 −1.03 Depersonalization Immature DS 0.45*** −2.49*** −2.25 −3.38*** −1.13 −1.76 −0.55 aDependent variable: emotional exhaustion. bLower confidence interval 95%; upper confidence interval 95%. c*p <0.05,**p < 0.01, ***p <0.001.

might be taught how to respond to the emotional demands of their work vulnerable to additional losses. It could be argued that encouraging while staying true to their own feelings. A forum where nurses can ex- nurses to increase their levels of mature defenses may be a difficult feat plore and express the inherent anxieties that arise within the nursing en- for any organization; however, an overall organizational policy that fo- vironment may help nurses to achieve conscious acceptance and to use cuses on the provision of personal and job resources and encourages more mature defense styles. Reflective practice and peer groups should personal development and self-care strategies may go some way toward be a common practice in health care environments. Regular clinical su- obtaining this objective. pervision would help nurses to address their own internal processes and provide them with a safe space to process any unpleasant experiences. DISCLOSURE Peer reflective groups may help nursing staff maintain the ability to The authors declare no conflict of interest. mentalize. There needs to be ward culture that provides nurses with the time to reflect on the individuality of each patient and deliver quality care. Those in senior management can enable compassion and stimulate REFERENCES mentalizing among staff by modeling these skills. Finally, the formative Aiken LH, Clarke SP, Sloane DM, Sochalski JA, Busse R, Clarke H, Giovannetti P, stages of the nursing profession require equal attention. Early interven- Hunt J, Rafferty AM, Shamian J (2001) Nurses' reports on hospital care in five tion in the form of reflective practice will equip young nurses with the countries. Health Aff (Millwood).20:43–53. tools to self-regulate while on placement. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH (2002) Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. Limitations 288:1987–1993. 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