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Frontline employees in the helping professions often perform their duties against a difficult backdrop, including a complex client base and ongoing themes of crisis, suffering, and distress. These factors combine to create an environment in which workers are vulnerable to workplace stress and burnout. The present study tested two models to understand how frontline workers in the homelessness sector deal with the suffering of their clients. First, we examined whether relationships between suffering and workplace functioning (job satisfaction and burnout) would be mediated by organizational identification. Second, we examined whether emotional distance from clients (i.e., infrahumanization, measured as reduced attribution of secondary emotions) would predict improved workplace functioning (less burnout and greater job satisfaction), particularly when client contact is high. The study involved a mixed-methods design comprising interview (
In human services such as the homelessness sector, frontline workers are often faced with confronting circumstances in their daily work with clients. Operating within this environment can be demanding for workers, both professionally and personally (
A range of traumatic antecedents can catalyze entry into homelessness (
Over and above the skills necessary to support people to cope with or exit homelessness, workers need the ability to remain resilient in the face of these challenges. Seeing clients’ pain and suffering can expose workers to vicarious emotional distress, with workers in the human services being particularly at risk (
Exposure to distressing human circumstances means workers may be vulnerable to workplace stress, and over time, these stresses can lead to
Given these risks, it is important to understand how workers can avoid burnout and protect themselves emotionally from the difficulties and suffering of their clients, while at the same time providing those very clients support and care. We tested two models to better understand the implications of exposure to others’ suffering for frontline workers in this field. We examined whether workers in this field might protect themselves from the consequences of exposure to suffering and maintain positive workplace functioning via identification with the organization (i.e., a mediational hypothesis). We also examined whether emotional distance from clients would predict improved workplace functioning, particularly when client contact is high. (i.e., a moderation hypothesis).
The social identity approach proposes that a person’s group memberships and social categories dynamically inform one’s self-concept and position relative to other individuals and groups (
One possible explanation arises when considering how workers forge a positive identity in the workplace despite adverse aspects of the role. Exposure to clients who are suffering and working with people experiencing homelessness may be considered ‘dirty work’, because it involves contact with stigmatized members of society (
Importantly,
There is a large literature on the benefits of group memberships, and identifying with the organization has been consistently linked with positive workplace outcomes. Shared social identity promotes communication (
Relevantly,
A growing literature on humanness and dehumanization indicates a possible alternative for how workers protect themselves from the emotional challenges of caring for others who are suffering. Empathy is associated with positive outcomes for care recipients in therapeutic contexts (see for example,
Recent quantitative evidence suggests that emotional distancing among health care workers is associated with improved coping with patients’ physical pain and mortality (
This makes it important to tease apart the concept of emotional distancing in order to understand what protection it might afford. From the outset, it is important to note that in the context of patient and client care, the present work seeks to explore targeted and subtle ways of engendering emotional distance from a dehumanization and infrahumanization framework (see
Infrahumanization can be considered a subtle form of humanness denial that operates at intergroup (
Moreover, the current evidence base on protective infrahumanization has only examined exposure to others’ physical pain and suffering. It remains an empirical question whether similar effects are observed when considering social pain. Modern approaches to homelessness conceptualize the experience and existence of homelessness as a symptom and expression of social exclusion (
Working in the homelessness sector is a challenging undertaking, and leaves workers exposed to the risk of burnout. We examined two models concerning the implications of exposure to clients’ suffering. First, building on the literature on social identity and dirty work, we proposed that acknowledging suffering can lead to the development of a positive organizational identity and this can protect workers in stigmatized roles by fostering meaningfulness. Second, an alternative literature points to emotional distancing as providing protection for workers exposed to the suffering of others. This proposes that ‘dialing down’ empathy and increasing emotional distance through infrahumanization is protective when empathetic interpersonal skills come under heavy demand – even though empathy is a key skill generally associated with positive client outcomes. While the existing evidence base has largely focused upon exposure to others’ physical pain (
Thus the present study extends on previous literature by examining these two possibilities in a novel caregiving context: provision of support services to people experiencing homelessness. To that end, we combined qualitative and quantitative approaches. We interviewed and surveyed a sample of frontline homelessness service providers to discover their experiences and to investigate what factors contribute to job satisfaction and burnout.
Ethical clearance was received from the University of Queensland Behavioral and Social Sciences Ethical Review Committee and the School of Psychology Ethics Review Committee, and gatekeeper approval for the study was secured from the employing organization. The sample consisted of 60 frontline service providers (18 male) between 23 and 65 years (
We employed a mixed-methods design comprising qualitative (interview) and quantitative (survey) components. The qualitative component explored workers’ experiences in direct service provision with clients, while the quantitative component was cross-sectional in design and measured client contact, infrahumanization, and client suffering (case history task), burnout, job satisfaction (workplace functioning), and organizational identification. We also took demographic and basic workplace information such as length of tenure.
Participants were first recruited for one-on-one semi-structured interviews and questionnaires delivered at the workplace (‘on-site phase’, see further below;
Interviews were carried out on-site to minimize disruption to service delivery, and ranged between approximately 15–60 min in duration (
Online participants were invited to visit the survey website at their convenience any time before the survey deadline. Once on the survey website, participants were given study information and invited to give informed consent by clicking a link to proceed. The online survey was presented in the same order as the on-site phase with the addition of four abridged interview questions at the end on empathy and self-care, adapted for an online open-text response format.
The complete semi-structured interview comprised 22 questions on a series of topics relating to work role, motivation, belief systems, client outcomes, and factors contributing to or detracting from clients’ ability to exit homelessness. Specific to the present work were five questions tapping empathy (
For both on-site and online phases, the survey consisted of the case history task, workplace functioning questionnaire, and demographic and basic workplace information items.
We developed two case history vignettes describing ‘Warren’, a 39 years-old man experiencing homelessness following a period of incarceration; and ‘Denise’, a 21 year-old woman escaping domestic violence. These vignettes were based on
Zero-order correlations
Descriptive statistics and zero-order correlations between perceived client suffering and workplace functioning variables.
Variable | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | |
---|---|---|---|---|---|---|---|---|---|
(1) Suffering | 6.32 (0.73) | ||||||||
(2) Job satisfaction | 5.96 (1.11) | ||||||||
(3) Identification | 5.12 (1.47) | ||||||||
(4) Burnout | 2.60 (0.81) | - |
- |
- |
|||||
(5) Burnout (exhaustion) | 3.10 (1.14) | -0.11 | - |
- |
|||||
(6) Burnout (lack of accomplishment) | 2.79 (1.12) | -0.21 | - |
- |
|||||
(7) Burnout (callousness) | 1.58 (0.81) | - |
- |
- |
0.20 | ||||
(8) Secondary emotions (negative) | 8.15 (5.17) | 0.07 | -0.09 | 0.19 | -0.01 | -0.05 | 0.12 | -0.11 | |
(9) Primary emotions (negative) | 9.02 (5.26) | 0.23 | -0.02 | 0.21 | 0.00 | 0.01 | 0.08 | -0.15 |
Descriptive statistics and zero-order correlations between length of tenure and workplace functioning variables.
Length of tenure (years) |
|||
---|---|---|---|
Sector | Center | Role | |
5.95 (6.44) | 4.29 (4.99) | 2.76 (2.84) | |
3.42 | 3.00 | 2.00 | |
1 | 1 | 1 | |
28 | 28 | 15 | |
Suffering | -0.09 | -0.06 | -0.13 |
Job satisfaction | -0.15 | -0.13 | -0.13 |
Identification | -0.04 | -0.09 | -0.19 |
Burnout | 0.24 | 0.23 | 0.24 |
Secondary emotions (negative) | 0.18 | 0.04 | |
Primary emotions (negative) | 0.15 | 0.15 | -0.05 |
We undertook mediation analyses
Second, we tested a bootstrapped mediation model (
Additional mediation analyses examining the indirect effect of suffering on each burnout subscale via organizational identification.
Burnout subscale | ||||
---|---|---|---|---|
Exhaustion | -0.12 | 0.21 | -0.3411 | -0.0049 |
Lack of accomplishment | -0.20 | 0.10 | -0.4649 | -0.0535 |
Callousness | -0.16 | 0.09 | -0.4259 | -0.0418 |
We also sought to test whether reverse mediation models could be supported by the data given the cross-sectional design we deployed. Specifically, this involved testing two models in which identification was retained as mediator, but where suffering served as the outcome variable, and satisfaction and burnout each as a predictor. First, with job satisfaction as predictor, we did not find support for mediation, with the indirect effect of job satisfaction via identification failing to account for a significant amount of the variance in suffering (
We tested a moderation model using multiple regression with the PROCESS macro (
Multiple regression analyses of infrahumanization and workplace functioning measures, with client contact as moderator.
Outcome | Predictor | Coefficient | |||||
---|---|---|---|---|---|---|---|
Burnout | Secondary emotion attribution (infra) | 0.00 | 0.02 | 0.00 | 0.996 | -0.043 | 0.042 |
Client contact % | -0.16 | 0.14 | -1.20 | 0.235 | -0.437 | 0.109 | |
Infra x contact | 0.02 | 0.03 | 0.68 | 0.500 | -0.036 | 0.073 | |
Exhaustion subscale | Secondary emotion attribution (infra) | -0.02 | 0.03 | -0.58 | 0.567 | -0.079 | 0.044 |
Client contact % | -0.12 | 0.19 | -0.62 | 0.536 | -0.509 | 0.268 | |
Infra x contact | -0.02 | 0.04 | -0.55 | 0.583 | -0.099 | 0.057 | |
Callousness subscale | Secondary emotion attribution (infra) | -0.02 | 0.02 | -0.97 | 0.336 | -0.705 | 0.024 |
Client contact % | -0.22 | 0.15 | -1.47 | 0.148 | -0.523 | 0.081 | |
Infra × contact | 0.01 | 0.03 | 0.30 | 0.763 | -0.052 | 0.069 | |
Lack accomplishment subscale | Secondary emotion attribution (infra) | 0.03 | 0.03 | 1.12 | 0.267 | -0.025 | 0.139 |
Client contact % | -0.17 | 0.19 | -0.91 | 0.368 | -0.539 | 0.203 | |
Infra × contact | 0.06 | 0.04 | 1.75 | 0.086 | -0.009 | 0.139 | |
Satisfaction | Secondary emotion attribution (infra) | -0.01 | 0.03 | -0.20 | 0.839 | -0.064 | 0.052 |
Client contact % | 0.31 | 0.19 | 1.67 | 0.101 | -0.062 | 0.679 | |
Infra × contact % | -0.03 | 0.04 | -0.80 | 0.427 | -0.104 | 0.045 |
We also analyzed the qualitative data arising from interviews and the online open-text responses from frontline staff (
These data were analyzed thematically with a top–down theoretical approach (
We implemented a theory-driven top–down analysis (
Workers recounted the difficulties they experienced in coming to terms with the pain and suffering their clients were feeling. However, acknowledging suffering was seen as an important step toward alleviating suffering.
Workers also indicated that alleviating suffering motivated them to keep going in their role, and that this desire to lessen clients’ pain united them with the organization more broadly. Specifically taking action aimed at reducing clients’ pain was also a way to cope with the emotional after-effects of exposure to suffering and horror.
…
Workers reported deriving a fundamental sense of meaning and purpose from their role, despite – or even because of – its challenging nature. Some workers recounted actively seeking out more challenging work, and a preference for their current role over other types of work seen as easier but less meaningful.
Some workers expressed a shared sense of solidarity in terms of their motivations and in facing workplace difficulties together, and that this helped them to function in their role.
For some, individual struggles and sacrifices in the workplace were reframed and contextualized within the collective; critically, these hardships offered deeper meaning and greater purpose when understood in the collective context.
We also examined the theme of empathy in workers’ practice with their clients. We again implemented a top–down theoretical approach to explore workers’ perspectives and experiences regarding empathy, and with an eye to better understanding why links between infrahumanization and workplace functioning did not emerge from the quantitative data. Responses were coded for presence or absence of reference to bounded empathy, conceptualized as any reference to the need for empathy, understanding, or authentic connection with clients, with the qualification that boundaries or limits were required. Of the 58 participants retained for qualitative data, 64% responses made specific reference to bounded empathy concepts.
An emerging theme was the desire to maintain a level of resiliency despite the challenges of the work. This touched on finding an optimal balance in dealing with clients experiencing homelessness – connecting with individuals in a way that fosters trust, rapport, and an authentic alliance, but that also allows the worker to stay in control, to regulate their emotions, and remain resilient despite the challenging and sometimes upsetting material being shared.
This desire to stay strong was also linked to the obligation to do one’s best for the client, with the view that emotionally mirroring clients would not only be damaging to oneself, but importantly would not be effective in working with clients and supporting them to reach sustainable solutions to their issues and concerns.
Workers also emphasized the need for clear lines between work and home life.
Reconciling a strong motivation to help clients versus the realities of what could be achieved was another component of the theme bounded empathy. Workers expressed a longing to provide a panacea to help all their clients to overcome their hardships – however, this was tempered with the clear pragmatic recognition that many clients experience complex problems and setbacks, and that often small incremental change was all that might be achieved.
…
Accepting the boundaries of one’s own personal sphere of influence, for instance by deferring to a higher power or religion, was another way workers reported dealing with and working through challenges in the face of seeming futility or personal ineffectiveness.
The present work examined how frontline workers in the homelessness sector deal with the suffering of their clients. These workers perform their duties against a difficult backdrop: a complex client base, ongoing themes of crisis, and distress, plus the stigma of their profession and minimal recompense for ‘dirty work’ (
When looking at perceived client suffering, we found evidence of a mediating role for organizational identification in two key relationships. Perceived suffering positively predicted job satisfaction, and the direct effect of suffering on satisfaction was no longer significant once the indirect path via identification was accounted for. Similarly, perceived client suffering predicted less burnout, and this again was fully mediated by organizational identification. These mediation models provide preliminary evidence to indicate that acknowledging client suffering may increase job satisfaction and reduce burnout by galvanizing organizational identification. We introduce this novel finding as the ‘Florence Nightingale effect’.
These results provide a counterpoint to the literature on vicarious exposure to the suffering of others in medical settings (
The Florence Nightingale effect therefore represents a novel contribution to the literature as a new approach to understanding the role of recognizing suffering for positive occupational identities. It contributes to the literature on organizational identification and ‘dirty work’, which highlights the value of identity solidarity in stigmatized occupations (
Drawn from a homelessness services context, our data did not reveal a negative association between infrahumanization and burnout, even for workers with high client contact. We were unable to explain patterns of burnout or job satisfaction in this cohort by reference to infrahumanization. This is in contrast to the findings reported by
There is the possibility that workers might be engaging in infrahumanization as a normative practice. Interestingly, qualitative evidence showed that nearly two–thirds of workers overtly discussed their connection with clients in terms of bounded empathy – where authentic connection to and understanding of clients’ circumstances is paramount, but the empathetic connection has strict boundaries, and suffering is “left at the door” when workers go home. This offers an interesting insight into how workers are conceptualizing their clients’ suffering and creating functional distance. More specifically, the qualitative findings shed light on the way suffering can be conceptualized by workers, and how workers articulate the role of empathy in their practice (for instance, being motivated by social justice ideals, and balancing client need with the need for workers to set boundaries;
Another explanation for why we did not find protective infrahumanization relates to the differences between social pain and physical pain. Our mediation models indicate that perceiving others’ social pain and suffering may actually serve to
This study has certain limitations. Despite the advantages of a field sample over a convenience sample in terms of ecological validity, we note the need for further research to rule out whether distinctive features characterizing this sample’s organization are borne out in other organizations within and beyond a homelessness context. For instance, it would be of interest to examine whether the Florence Nightingale effect prevails in other ‘helping’ professions, and organizational settings where there are ostensibly different relationships between the worker and care-recipient, as well as different organizational goals and norms. Such contexts might include clinical psychology practice, or delivery of non-medical humanitarian aid (e.g., civil capacity-building) by military and non-government organizations. Similarly, while we focused on organizational identification, future research might want to focus on examining whether similar effects are obtained when professional identification is measured. Strong professional identity could also feasibly serve a protective function. It would also be valuable to quantitatively examine the role of perceived efficacy to ameliorate suffering. For homelessness workers, recognizing social pain in their clients may be associated with positive functioning because it is considered within their collective ability to alleviate that suffering. Specifically probing these and other themes (such as interpersonal authenticity and perceived efficacy to ameliorate different kinds of suffering) could deliver further insights into how workers might be framing these challenges.
Further, sampling those presently employed may have inadvertently excluded workers who are struggling or already burnt out, with attrition of these workers from the sector making their views and experiences harder to access. While the sample size of the present study was adequate, it was also smaller than the other studies in the literature. We took steps to mitigate this by utilizing bootstrapping in our analyses, with the aim of increasing power and coverage probability (
Assessing how workers attribute emotions with vignettes of course only approximates the process of considering a real client’s emotional state. However, it allowed us to respect client confidentiality constraints, and to target emotion attribution for individuals, not clients generally. We have also argued that the use of emotion attributions rather than traits to measure infrahumanization is a more direct way to target emotional distancing practices. This differs from the approach taken by
In terms of mediation, we have found evidence of a mediating role for organizational identification in explaining the respective relationships between perceived suffering and reduced burnout and increased job satisfaction. We tested reverse models with suffering as the outcome variable, and the data do not support these reverse models. Furthermore, as discussed, qualitative data yielded nominal support for our posited mediation models. Nevertheless, due to the cross-sectional design we used in this study, we cannot rule out the possibility that an externality or unmeasured variable or variables might provide an alternative explanation for these findings (
It is a special undertaking to respond to the suffering of others and support those in need, and doing so carries both reward and challenges. Frontline workers in the homelessness sector routinely deal with clients who are suffering, and this challenging environment means they are vulnerable to compassion fatigue and burnout. Previous research suggested that infrahumanization of patients and clients could be protective for workers in a medical context. However, we failed to find evidence that infrahumanization explained workplace functioning in the form of burnout and satisfaction. Rather, with two mediation models we report that perceived client suffering predicts reduced burnout and increased satisfaction, with a mediating role for organizational identification in each of these relationships. We present this as the Florence Nightingale effect – whereby perceived client suffering is linked to increased identification with the organization, which in turn predicts less burnout, and more job satisfaction. Ultimately, seeing another human being suffering is part of the everyday experience for workers in the homelessness sector, and social psychological perspectives have much to offer in extending our understanding of the difficulties facing workers in the sector. In the meantime, people experiencing homelessness rely on the support and generosity of these workers: their important work continues.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
LF, JJ, MJ, EG, and ZW, School of Psychology, University of Queensland. CP, Institute for Social Sciences Research, University of Queensland. We thank Catherine Philpot for her assistance with liaison and data collection. This research was supported by a Linkage Project Grant awarded to JJ and CP from the Australian Research Council (LP110200437).
As anticipated, we surmise that the latter reflects the somewhat gender-segregated nature of service delivery, where participants who frequently work with clients of one gender are less likely to work often with clients of the other.
We detected significant differences between vignettes in negative secondary and primary emotions, with participants attributing ‘Denise’ a greater median number of negative secondary (
Reliability for two-item scales is a Spearman-Brown-corrected correlation (
Variables were screened for violations of normality assumptions. Client suffering and job satisfaction were negatively skewed (suffering: -1.34,
We conducted mediation analyses with untransformed data, then repeated mediation analyses with transformed data; the indirect effect of suffering via workplace identification on each of the workplace functioning variables prevailed regardless of whether transformed or untransformed data were used. Therefore the untransformed data are presented, consistent with convention (
Names have been substituted to protect participants’ confidentiality.