Intensive & Critical Care Nursing 46 (2018) 92–97

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Intensive & Critical Care Nursing

journal homepage: www.elsevier.com/iccn

Research article

The association between spiritual well-being and burnout

in intensive care unit nurses: A descriptive study
Hyun Sook Kim a, Hye-Ah Yeom b,⇑
a
Department of Nursing, Yonsei University Health System, Yonsei Cancer Center, South Korea
b
The Catholic University of Korea College of Nursing, 222 Banpo-Daero, Seocho-Gu, Seoul 06591, South Korea

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To describe the spiritual well-being and burnout of intensive care unit nurses and examine
Accepted 26 November 2017 the relationship between these factors.
Research methodology: This was a cross-sectional descriptive study. The participants were 318 intensive
care unit recruited from three university hospitals in South Korea. The survey questionnaire included
Keywords: demographic information, work-related characteristics and end-of-life care experience, along with the
Intensive care units Spiritual Well-Being Scale and Burnout Questionnaire. The data were analysed using descriptive statis-
Nurses
tics, t-tests, ANOVA with Scheffé test and a multiple regression analysis.
Spirituality
Professional burnout
Results: The burnout level among intensive care unit nurses was 3.15 out of 5. A higher level of burnout
was significantly associated with younger age, lower education level, single marital status, having no reli-
gion, less work experience and previous end-of-life care experience. Higher levels of spiritual well-being
were associated with lower levels of burnout, even after controlling for the general characteristics in the
regression model.
Conclusion: Intensive care unit nurses experience a high level of burnout in general. Increased spiritual
well-being might reduce burnout among intensive care unit nurses. Younger and less experienced nurses
should receive more attention as a vulnerable group with lower spirituality and greater burnout in inten-
sive care unit settings.
Ó 2017 Elsevier Ltd. All rights reserved.

Implications for clinical practice

 Support for spiritual well-being may reduce burnout among intensive care nurses aged in their twenties and nurses with less than
five years of clinical experience, both of whom are considered vulnerable groups to burnout.
 Interventions related to spiritual well-being may reduce burnout of intensive care nurses.
 Education in hospice care might increase the spiritual well-being levels of intensive care nurses in the future.

Introduction professional groups, experience higher burnout levels (Embrico

Burnout is defined as perceived feelings of physical and emo-
tional exhaustion due to stress (Felton, 1998). It can arise after con-
sistent exposure to prolonged stress resulting in physical and
psychological imbalances (Epp, 2012). Nurses, compared to other
⇑ Corresponding author.
E-mail address: yha@catholic.ac.kr (H.-A. Yeom).
et al., 2007; Guntupalli et al., 2014). Burnout in nurses occurs for
reasons such as chronic nursing shortages and understaffing, the
lack of a supportive work climate and increased patient severity
(Cho and Kim, 2014).
Intensive care unit (ICU) nurses are known to be especially vul-
nerable to burnout during critical care practice, because of the high
level of patient acuity, high workload, exposure to unexpected
patient death and perceived conflicts with patients or other staff

https://doi.org/10.1016/j.iccn.2017.11.005
0964-3397/Ó 2017 Elsevier Ltd. All rights reserved.
 H.S. Kim, H.-A. Yeom / Intensive & Critical Care Nursing 46 (2018) 92–97
(Burgess et al., 2010; Teixera et al., 2014). The ICU work climate
might also contribute to burnout, given that ICUs are where
patients with the highest severity conditions are admitted. ICU
nurses are expected to provide skilled nursing care under a 24-
hour monitoring system and are often exposed to emergency sit-
uations (Park and Shin, 2013; Shu-Ming and Anne, 2001). They
focus on providing quality care to maximize patient survival.
However, when these nurses experience the death of a
terminal-stage patient with a limited chance of recovery, they
may experience emotional fatigue and greater burnout (Renea
and Karin, 2005).
Because burnout is a subjective feeling based on personal char-
acteristics and environmental stress, ICU nurses should be aware of
their psychological status and needs to prevent burnout at work.
One potential personal protective factor of burnout is spiritual
well-being. Spiritual well-being is a peaceful state characterised
by fulfillment of spiritual needs, life stability, and balanced rela-
tionships with self, others and the environment, without spiritual
suffering and conflicts (Yoo et al., 2006). The concept of spiritual
well-being is based on the assumptions that spirituality controls
the life course and a human being is an integration of spirit, body,
and mind, all of which are necessary for internal harmony and
peace (Fiori et al., 2004). Individuals with optimal levels of spiritual
well-being are likely to find purpose and meaning in life and show
ready recovery from life stress (Sung, 2009a).
To obtain spiritual well-being, ICU nurses must seek physical,
psychological, and spiritual integration during everyday practice.
They should assess their own spiritual well-being, as this might
have indirect positive effects on the critically ill patients under
their care (Attia et al., 2012; Sung, 2009a). There is evidence of
an association between spiritual well–being and burnout in vari-
ous populations; however, little of this research has examined
this association in ICU nurses, who are in great need of burnout
prevention. Specifically, in South Korea, spiritual well-being has
been examined in many nursing workforce groups, including
nursing students (Lee, 2004; Sung, 2009b), hospice unit staff
(Yoo et al., 2006) and oncology unit nurses (Kim and Young,
2013), but not ICU nurses. Overseas studies have examined the
mediating role of burnout between spirituality and care beha-
viours (Kaur et al., 2013), but have not considered a direct path
from spirituality to burnout in ICU nurses. They have also focused
on the religious aspect of spirituality (Chew et al., 2016;
Musgrave and Mcfarlane, 2004), even though the construct of
spiritual well-being comprises both religious and existential com-
ponents. Whereas religious well-being deals with religiosity as
the source of spiritual balance, existential well-being refers to
the basic spiritual needs shared by individuals with an interest
in exploring the meaning and purpose of life at an existential
level (Lee, 2002).
More recently, there has been growing interest in protective
strategies for burnout among healthcare professionals working
in the ICU (Moss et al., 2016). This study was based on the notion
that spirituality is a potential protective factor for burnout among
ICU nurses and therefore might be useful in interventions to
reduce burnout. Everyday experiences of spiritual well-being
could make end-of-life care settings less stressful and burden-
some. To examine this hypothesis, this study aimed to assess
the levels of spiritual well-being and burnout among ICU nurses
and examined the associations between these variables. Specific
research questions include (1) what are the levels of spiritual
well-being and burnout among ICU nurses in South Korea? (2) What
is the correlation between spiritual well-being and burnout in ICU
nurses? (3) What are the differences in spiritual well-being and
burnout in ICU nurses by general characteristics? (4) Does spiritual
well-being mediate the relationship between end-of-life care experi-
ences and burnout in ICU nurses?
93
Methods
Design & sample
This was a cross-sectional descriptive study. Participants were
318 ICU nurses recruited from three university hospitals in the
metropolitan area of Seoul, South Korea. All participants were reg-
istered nurses who had worked in an ICU for more than one year.
The initial sample size of 340 was estimated with G*Power based
on a significance level of 0.05, a power of 0.80, and a medium effect
size. Of the surveys distributed to the 340 ICU nurses, 338 ques-
tionnaires were returned (return rate 99.4%). Two nurses refused
participation because of a busy work schedule and lack of interest
in the research, and there were no systemic differences between
those who participated and those who did not. Of the 338 ques-
tionnaires, 20 surveys were excluded due to the incompleteness
of the data; thus, 318 surveys were included in the final analysis.
Measurements
General characteristics included age, gender, marital status,
religion, education and perceived life satisfaction. Nursing career
characteristics included current work position and department,
past work experience, and ICU work experience. Questions on
end-of-life care experience included past end-of-life care experi-
ence, previous education on end-of-life care, and previous bereave-
ment experience in the family.
Spiritual well-being
Spiritual well-being was measured using the Spiritual Well-
Being Scale (SWBS), originally developed by Ellison (1982), and
was translated into Korean by Lee (2002). The SWBS comprises
20 items, including 10 items each on religious and existential
well-being. The scale is rated on a 5-point Likert scale from 1 (very
much) to 5 (not at all). In the study using the Korean translation
version, the mean item scores ranged from 2.84 to 3.92 out of 5
points (Lee, 2002). A higher score indicated a higher level of spiri-
tual well-being. The Cronbach’s alpha reliability of the SWBS in the
current study was 0.91, while the Cronbach’s alpha reliability for
the sub-domains included 0.94 for religious well-being and 0.85
for existential well-being.
Burnout
Burnout was measured using the scale developed by Pines and
Kanner (1982), and translated into Korean by Pick (1983). The scale
comprises 20 items measuring physical burnout (6 items), emo-
tional burnout (7 items), and psychological burnout (7 items).
Emotional burnout refers to higher levels of negative emotions
such as anxiety or embarrassment associated with various feelings
that occur in a person’s mind. Psychological burnout refers to
stress-related mental exhaustion associated with brain capacity,
such as decreased concentration and negative thoughts. Each item
was rated on a 5-point scale from 1 (never) to 5 (always), with total
scores ranging from 20 to 100. In the study using the Korean trans-
lation version, the mean item scores ranged from 1.83 to 4.01 out
of 5 points (Pick, 1983). Higher scores indicated greater burnout.
The Cronbach’s alpha reliability of the scale in the current study
was 0.85.
Data collection procedure
The current study was approved by the institutional review
board (IRB) of University of Korea Ethics Committee (IRB approval
number MIRB-00E59-001). The data were collected from January
to February 2014. After IRB approval, participants were recruited
94 H.S. Kim, H.-A. Yeom / Intensive & Critical Care Nursing 46 (2018) 92–97

from the nursing departments of the study sites. Researchers pre-
sented the study aim verbally to potential participants in the ICUs,
and explained the data collection procedures. Then, the question-
naires were distributed to those who agreed to participate and
the completed questionnaire were collected in sealed envelopes.
was used to examine the association of spiritual well-being and
burnout. The mediating effect of spiritual well-being on the rela-
tionship between end-of-life care experience and burnout was
examined using regression analysis based on the method by
Baron and Kenny (1986).

Data analysis Results

The data were analyzed using PASW Statistics 18.0. Descriptive
statistics were calculated for the general characteristics, spiritual
well-being, and burnout. Associations of spiritual well-being and
burnout with general characteristics were examined using t-tests
and ANOVA using Scheffé test for the post-hoc analysis. The corre-
lations between spiritual well-being and burnout were tested
using Pearson‘s correlation coefficient. Multiple regression analysis
General characteristics
Participants’ general characteristics are presented in Table 1.
Participants’ mean age was 29.8 years (SD = 5.71), and the majority
were women (97.2%), unmarried (69.8%) and had baccalaureates in
nursing (69.2%). About sixty percent of participants (59.7%)
reported having a religion. In terms of work position, most partic-

Table 1
Differences in spiritual well-being and burnout by general characteristics (N = 318).

Variables M ± SD n(%) Spiritual well-being* Burnout**

M ± SD t or F (p) M ± SD t or F (p)
Age (year) 29.79 ± 5.71
21–29 213(67.0) 61.63 ± 10.50ab 16.18 (<0.001) 3.26 ± 0.42c 10.37 (<0.001)
30–39 90(28.3) 65.61 ± 10.61a 3.02 ± 0.56c
40 15(4.7) 70.13 ± 10.24b 2.98 ± 0.27
Gender
Male 9(2.8) 62.22 ± 11.08 0.040 (0.968) 3.29 ± 0.46 0.69 (0.491)
Female 309(97.2) 63.19 ± 10.76 3.18 ± 0.47
Marital status
Single 222(69.8) 61.95 ± 10.50 3.12 (0.002) 3.24 ± 0.44 3.13 (0.002)
Married 96(30.2) 65.96 ± 10.86 3.06 ± 0.52
Education (degree)
Associate 66(20.8) 62.41 ± 9.79 6.18 (0.046) 3.17 ± 0.44c 14.49 (0.001)
Baccalaureate 220(69.2) 62.66 ± 10.90 3.23 ± 0.46d
Master 32(10.0) 68.13 ± 10.62 2.91 ± 0.53cd
Religion
Yes 190(59.7) 66.78 ± 10.72 8.41 (<0.001) 3.12 ± 0.48 2.75 (0.006)
No 128(40.3) 57.79 ± 8.30 3.27 ± 0.44
Life satisfaction
Satisfied 250(78.6) 3.73 ± 0.52 0.21 (0.838) 3.10 ± 0.43 6.27 (<0.001)
Not satisfied 68(21.4) 3.71 ± 0.55 3.48 ± 0.48
Work department
Medical ICU 94(29.6) 64.07 ± 12.16 5.39 (0.370) 3.20 ± 0.44 12.68 (0.027)
Surgical ICU 56(17.6) 62.91 ± 8.38 3.15 ± 0.48
Neonatal ICU 57(17.9) 61.16 ± 9.60 3.36 ± 0.46cd
Neurosurgical ICU 53(16.7) 63.34 ± 9.27 3.18 ± 0.47
Coronary Care Unit 40(12.6) 62.38 ± 12.74 3.07 ± 0.45c
Heart-surgical ICU 18(5.6) 66.72 ± 12.14 2.93 ± 0.51d
Job position
Staff nurse 274(86.2) 62.27 ± 10.60 3.64 (<0.001) 3.23 ± 0.45 4.29 (<0.001)
Unit manager 44(13.8) 68.68 ± 10.13 2.89 ± 0.49
Total work experience (year) 6.77 ± 5.67
<5 151(47.5) 61.37 ± 11.55 2.93 3.28 ± 0.43 3.53
5 167(52.5) 64.78 ± 9.73 (0.003) 3.10 ± 0.48 (<0.001)
ICU work 5.53 ± 4.32
experience (year)
<5 174(54.7) 61.44 ± 11.45 3.41 (0.001) 3.28 ± 0.44 4.04 (<0.001)
5 144(45.3) 65.24 ± 9.46 3.07 ± 0.48
Previous end-of-life care experience
Yes 294(92.5) 63.37 ± 10.79 2.20 (0.028) 3.17 ± 0.47 2.10 (0.037)
No 24(7.5) 58.21 ± 9.15 3.40 ± 0.42
Previous education on end-of-life care
Yes 120(37.7) 64.48 ± 9.54 2.20 (0.028) 3.16 ± 0.44 0.70 (0.483)
No 198(62.3) 62.36 ± 11.37 3.20 ± 0.49
Previous bereavement experience for family
Yes 225(70.8) 63.38 ± 10.43 0.56 (0.576) 3.15 ± 0.46 2.13 (0.034)
No 93(29.2) 62.63 ± 11.54 3.27 ± 0.49

a–d: Scheffe test (mean with the same letter were significantly different p < 0.05. ICU = Intensive Care Unit.
*
A higher score indicated a higher level of spiritual well-being.
**
A higher score indicated a higher level of burnout.
 H.S. Kim, H.-A. Yeom / Intensive & Critical Care Nursing 46 (2018) 92–97 95

Table 2 less educated (p = .001), and less experienced (p < 0.001) showed
Levels of spiritual well-being and burnout (N = 318). significantly higher levels of burnout than did their counterparts.
Variables Mean ± SD Higher burnout was also found in nurses who had a staff nurse
Spiritual well- being 3.16 ± 0.54 position (p < 0.001), had no religion (p = 0.006), had not cared for
Existential well-being 3.38 ± 0.50 dying patients previously (p = 0.037) and had no bereavement
Religious well-being 2.93 ± 0.76 experience for family (p = 0.034) than did their counterparts. Burn-
Burnout 3.18 ± 0.47 out levels were also significantly higher among nurses working in
Physical burnout 3.43 ± 0.63
Emotional burnout 3.28 ± 0.49
neonatal ICUs (p = 0.027) compared to other groups (Table 1).
Psychological burnout 2.87 ± 0.56

Association between spiritual well-being and burnout

ipants were staff nurses (86.2%). About one-third of participants
(29.6%) were working in medical ICUs. Participants had been work-
ing as nurses for an average of 6.77 years and the mean ICU work
experience was 5.53 years. Regarding end-of-life care experience,
92.5% of participants had cared for dying patients in the past, while
more than half (62.3%) reported that they had not received educa-
tion in hospice care. Of the participants, 70.8% reported no previous
experience in losing a family member (Table 1).
Spiritual well-being
The mean SWBS score was 3.16 out of 5 (range 2.10–4.15). The
mean existential well-being score (3.38) was higher than the mean
religious well-being score (2.93) (Table 2). Participants who were
aged 30 years or older (p < 0.001), married (p = 0.002), and were
in administrative positions (p < 0.001) had significantly higher
SWBS scores than did others. Similarly, higher scores were found
in those with a religion (p < 0.001), a master’s degree or higher
(p = 0.046), more than five years of work experience in nursing
practice (p = 0.003) or in ICUs (p = 0.001), experience in caring for
dying patients (p = 0.028) and experience in hospice education (p
= 0.028) (Table 1).
Because the religious well-being score might have affected the
overall spirituality score, we set existential well-being score, which
does not include religiosity as its component, as the dependent
variable and performed an additional analysis. Existential well-
being levels were found to be significantly higher among nurses
who were aged 40 years or older (F = 3.12; p = 0.046), married (t
= 2.48; p = 0.014), had a master’s degree or higher (F = 3.36; p =
0.010), had a religion (t = 1.99; p = 0.047) and worked in a unit
management position (t = 2.67; p = 0.008).
Burnout
The mean burnout score was 3.18 out of 5 (range 1.65–5). Phys-
ical burnout had the highest score of the subscales (3.43) (Table 2).
Nurses who were aged 21–29 years (p < 0.001), single (p = 0.002),
In the correlation analysis, burnout was negatively correlated
with spiritual well-being (r = 0.48, p < 0.001). In the hierarchical
regression equation, residual analysis confirmed that the assump-
tions of multicollinearity, linearity, normality, and equality of vari-
ance were upheld. Three-step hierarchical regression analysis was
conducted with the following order of entry of independent vari-
ables: demographic factors for step 1, previous end-of-life care
experiences for step 2, and spiritual well-being for step 3. The addi-
tion of spiritual well-being to the step 2 equation resulted in 15.9%
of the explained variance in burnout. Significant factors predicting
burnout included younger age (ß = 0.13), previous bereavement
experiences for family (ß = 0.14), and lower levels of spiritual
well-being (ß = 0.31) (Table 3).
To examine the mediating role of spiritual well-being on the
relationship between end-of-life care experience and burnout,
the three-step analysis of Baron and Kenny (1986) was conducted:
(1) regression of spiritual well-being on end-of-life care experience
(ß = 0.079, p = 0.172), (2) regression of burnout on end-of-life care
experience (ß = 0.151, p = 0.008), and (3) regression of burnout on
end-of-life care experience as a predictor (ß = 0.146, p = 0.011)
with spiritual well-being as the mediator (ß = 0.068, p = 0.233).
There was no mediating effect of spiritual well-being on the rela-
tionship between end-of-life care experience and burnout, as the
analyses in step 1 and step 3 were not statistically significant.
Discussion
In this study, the majority of participants were female (97.2%),
and more than half were under 30 years of age (67%) and had more
than five years of work experience (52.5%). Considering that 96% of
all nurses in South Korea are female and more than half are less
than 30 years old (53.6%) and have over 5 years of work experience
(53.1%) (KHIDI, 2014), the distributions of gender, age and senior-
ity in study participants were similar to the national distributions.
ICU nurses’ burnout level was 3.18 out of 5 in this study;
although it is difficult to judge the meaning of this score because
of the absence of established cut-offs for the scale, it was relatively

Table 3
The Association between Spiritual Well-Being and Burnout in ICU Nurses.

Variables B S.E. ß t Sig. Adj R2 F(p)

Step 1
Age 0.013 0.003 0.222 4.019 0.001 0.046 16.150 (<0.01)
Step 2
Age 0.012 0.003 0.198 3.586 0.001 0.069 8.801
Previous end-of-life care experience (1 = yes) 0.131 0.077 0.093 1.695 0.091 (<0.01)
Previous bereavement experience for family 0.107 0.041 0.142 2.601 0.010
(1 = yes)
Step 3
Age 0.008 0.003 0.131 2.450 0.015 0.159 15.841
Previous end-of-life care experience (1 = yes) 0.093 0.074 0.067 1.270 0.205 (<0.01)
Previous bereavement experience for family 0.102 0.039 0.136 2.621 0.009
(1 = yes)
Spiritual well-being 0.198 0.034 0.312 5.843 0.001
96 H.S. Kim, H.-A. Yeom / Intensive & Critical Care Nursing 46 (2018) 92–97
higher than those among South Korean nurses in oncology units
(2.73) (Kim, 2004) and general wards (2.81) (Cho et al., 2004) using
the identical scale. As for comparisons with overseas studies, ICU
nurses in this study had higher burnout levels than did Turkish
nursing home nurses (2.43) based on the same scale
(Mandiracioglu and Cam, 2006). High levels of burnout have also
been reported by ICU nurses in England (Burgess et al., 2010), Spain
(Iglesias et al., 2010), and the US (Bienvenu, 2016; Braithwaite,
2008), although the scales used were different. Therefore, in gen-
eral, ICU nurses experience higher levels of burnout, possibly
because of their practice of caring for critically ill patients and con-
sistent exposure to the possibility of patients’ death.
As for the sub-domains of burnout, physical burnout scores
were the highest, supporting the notion that physical burnout is
a significant problem among registered nurses (Shin and Shin,
2003; Park, 2009). In South Korea, most ICU nurses are hired full-
time and thus are required to work eight hours per day for 5 days
under three shifts (Kim et al., 2005; Park and Shin, 2013). Although
work conditions in ICUs have improved (Stone and Gershon, 2006;
Stone et al., 2006), ICU nurses are still at risk of overt physical
tiredness; thus, ways to reduce their work overload should be fur-
ther explored.
Burnout levels in this study were higher among nurses aged in
their twenties and nurses with less than five years of clinical expe-
rience, suggesting that younger and less experienced nurses should
receive more attention as a vulnerable group for burnout in ICU
settings. Burnout levels were higher among nurses working in
neonatal ICUs than among nurses in other types of ICUs, implying
that nurses caring for neonates might struggle with a more bur-
densome work climate, possibly due to the demanding job of oper-
ating advanced technologies and delivering empathetic care to
neonates and their families (Braithwaite, 2008). The three hospitals
from which research data were collected did not have paediatric
ICUs. Therefore, all study participants who took care of children
in this study were working in neonatal ICU. Burnout levels were
also higher among ICU nurses who had not received education in
end-of-life care than among nurses who had such experiences. It
is plausible that end-of-life care education for ICU nurses would
better prepare them to care for dying patients, and would thereby
reduce their burnout levels. Further intervention studies to exam-
ine the effects of end-of-life care education on the burnout of ICU
nurses are needed.
The spiritual well-being of ICU nurses was 3.16 out of 5.
Because the spirituality scale is a continuous scale without a cut-
off, it was difficult to precisely define the meaning of this score
is. When compared to the results of previous studies using the
same scale, the spiritual well-being levels of ICU nurses in this
study were higher than were those reported for oncology unit
nurses (2.68) (Lee, 2015) and nursing students (2.65) (Sung,
2009b) in South Korea, but were lower than were those reported
in overseas studies including oncology nurses in Israel (4.13)
(Musgrave and Mcfarlane, 2004) and nursing students in England
(3.8) (Beauvais et al., 2014). Regarding the sub-domains, ICU
nurses had higher scores on existential well-being than religious
well-being, indicating that ICU nurses were more interested in
seeking the meaning of life in the empirical world in the present
time than in focusing on their religious orientation in an effort to
achieve eternal peace in a theological context. These results are
also consistent with the findings of prior studies (Sung, 2009a;
Yoon, 2009), supporting the notion that the existential aspect of
spiritual well-being is more dominant among ICU nurses.
In this study, spiritual well-being levels were higher among ICU
nurses who had a religion than among those who did not, support-
ing the notion that religion influences the spiritual well-being of
ICU nurses (Ntantana et al., 2017). This study also demonstrated
that spiritual well-being was significantly associated with factors
related to end-of-life care. Both previous end-of-life care experi-
ence and previous education in end-of-life care were positively
associated with spiritual well-being. This suggests that end-of-
life care is an important learning domain for ICU nurses, and that
preparation to care for dying patients through well-tailored end-
of-life care education may improve nurses’ spiritual well-being.
In the prediction model, a significant association of spiritual
well-being with burnout was found, as hypothesised. Specifically,
lower levels of spiritual well-being were associated with higher
levels of burnout among ICU nurses. The theoretical assumption
underlying this hypothesis is that spiritual well-being helps ICU
nurses maintain internal peace and psychological stability, which
may buffer the influence of job-related stress on burnout. In fact,
the role of spirituality in preventing burnout among workers in
end-of-life care settings has been reported with mixed findings
in diverse ethnic groups (Holland and Neimeyer, 2005; Kaur
et al., 2013; Ntantana et al., 2017). In this study, there was no sig-
nificant mediating role of spiritual well-being in the relationship
between ICU nurses’ end-of-life care experience and burnout.
These findings imply that the inter-relationships among these vari-
ables are complex and that other predictor variables might be
involved in understanding the burnout of ICU nurses. However,
due to the cross-sectional, descriptive nature of the study design,
it was not possible to determine the causal relationship among
these variables. Further replication studies should be conducted
to understand the complex interplay between spiritual well-
being and burnout in ICU nurses, and other confounding variables
conceptually related to burnout should be evaluated in future
studies. It is also needed to examine whether spiritual wellbeing
is a mediating factor between end-of-life care experience and
burnout using a more concrete structural equation modeling with
a greater number of variables.
The scale used to measure burnout in this study was designed
specifically for nurses; however, it is not universally used, which
limits comparison of our study results with the findings from the
international literature. Therefore, it is necessary to measure Kor-
ean ICU nurses’ burnout using other widely used scales, such as
the Maslach Burnout Inventory, in a future study, so that the
results of our study can be more concretely compared with those
of previous studies conducted in other cultures.
Limitations
This study has several limitations. Due to the cross-sectional
study design, it is not possible to establish causality among vari-
ables. The convenience sampling approach may also have resulted
in a selection bias. The generalisability of the findings is limited
due to the collection of the data from one group of Korean nurses.
Since the sample of this study was a group of nurses recruited from
tertiary care hospitals in South Korea, the findings should not be
generalised to other regions or cultures.
Conclusion
The levels of spiritual well-being among South Korean ICU
nurses were moderate, and were significantly associated with their
burnout level. The ICU nurses had higher existential well-being
scores than religious well-being scores. A high-risk group for
higher burnout levels included younger ICU nurses who had previ-
ous bereavement experiences with family and lower levels of spir-
itual well-being. Enhanced spiritual well-being might be a
protective factor for burnout among ICU nurses, and could be used
as a prevention strategy for lowering burnout levels. Future
research should incorporate various environmental variables into
the prediction model and identify the potential moderating effect
 H.S. Kim, H.-A. Yeom / Intensive & Critical Care Nursing 46 (2018) 92–97
of spiritual well-being on the relationship of environmental factors
and burnout in ICU nurses.
Role of funding source
This research was supported by Basic Science Research Program
through the National Research Foundation of Korea (NRF) funded
by the Ministry of Education, Science and Technology
(2017R1A2B1010413).
Ethical statement
This study was approved by the Institutional Review Board
(IRB) of the Yonsei University Health System of Korea Ethics Com-
mittee (IRB approval number MIRB-00E59-001). Informed consent
was obtained from all study participants, and the survey question-
naires were distributed to those who agreed to participate in the
study voluntarily.
Conflicts of interest
No conflict of interest has been declared by the authors.
Acknowledgment
The authors would like to Ms Hankyo Choi for statistical consul-
tation for this work.
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