International Archives of Occupational and Environmental Health https://doi.org/10.1007/s00420-021-01725-8 ORIGINAL ARTICLE Resilience and occupational health of health care workers: a moderator analysis of organizational resilience and sociodemographic attributes Lila Gonçalves1 · Roser Sala1 · José‑Blas Navarro2 Received: 4 January 2021 / Accepted: 13 April 2021 © The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021 Abstract Objectives Although previous studies have proposed a positive influence of resilience on the mental and physical health of health care workers, empirical evidence on its relationship with occupational health remains scarce. This study aimed to analyze the relationship between individual resilience and several occupational health indicators, as well as exploring the moderating role of organizational resilience and sociodemographic attributes on this relationship. Methods A cross-sectional design was used with a questionnaire applied to a sample of 325 workers from the Spanish health care sector. Results Individual resilience was significantly associated with the indicators of occupational health. A direct effect of individual resilience on job satisfaction was found. The influence of resilience on the perception of fatigue and suffering from an illness was reverse. Age moderated the impact of resilience on the perception of stress and medical leave. Besides, organizational resilience proved to be an important adjustment variable in job satisfaction and perception of stress. Conclusions The findings show the relevance to take both individual and organizational resilience into account when apply- ing intervention programs to improve the occupational health of health care workers. Keywords Resilience · Occupational health · Organizational resilience · Health care workers Introduction clinical cases or conflicts with patients. Health care pro- fessionals may also have to deal with organizational issues Resilience embodies the personal qualities that enable one to specific to their workplace. Finally, external organizational thrive in the face of adversity (Connor and Davidson 2003). pressure such as scrutiny of practices is another source of Recently, resilience has become increasingly important in stressful work (Robertson et al. 2016). the workplace (Mills et al. 2013). According to Rook et al. Frequent workplace stress can have a negative impact on (2018), resilience is a key characteristic of a successful the physical and mental wellbeing of health care profession- employee in today’s turbulent work environment. als (Clark et al. 2016; McCann et al. 2013); while exist- In the healthcare sector, there are many stressful work ing literature presents evidence that resilience has a posi- circumstances. First, challenges can arise from complex tive impact on mental health. Aburn et al. (2016) identified good mental health as a proxy for resilience. Individuals with high levels of resilience tended to have less psycho- * Lila Gonçalves logical health problems. Several studies link resilience with lila.goncalves@ciemat.es burnout, fatigue and stress in healthcare workers (Lebares 1 CISOT Socio‑Technical Research Centre of CIEMAT et al. 2018; Mealer et al. 2017; Shatté et al. 2017; Winwood (Research Centre on Energy, Environment et al. 2013). and Technologies), Mòdul de Recerca A, 1st Floor, Office There are also studies that pointed out the positive impact MRA 123, Plaça del Coneixement, Universidad Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Catalonia, Spain of resilience on physical health (Ezeamama et al. 2016). 2 Siu et al. (2009) found resilience was inversely related to Department of Psychobiology and Methodology of the Health Sciences, Universitat Autònoma de Barcelona, physical symptoms and injuries at work among health care 08193 Bellaterra, Spain workers. 13 Vol.:(0123456789) International Archives of Occupational and Environmental Health Research has begun to explore the impact of resilience on Organizational resilience assessment includes two fac- employees as an organizational factor that produces impor- tors: planning and adaptive capacity (Gonçalves et al. 2019). tant benefits, such as a reduction in absenteeism (Andolo Planning implies the use of predetermined planning capaci- 2013), and a better job satisfaction (Waddimba et al. 2016) ties for the continuity of the business and risk management in health care professionals. Nevertheless, the studies in this initiatives. Adaptive capacity relates to the ability to deal regard are scarce and it is necessary to go in-depth in other with the organization’s needs before they become critical, aspects such as the association between resilience and occu- and it emerges as a result of strong leadership and culture pational health (occupational accidents, medical leaves). (Lee et al. 2013a, b). There are very few studies relating organizational resil- Sociodemographic variables ience and individual resilience (IR). Resilient employees, when facilitated and supported by the organization, have Literature shows the importance of considering sociodemo- the capability to apply resources to continually adapt and graphic variables in the study of resilience. Age and gender flourish at work, even when faced with challenging circum- are the most frequently connected to resilience (Lee et al. stances (Kuntz et al. 2016). As highlighted by Seville (2018) 2013a, b). Although some research reported a negative having good people and getting the best out of them, espe- association between age and resilience (Beutel et al. 2009) cially in times of great stress, is essential for organizational most have shown a positive relationship (Chen et al. 2016; resilience. Gillespie et al. 2009; Martínez-Martí and Ruch 2017). Like- In that sense, organizations can promote resilience by wise, in some research, men were more resilient (Campbell- designing a work environment that supports people and posi- Sills et al. 2009), while in others, women were more resilient tively influences the acquisition and use of resilience skills (Sull et al. 2015). (Wachs et al. 2015), or enhancing employees’ capacity to Research around resilience in health care organizations manage uncertainty (Weick and Sutcliffe 2015). has focused on analyzing specific occupations, such as The health of the workforce is essential for a health sys- nurses and doctors. Sull et al. (2015) explored the associa- tem to respond to crisis, but in many cases, frontline health tion of work role and resilience and found that clinical staff care workers themselves are amongst the most vulnerable reported lower levels of resilience than administrative staff. individuals (Gostin and Friedman 2015). Worksite programs Sociodemographic variables can also be considered designed to improve resilience in health care employees have important moderators of the relationship between resilience shown efficacy in improving resilience, quality of life and and health. Hu et al. (2015) found that age moderated the health behaviors (Werneburg et al. 2018). However, focusing relationship between resilience and negative indicators of all efforts on enhancing individual resilience may inadvert- mental health. Gender was also a relevant moderator: female ently lead organizations to reduce their focus on changing participants presented a stronger effect size on the relation- the environment to reduce exposure to adversity. Research ship between resilience and all indicators of mental health. that describes both personal and environmental factors that No research has been found concerning the moderating contribute to resilience is needed (Britt et al. 2016). effect of work role in the relationship between resilience and Despite the studies referred above, no specific findings workers ‘health. have been identified regarding the influence of organiza- tional resilience in the relationship between individual resil- Organizational resilience ience and occupational health. This is a relevant research area, because in case of organizational crisis the health of Resilience in health care can be described as a character- the workers could be more impacted. According to Shoss istic of individuals, as well as a property of teams, and of et al. (2018), resilience is most important when job insecu- the whole organization (Jeffcott et al. 2009). Recent health rity is high. systems adversities such as the Ebola outbreak of 2014–2016 Based on the previous review, this study aims to analyze and the global financial crisis of 2008 have increased the the relationship between individual resilience and several interest in the concept of organizational resilience (Barasa occupational health indicators of employees in the health et al. 2018). In addition, Hanefeld et al. (2018) highlight the care sector. It is also aimed at exploring the moderating role need to make nowadays health systems more resilient. of sociodemographic variables and organizational resilience Organizational resilience (OrRe) is organization’s ability in this relationship. It was hypothesized that (1) individual to survive and even strengthen itself in times of crisis. It is resilience would have a direct impact on job satisfaction and more visible after a natural disaster; however, in everyday inversely on the perception of stress, perception of fatigue, life, organizations have to handle a variety of adversities medical leave, accidents and illness, (2) the effect of indi- in which organizational resilience is extremely important vidual resilience on occupational health would have a greater (Stephenson et al. 2010). impact on women, (3) the effect of individual resilience 13 International Archives of Occupational and Environmental Health on occupational health would have a greater impact in the The sample consisted of 325 workers from three health- elderly, (4) the work role would have a moderating role in the care organizations in Barcelona, Spain (Table 1). The age impact of individual resilience on occupational health, (5) of participants ranged from 20 to 67 years, with a mean of organizational resilience would have a moderating effect on 44.5 years (SD = 9.4), and 78.8% of them were women. From the influence of individual resilience on occupational health. the total sample, 72.2% were professionals taking direct care of patients (doctors, nurses, ancillaries), while 27.8% were the administrative staff. Most of the participants (86.5%) were full-time workers. The mean score of the seniority was Materials and methods 15.7 years in the organization (SD = 9.0). Participants Procedure This study presents an observational, non-randomized and This research was reviewed and approved by the Eth- cross-sectional design. To access the sample, the research ics Committee and the Occupational Health and Human team contacted the Catalan Association for Health Preven- Resources Committee. Anonymity and confidentiality of tion, from where the study was disclosed to various health- the data were guaranteed, in strict compliance with ethical care organizations. Three hospitals accepted to participate. research guidelines. The questionnaires were administered The entire staff of the participating healthcare organizations in paper or electronically. In one of the organizations, it was was invited to participate in the study. The employees were administered mainly in paper with the support of Human invited through various e-mails from the Human Resources Resources and Occupational Health departments. A person Department, which indicated the interest of a wide participa- in charge of both departments distributed the questionnaires tion. The final sample thus corresponds to a non-probabilis- in a sealed envelope to all the organization’s personnel. The tic convenience sample. participants voluntarily deposited the questionnaires in a Table 1  Description of the Variable Total sample (N = 325) sample Gender—N (%) Males 69 (21.2%) Females 256 (78.8%) Age—M (SD) 44.52 (9.38) Seniority—M (SD) 15.66 (8.99) Work role—N (%) Patient care professionals 226 (72.17%) Administrative staff 87 (27.83%) Hours workday—N (%) Full time (40 h per week) 281 (86.5%) Part time (20 h or less) 18 (5.5%) Others (more than 20 h) 26 (8.0%) Planning—M (SD) 5.34 (1.14) Adaptive capacity—M (SD) 4.36 (1.40) Individual Resilience [0–4] 3.08 (0.51) Occupational Health [0–4] Job satisfaction—M (SD) 2.96 (0.81) Perception of stress—M (SD) 2.06 (1.10) Perception of fatigue (Yes)—N (%) 142 (43.7%) Medical leave (Yes)—N (%) 65 (20.0%) Occupational accidents (Yes)—N (%) 38 (11.7%) Illness (Yes)—N (%) 73 (22.5%) The minimum and maximum possible values are indicated between brackets 13 International Archives of Occupational and Environmental Health mailbox provided for such purposes in the hospital. The diagnosed by a doctor or psychologist?”. Job satisfaction and entire data collection process took 3 weeks. A couple of perception of stress were measured using a 5-point Likert reminders via e-mail were sent to encourage participation. scale (0 = totally disagree; 4 = totally agree). A dichotomous In the other two organizations, the questionnaire was admin- scale (no/yes) was used for the last four items. As these are istered mainly electronically. For this, the Department of unique items for each indicator, no internal consistency Human Resources sent a formal e-mail to the entire organi- results are reported. zation staff, providing all the relevant information of the To minimize biases associated with the mono-method study and inviting to access the questionnaire through a (such as social desirability bias), different actions were car- link. To encourage participation, a reminder email was sent ried out as recommended by Podsakoff et al. (2003). First before the end of the 3-week period. Those who did not of all, all the information regarding the study and ethical have regular access to the computer at their usual workplace standards were expressed on the first page of the question- used the paper version, which was provided by the Occupa- naire. Second, staff were allowed to fill out the question- tional Health Department. Therefore, due to differences in naire anonymously (in privacy), which may reduce bias and the start-up time of the different organizations involved, data fear of reprisals by providing higher confidentiality. Third, collection began in January 2018 and ended in April 2018. data collection was done with reliable and well-established measures. Similarly, the use of mixed-mode formats allowed Instruments health professionals a greater flexibility to fit the survey within their busy schedules. For the same reason, instru- Individual resilience was evaluated with the short version ments were used in their short-form versions. of the CD-RISC-10 (Connor and Davidson 2003) adapted to Spanish by Soler et al. (2016). A 5-point Likert-type Data analysis response format was used (1 = not true at all; 5 = true nearly all of the time). Examples of the type of items contained in Data analysis was carried out using Stata 14 using a sample this scale are “I am able to adapt to change” and “I tend to of 325 valid cases. Because the main objective of the study recover after adversity”. The alpha coefficient in the original was to estimate effects using multiple regression models, the scale was 0.87. The same result was obtained in our sample. minimum sample size was calculated following the proposal Organizational resilience (OrRe) was measured using the of Green (1991), assuming a medium effect size (f2 = 0.15) Benchmark Resilience Tool short-form (BRT-13B) devel- and a model with a maximum of 8 predictors (IR, interac- oped by Whitman et al. (2013) and validated in Spanish tions of IR with the two OrRe and a maximum of 5 adjusting by Gonçalves et al. (2019). The BRT-13B has two factors: terms). The result indicated that the sample should contain planning and adaptive capacity. This shorter questionnaire at least 108 participants. No restrictions were imposed to consists in 13 items on a Likert response scale with eight achieve a highest sample size as it finally was. The missing options from 1 (strongly disagree) to 8 (strongly agree). information was scarce, with a maximum of a 3.7% for pre- It includes questions such as “In our organizations we are dictors variables (work role) and a 0.6% for outcome meas- mindful of how a crisis could affect us”, “Our organization ures (occupational accident). Cases with missing data were maintains sufficient resources to absorb unexpected change” removed from analysis using listwise approach. Descriptive or “Staff have the information and knowledge they need to statistics and Pearson correlations were calculated to provide respond to unexpected problems”. Results of Cronbach’s background information on the sample characteristics. To alpha obtained in the original scale validated in Spain was analyze the influence of IR on occupational health several 0.81 in the planning factor and 0.92 in the adaptive capacity regression models were estimated. Linear regression was factor (Gonçalves et al. 2019). In our sample, Cronbach’s applied to analyze job satisfaction and perception of stress, alpha coefficient of 0.71 was obtained in planning, and 0.90 while logistic regression was employed in the analysis of the in adaptive capacity. four binary outcomes: perception of fatigue, medical leave, Occupational health questionnaire by Martín et al. (2007) occupational accident and illness. was used to measure worker’s health status based on the The moderating or adjusting role of the two OrRe sub- following attributes: job satisfaction, perception of stress, scales, age, gender and work role was assessed through the perception of fatigue, medical leave, occupational accident, next modelling sequence. First, it was analyzed if planning illness. Each of these variables was measured with a sin- and adaptive OrRe moderated the influence of IR on each gle item: “I am very satisfied with my work”, “I am very occupational health indicator. In case of non-significant stressed”, “Lately you have been more fatigued or tired results, the two interaction terms were eliminated from the than usual”, “Have you had any medical leave in the last model and it was evaluated if they were necessary as adjust- 12 months?”, “Have you suffered a work-related accident ment variables. To do this, the adjusted effect of IR was in the last 5 years?”, “Do you have a disease that has been compared with the unadjusted one. If the change was greater 13 International Archives of Occupational and Environmental Health than 10%, the adjusted model was selected. Secondly, the Table 3 shows the results of linear (Job satisfaction and process was repeated for the three sociodemographic vari- Perception of stress) and logistic regression (Perception ables (age, gender and work role) but, in this case, the analy- of fatigue, Medical leave, Occupational accidents and sis of the interaction between the moderator and individual Illness). IR was significantly associated with the indica- resilience was carried out step by step, eliminating non- tors of occupational health. A direct effect of IR on job significant interactions one by one. satisfaction (B = 0.479; p < 0.001) was found. The influ- In the presence of interaction between IR and age, fol- ence of IR on the perception of fatigue and suffering lowing Demaris (2004), the effect of IR was calculated for from an illness was reverse. Thus, a greater IR implies three representative values of age, one close to the minimum less fatigue (OR = 0.590; p = 0.027) and less presence of (25 years), one close to the maximum (65 years), and one illness in health workers (OR = 0.494; p = 0.011). Inter- close to the mean (45 years). action effects between IR and age were found when the As odds ratios provided by logistic regression models are outcomes were stress (p = 0.031) and having had some difficult to interpret, for the four binary outcomes an indirect medical leave (p = 0.029). The effect of IR on both out- estimation of the relative risk was obtained through Poisson comes was inverse and statistically significant only in regression models with robust estimation of the variance older workers (B =  − 0.817; p = 0.007 for the perception of (Lin and Wei 1989). stress) (OR = 0.207; p = 0.026 for having had some medi- To evaluate the internal consistency Cronbach’s alpha cal leave). Figures 1 and 2 show graphically the modera- coefficients were calculated. tion effect of age on the association between IR and stress and in the risk of a medical leave. Regarding OrRe, results showed no moderation in the Results relationship between IR and occupational health. However, adjusting was necessary by planning and adaptive capacity The sociodemographic characteristics of the sample are of the organization in the linear models assessing the effect shown in Table 1. of IR both on job satisfaction and perception of stress. Mean scores in Table 1 showed a perception of adequate Age, gender and work role were also necessary as adjust- OrRe, with greater results in the ability to plan crisis situa- ment variables in the analysis of the influence of IR on the tions than the adaptive capacity of the organization. Health indicators of occupational health considered in this study. care workers obtained medium to high scores of IR. Health The analysis of the indirect estimation of the relative indicators results indicated that job satisfaction was high, risk (RR) through Poisson models for the four binary and the perception of stress was medium. The perception occupational health indicators revealed that increases in of fatigue obtained the highest percentage and occupational IR were associated with a decrease in the risk of perceived accident had the lowest. The original scales used in the study fatigue (RR = 0.751; p = 0.026) and the risk of being ill are taken as a reference for these results. (RR = 0.595; p = 0.008). The association of IR with a The correlations obtained between resilience (individual medical leave and with having occupational accidents did and organizational) and occupational health variables are not reach statistical significance in this analysis (Table 4). shown in Table 2. IR was positively related with job sat- isfaction and with OrRe, while negative correlations were obtained with stress, fatigue and illness. Table 2  Correlations between individual resilience, organizational resilience and occupational health Measure 2 3 4 5 6 7 8 9 1. Individual resilience 0.230** 0.250** 0.358** − 0.111* − 0.120* − 0.030* 0.124 − 0.142* 2. Planning (OrRe) 0.633** 0.246** − 0.057 − 0.053 0.063 0.035 − 0.070 3. Adaptive capacity (OrRe) 0.327** − 0.128* − 0.113* − 0.012 − 0.023 − 0.025 4. Job satisfaction − 0.217** − 0.203** − 0.099 − 0.006 − 0.129* 5. Perception of stress 0.438** 0.141* 0.067 0.159** 6. Perception of fatigue 0.132* 0.124* 0.164** 7. Medical leave 0.204** 0.191** 8. Occupational accidents 0.009 9. Illness * p < 0.05; **p < 0.01 13 International Archives of Occupational and Environmental Health Table 3  Linear/logistic regression of occupational health indicators on individual resilience B |t| p CI 95% B Job ­satisfactiona 0.479 5.57 < 0.001 0.310; 0.648 Perception of s­ tressb Age = 25 0.351 1.20 0.233 − 0.227; 0.930 Age = 45 − 0.233 1.84 0.068 − 0.483; 0.017 Age = 65 − 0.817 2.70 0.007 − 1.412; − 0.222 OR χ2 p CI 95% OR H–L (p) c Perception of f­ atigue 0.590 4.92 0.027 0.371; 0.941 0.236 Medical ­leaved 0.214 Age = 25 3.592 3.09 0.079 0.863; 14.957 Age = 45 0.862 0.25 0.615 0.484; 1.537 Age = 65 0.207 4.97 0.026 0.52; 0.827 Occupational ­accidentsc 2.191 4.10 0.053 1.025; 4.680 0.885 Illnessc 0.494 6.50 0.011 0.287; 0.849 0.873 H–L: Hosmer–Leme show goodness of fit statistic a Adjusted by planning, adaptative capacity, age, gender and work role b Adjusted by planning, adaptative capacity, gender and work role c Adjusted by age, gender and work role d Adjusted by gender and work role Fig. 1  The moderating effect of age on the relationship between individual resilience and per- ception of stress Discussion The effect on the two other occupational health indicators was moderated by age. Thus, the impact of IR on stress This is the first research that explores the impact of IR on and medical leave was statistically significant for older occupational health indicators, and the moderating role employees. The hypotheses on gender and role moderation of OrRe and sociodemographic attributes. IR was signifi- were not supported; however, both variables were found to cantly associated with occupational health. A direct effect play a relevant adjustment role in the relationship between of IR on job satisfaction was identified. The influence of IR and the following indicators: job satisfaction, perceived IR on fatigue and the occurrence of an illness was inverse. stress, fatigue and medical leave. Likewise, no moderation of OrRe on the relationship between IR and occupational 13 International Archives of Occupational and Environmental Health Fig. 2  The moderating effect of age on the relationship between individual resilience and pro- portion of medical leave Table 4  Relative risk of binary occupational health indicators on workers. Similar results between IR and mental health indi- individual resilience cators were obtained by Hu et al. (2015). Resilience has RR χ2 p CI 95% RR been associated with functional connectivity of brain regions involved in emotional flexibility, recovery capability, and Perception of f­ atiguea 0.751 4.97 0.026 0.584; 0.966 inhibitory control process (Shi et al. 2019). According to Medical ­leaveb Gloria and Steinhardt (2016) positive emotions may enhance Age = 25 2.654 2.16 0.142 0.722; 9.760 resilience directly as well as indirectly through the mediating Age = 45 0.907 0.15 0.701 0.550; 1.494 role of coping strategies. Some studies pointed out that older Age = 65 0.310 3.80 0.051 0.095; 1.007 workers are better in terms of using adaptive emotion regu- Occupational ­accidentsa 1.998 3.53 0.060 0.971; 4.114 lation strategies. Scheibe et al. (2016) support an older-age Illnessa 0.595 7.11 0.008 0.406; 0.871 advantage in emotion regulation in health care professionals RR relative risk via enhanced use of adaptive strategies (e.g. positive reap- a Adjusted by age, gender and work role praisal) and lower use of maladaptive strategies (e.g. rumi- b Adjusted by gender and work role nation). Therefore, emotional regulation of resilient older workers could explain the results of this study. Interestingly, IR was positively related to the two dimen- health was found. However, the two dimensions of OrRe sions of OrRe. Workers with high resilience reported higher were necessary as adjusting terms when assessing the planning and adaptive capacity of their organizations. effect of IR on job satisfaction and perception of stress. Although the results showed no moderation effect of OrRe, Findings are consistent with other studies that have also it was necessary to adjust the results for planning and adap- identified high levels of resilience and high levels of job tive capacity in job satisfaction and perception of stress. satisfaction in health care professionals (Zheng et al. 2017; Matheson et al. (2016) propose that for a health care profes- Hudgins 2016; Kašpárková et al. 2018). Thus, individuals sional working in a challenging setting to be resilient, their that are more resilient are more satisfied with their job. personal resilience must align with workplace resilience. As expected, a greater IR implies less fatigue and less Anyway, our findings are in an exploratory phase and more presence of illness. A previous longitudinal study concluded research is required. that resilience reduced nurse fatigue (Saksvik-Lehouillier This study has several practical implications. First, an et al. 2012). Another study with health care workers pointed organizational resilience culture in hospitals should be out that resilient individuals had a better perceived immune developed, which means that Occupational Health and functioning and less physical/psychological symptoms Safety Units give a high priority to resilience. The Human (Lantman et al. 2017). Resources department can play a significant role in creating The impact of IR on stress and medical leave was mod- a ‘resilience culture’ in which all people are aware of what erated by age, being inverse and only significant in older resilience is, and in making interventions that can help to 13 International Archives of Occupational and Environmental Health promote individual and organizational resilience (Branicki Acknowledgements We are grateful to the Catalan Health Care Pre- et al. 2016). Second, such interventions can be promoted vention Association for the support for access to hospitals. through practical strategies and must be an integral part Funding The Ministry of Economy and Competitiveness of Spain of an organization’s policies (Salanova et al. 2016). Third, under predoctoral Grant (ID13-PREMM0-13) supported this work. many of these techniques can help health care employees in changing their thoughts and emotions in order to be more Declarations positive, compassionate and aware (Pipe et al. 2012). Fourth, workplace programs designed to improve resilience can Ethical approval This research project was reviewed by the Ethical increase health behaviours (Werneburg et al. 2018) as well Committee of the hospitals, which granted authorization to perform as health and well-being in health care workers (Robertson the study. et al. 2016). Fifth, resilience should become a fundamental aspect for the creation of public health policies (Ziglio et al. Conflict of interest No potential conflict of interest was reported by the authors. 2017). Finally, improvements in resilience may foster a more dynamic workforce that is able to continue responding to long-lasting crises, such as the recent COVID-19 pandemic (Mahaffey et al. 2020). 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