Resilience: its determinants and effects in parents of critically ill children and in pediatric intensive care staff

Resumen

ABSTRACT. Background and objectives: after facing difficult or potentially traumatic situations some people develop psychological disorders, such as traumatic stress or depression. On the contrary, others are able to quickly return to normal. These people are labelled as “resilient”. In order to know how to help people to face their problems in the best possible way, it is important to know which the determinants of resilience are. For that reason, the aim of the first part of this doctoral dissertation (part I) is to explore in which degree resilience depends on protective personality factors and in which degree on the coping strategies that people use. Furthermore, as a consequence of the difficulties faced in the past, every individual has a degree of subjective resilience, that is, a perception about his/her own degree of resilience. Such perception can be used as a variable to predict future psychological adaptation in people facing potentially traumatic situations. Thus, the second and the third parts of this dissertation (parts II and III) are aimed at exploring in which degree subjective resilience, along with other psychological variables (such as stress or coping strategies), predicts psychological consequences –positive and negative- derived from having experienced a potentially traumatic situation. These studies have been conducted in parents after their child’s discharge from a Pediatric Intensive Care Unit (PICU), and in PICU professionals because both groups are exposed to difficult situations which can potentially impact their mental health. Methods: to study the determinants of resilience 430 adults (256 general population, 77 adults with HIV or cancer and 97 parents of children with cancer or development problems) completed questionnaires assessing coping strategies, protective and risk personality factors and resilience. As, until now, did not exist adequate measures to assess many of these constructs in adults and in Spanish language, some questionnaires 7 have been adapted and validated (adaptation of the Brief Resilience Scale to Spanish, and development of the Situated Subjective Resilience Scale for Adults, the Situated Coping Questionnaire for Adults and the Resiliency Scale for Adults). With the purpose of validating these tools, correlational, regression and confirmatory factor analyses were conducted. Besides, to explore in which degree coping and personality factors predict resilience, correlational, regression and path analyses with latent variables were carried out. In the second place, to explore the effects of resilience over mental health in parents of critically ill children (part II) a longitudinal study was conducted. A total of 196 parents completed resilience, perception of severity of their child’s medical condition, emotions and stress questionnaires when their child was discharged from PICU. As there was no brief scale to explore the parental stress produced by the PICU stimuli, the Abbreviated Parental Stress Scale for Pediatric Intensive Care Unit was developed and validated. Three and six months after the child’s discharge, parental levels of anxiety, depression, traumatic stress and posttraumatic growth were evaluated. The psychometric properties of the measure used to assess posttraumatic growth (The Posttraumatic Growth Inventory) had never been explored among this population, so we conducted an additional study to do it. With the purpose of studying how resilience, perceived severity, emotions and stress predicted parental anxiety, depression, posttraumatic stress and posttraumatic growth, path analyses with latent variables were conducted. In the studies conducted on PICU professionals (part III) we carried out a multicentric cross-sectional study. A total of 298 physicians, nurses and nursing assistants working in PICU and 189 working in other units completed resilience, coping, burnout, traumatic stress, posttraumatic growth and satisfaction with life questionnaires. Correlational, regression and path analyses with latent variables were conducted to 8 explore how resilience and coping are related to the psychological negative (burnout, traumatic stress) and positive (posttraumatic growth) outcomes derived from working in a PICU. The same kind of analyses were used to explore how these consequences affect professionals’ life satisfaction. Results and conclusions: the studies included in part I show, in the first place, that the assessment tools adapted or developed have adequate psychometric properties. In the second place, the results show that coping and personal protective and risk factors predict more than 60% of the total variance in resilience. Data –correlational in nature– support the model according to which the relation between coping strategies and resilience is mediated by the personality factors assessed. People who use more the problem-focused coping style and less the emotion-focused coping style showed higher scores in sense of mastery and sense of relatedness, and also lower scores in emotional reactivity. Sense of mastery was related to higher resilience, while emotional reactivity and sense of relatedness with lower resilience. These results suggest that interventions aimed at fostering resilience should focus on avoiding the emotion-focused coping style and promoting the problem-focused coping style, preventing that people exclusively rely on their social support to face difficulties. Results from part II showed, in the first place, that during their child’s admission to PICU parents showed high rates of stress, but also of positive emotions. Three and six months post-discharge, parents showed high rates of posttraumatic stress, anxiety, depression and posttraumatic growth. In the second place, our results showed that around 50% of the variance in anxiety, depression and posttraumatic stress can be predicted mainly from the parental level of subjective resilience –whose effect is indirect– and the extent to which they experience stress during their child’s critical hospitalization. On the other hand, more than 20% of the variance in posttraumatic growth could be predicted 9 from resilience and the degree in which parents experience positive emotions during their child’s admission. Parents who showed higher psychopathology were also those who referred higher growth, which shows that the positive and negative effects of the traumatic experience tend to coexist in the same person. Results from part III showed, in the first place, that professionals report high levels of burnout and traumatic stress, but also of posttraumatic growth and satisfaction with life. Professionals showed higher distress and growth when the death of a patient or conflicts with work colleagues had occurred recently in the unit where they work. The problem-focused coping style predicted lower burnout and posttraumatic stress levels, while the emotion-focused coping style predicted higher levels of these negative outcomes. Additionally, both types of coping styles were related with higher posttraumatic growth. Resilience was not directly related neither with distress nor growth. As occurred in the case of parents, professionals with higher posttraumatic stress levels showed higher growth. Professionals with lower burnout and posttraumatic growth showed better satisfaction with life. The above mentioned three parts of this doctoral dissertation will be next exposed in thirteen articles. Future lines of intervention to increase resilience and adaptation to potentially traumatic situations will be proposed in the discussion of such articles and in the general discussion of the thesis, with an emphasis in the field of pediatric intensive care. We expect that this will contribute to improve mental health in parents of children after this experience, and in professionals working in pediatric intensive care.