Workplace Spirituality, Compassion Satisfaction, Burnout, and Secondary Traumatic Stress: A Cross-Sectional Study in Iranian Nurses

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Introduction
Professional quality of life (ProQOL) refers to how a person feels about his job as a helper. ProQOL includes two positive (compassion satisfaction) and negative (compassion fatigue) dimensions [1]. Compassionate satisfaction (CS) is a positive and satisfying feeling of providing care, including satisfaction with helping others and a sense of the social value of their work [2]. CS occurs when empathy is evoked to contribute to altruistic performance and relieve patients' pain. CS helps nurses to cope with the negative aspects of work with hope, optimism, and willingness to continue serving. Terefore, care, compassion, and empathy for patients afect the personal and professional life of nurses [3]. Compassion fatigue (CF) can appear in two ways: burnout (BO) and secondary traumatic stress (STS) [1]. CF is the price of medical care and is common among the staf of healthcare centers due to dealing with the hardships and sadness of patients. BO, as one of the components of CF, includes emotional exhaustion, depersonalization, and personal inadequacy [2], which can signifcantly afect patients' health outcomes and employees' morale. Another component of CF is STS, which is an acute response to the care of trauma patients or traumatic stressful events. Te negative impacts of STS include cases such as fear, sleep disorders, and avoiding remembering traumatic experiences [4].
Nurses are prone to stressful events and are at risk of experiencing the negative efects of BO and STS. Long-term experience of work-related exhaustion can reduce nurses' professional life quality [1]. Health care workers' low quality of life causes negative impacts such as lack of communication with the patient, poor attitude to work, lack of interest, lateness, or absenteeism from work [2]. In addition to knowledge, nurses need a good quality of life, personal and professional self-care practices, listening skills, emotion management, and stress management to provide highquality care. It is very important that they feel cared for by their work and social environments, which help maintain an adequate emotional balance to face adverse situations [5].
Various work-related factors may afect healthcare workers' professional quality of life. However, previous studies do not specify exactly which variables related to the workplace may afect the ProQOL of nurses [6]. In recent decades, spirituality and religion have been increasingly studied, generally showing a positive efect on physical and mental health. Nurses use diferent strategies to overcome burnout. Meanwhile, spiritual and religious beliefs are an important way to handle challenges and burnout [7].
Workplace spirituality (WPS) has emerged as a new paradigm in recent years in the management and business literature [8]. WPS indicates that people have a sense of meaning and purpose in their work, and its meaning goes beyond material rewards and creates a feeling of happiness and energy in a person [9]. According to Milliman et al., WPS can be conceived at three levels. Te frst dimension is the "individual level," which represents a person doing "meaningful work" while fnding joy and being energized by purposeful work. Te second dimension is the "group level." Tis level creates a "sense of community" within the workplace. Here, there is a connection to coworkers and the support of the team. Te third dimension is "alignment with organizational values." Here, the goal is for employees to feel cared for by the organization, and to identify with the mission and values of the organization [10,11].
Previous studies have shown that positive WPS can make nurses productive, perform well at work, and be emotionally intelligent, committed, and satisfed [12]. Several studies have indicated that spirituality is associated with BO [7,13,14]. Several studies' fndings showed that there is no relationship between spirituality and BO [15,16], CS, and STS (15). It was found that there are discrepancies in these studies. Based on the above arguments, this study aimed to [1] assess the levels and associations of WPS, CS, BO, and STS among Iranian nurses and [2] identify the impact of WPS components (meaningful work, sense of community, and alignment with organizational values) on CS, BO, and STS while controlling for demographic variables.

Study Design.
Tis study was designed as a descriptive, cross-sectional, and correlational study. Te investigation is based on strengthening the reporting of observational studies in the epidemiology statement (STROBE) supplementary materials available (here).

Sample and Setting.
Te present study was conducted in fve hospitals afliated with the Arak University of Medical Sciences, Iran. Te research population included all nurses working in these hospitals from June 2022 to December 2022. Te study inclusion criteria include having at least a bachelor's degree in nursing, willingness and consent to participate in this study, having at least six months of clinical work experience, not having the death of one of the family members in the last six months based on the nurse's statements, and not having a psychiatric record. Failure to return or fll the questionnaires incompletely was considered the exclusion criterion.
Based on Morgan's table, the number of samples was estimated to be n � 295, which were selected using the stratifedproportional sampling. In this way, taking into account the number of nurses in each hospital, the contribution of that hospital to the total sample was determined. In order to select the given number of samples from each hospital, a table of random numbers was used based on the prepared list of nurses. A total of 295 questionnaires were distributed and completed. Te retrieval rate of the questionnaires in the study was 100%.

Data Collection
Tools. Personal information form (age, gender, marital status, and work experience), the scale of workplace spirituality, and Professional Quality of Life version 5 (ProQOL-5) were used for data collection.

Te Scale of Workplace Spirituality.
Workplace spirituality was measured using adapted three-dimensional scales developed by Milliman et al. (2003). Tis scale was based on Ashmos and Duchon (2000), initially drawn from the healthcare sector. Te reliability of the instrument for each dimension has a Cronbach's α value ranging from 0.88 to 0.94, as reported by Milliman et al. [10]. Te scale has been used in research studies. Evidence of its validity and reliability has been reported in numerous studies [8,17].
Tis scale was rewritten in the Persian language by Alizadeh with some changes for nurses, which includes 20 items. It is scored on a fve-point Likert scale (from completely disagree � 1 to completely agree � 5). Te scale includes three dimensions of meaningful work (6 items), sense of community (7 items), and alignment with the organization's values (7 items). Te minimum and maximum scores were 20 and 100, respectively. Tis questionnaire has content and face validity in Iran, and reliability with a Cronbach's alpha coefcient of 0.882 [18]. Also, Cronbach's alpha of the questionnaire was reported to be 0.88 in a study by Kabiri et al. on the nursing population in Iran [19]. In the present study, the reliability of the questionnaire was calculated for each subscale: meaningful work (α � 0.824), sense of community (α � 0.784), and alignment with organizational values (α � 0.862). Te Cronbach's alpha coefcients >0.7 indicated that the reliability of the scale of workplace spirituality had been approved. 2 Perspectives in Psychiatric Care

Professional Quality of Life Version 5 (ProQOL-5).
Tis scale contains 30 items in three subscales of CS (10 items), BO (10 items), and STS (10 items), which give three distinct scores and do not have a total score. Scoring is based on a 5-point Likert scale from 1 � never to 5 � always. 5 out of 10 questions of the burnout scale are reverse questions that are scored from 1 � always to 5 � never. Te range of scores in each subscale is between 10 and 50. Te cutof points for all three subscales in this questionnaire are 22 and 42. Scores of 22 or less are considered low, the range of 23 to 41 is considered moderate, and scores 42 and higher are considered high levels of CS, BO, and STS [20]. Te scale has been widely used in research studies. Evidence of its validity and reliability has been reported in numerous studies [3,[21][22][23]. In the present study, the reliability of the questionnaire was calculated for each subscale: CS (α � 0.84), BO (α � 0.74), and STS (α � 0.78). Te Cronbach's alpha coefcients >0.7 indicated that the reliability of ProQOL-5 had been approved.

Data Collection.
Te data collection started with presenting the introduction letter of the research and technology vice-chancellor of the Arak University of Medical Sciences. Te researcher gave the scales to the nurses in the wards in person and inside the envelope. After explaining the objectives of the study, obtaining written informed consent, and assuring the confdentiality of the information, if the person agreed and met the criteria for entering the study, they were invited to go to the nursing rest room in the ward to complete the scales. Te scales were completed by nurses through selfreporting. Te nurses were asked to complete the scales at the appropriate time and specify a time to collect the scales.

Data
Analysis. Te data were analyzed by SPSS24 and statistical tests. Descriptive statistics (frequency, percentage, mean, and standard deviation) and inferential statistics (Pearson's correlation coefcient and enter the method of multiple regression) were used in this study. Te correlation among WPS, CS, BO, and STS was analyzed by the Pearson's correlation coefcient because the distribution of scores from the main variables was normal. After an examination of correlations, multiple regression analyses were completed to examine associations of each of the three dependent variables representing aspects of professional quality of life (CS, BO, and STS), with a model including three independent variables (the three components of WPS, including meaningful work, sense of community, and alignment with organizational values) and fve control variables (age, gender, marital status, and years of work experience). Te data from this study were suitable for multiple regression analysis, with a Durbin-Watson score of 1.816-1.902 (1.50-2.50) and a tolerance score of 0.193-0.924 (>0.1) and a VIF of 1.082-5.185 (<10). All variables were examined before data analysis and were found to be adequately homoscedastic and linear. Skew and kurtosis statistics and normal probability plots showed the data were distributed normally, and tolerance and variance infation factors indicated no issues with collinearity. A p < 0.05 was considered statistically signifcant.

Ethical Considerations.
Te Ethics Committee of the Arak University of Medical Sciences approved this study (IR.ARAKMU.REC.1401.084). All participants were informed about the objectives and method of the study. Tey were also informed that participation in the study is voluntary; therefore, they could refuse to participate or withdraw from the study at any time. Also, the information of all research participants was kept confdential. Finally, the participants who agreed to participate in the study were asked to sign a written consent.

Characteristics of Participants.
A total of 295 questionnaires were distributed, of which 295 were returned, giving an over-all response rate of 100%. Nurses participated in this study, including 250 females (84.7%) and 45 males (25.3%). Also, 100 participants (33.9%) were married and the rest (66.1%) were single. Te mean age of nurses was 33.63 years, with a standard deviation of 6.42 years. Further, the mean working background of nurses was 9.70, with a standard deviation of 6.40 years.  Table 1). Te mean scores for the dimensions of "meaningful work," "sense of community," and "alignment with the organization's values" were 3.41 (0.72), 3.37 (0.64), and 2.73 (0.77), respectively. Most of the nurses reported moderate levels of CS (76.3%), BO (80%), and STS (86.1%) ( Table 2).

Correlations of Workplace Spirituality, Compassion Satisfaction, Burnout, and Secondary Traumatic
Stress. CS has a negative and signifcant relationship with each BO (r � −0.648 and p < 0.001) and STS (r � −0.142 and p � 0.014). Participants higher in CS had lower BO and STS scores. Also, a positive and signifcant relationship was reported between BO and STS (r � 0.586 and p < 0.001). Participants who reported higher levels of BO had higher levels of STS (Table 1).
WPS and CS had a positive and signifcant relationship (p < 0.001 and r � 0.558). Also, an inverse and signifcant relationship were between WPS and BO (r � −0.478 and p < 0.001), but there was no signifcant relationship between WPS and STS (p > 0.05). Participants who reported higher levels of WPS had higher CS and lower BO scores (Table 1).

Perspectives in Psychiatric Care
Burnout, and Secondary Traumatic Stress. Te total model predicting CS (Table 3, Column 1) explained 42.7% of the variance in CS scores. Meaningful work (B � 4.523 and p < 0.001) and a sense of community (B � 2.089 and p < 0.001) from WPS subscales had a signifcant efect on CS. Participants higher in meaningful work and a sense of community had higher CS scores. Among the control variables, the mean score of CS was signifcantly higher in female nurses than in male nurses. Table 3, Column 2 shows the model associated with burnout, which explains 34% of the variance in burnout scores. Meaningful work was the only variable that signifcantly contributed to burnout in this model, with higher meaningful work scores predicting lower levels of burnout (B � −4.602 and p < 0.001). None of the control variables or other WPS subscales signifcantly contributed to the model. Te regression coefcients for the fnal model predicting STS are included in Column 3 of Table 3. Te total model was signifcant and predicted 8.6% of the variance in STS scores. Meaningful work (B � −2.593 and p < 0.001) and alignment with organizational values (B � 2.230 and p < 0.001) from WPS subscales had a signifcant efect on STS. Participants higher in meaningful work had lower STS scores. Participants who reported higher levels of alignment with organizational values had higher levels of STS.

Discussion
Te frst aim of the current study was to assess nurses' perceptions of WPS, CS, BO, and STS and the relationships between these variables. Te results of the present study showed that WPS is in moderate-high level. In the present study, the highest WPS level was perceived as "meaningful work," while the lowest was reported as "alignment with the organization's values." WPS is experienced by nurses who are passionate and energetic at work, their job satisfes them, and they have found meaning and goal in their job. Tey have efective relationships with other colleagues [24]. It is suggested that nurse managers create an environment whereby nurses believe that there is a high sense of ethics and integrity so that their welfare and that of society are valued.
Most of the nurses reported moderate levels of CS, BO, and STS. In the present study, the mean score of CS is lower than the study results of Cuartero-Castañer et al.  [2,5,6]. Te above studies were conducted during the Covid-19 pandemic; the reason for the inconsistency can be seen in the fact that other healthcare professions participated in the above studies. Te mean of BO and STS subscales in the present study was higher than the previous studies, except for a study by Azizkhani et al. in Iran. Te inconsistency can be attributed to the diferent role and workload of nurses in diferent countries during the Covid-19 pandemic, and Iran, as one of the Asian countries, has been afected by this situation [2].
In this study, participants higher in CS had lower BO and STS scores. Also, participants who reported higher levels of BO had higher levels of STS. In other studies, similar relationships with the present study were reported between CS and BO and between BO and STS [2-4, 25, 26]. Te relationship in the present study between CS and STS was inconsistent with the studies by Bahari et al. in Saudi Arabia and Yadollahi et al. in Iran. Te results of these studies showed a positive, weak, and signifcant relationship between CS and STS [3,26]. Also, the study results of Yildirim and Ertem showed no signifcant relationship between CS and STS [25]. However, the results of some studies are consistent with the present study [2,4].
Participants who reported higher levels of WPS had higher CS and lower BO scores. Consistent with the present study, the results of a review by De Diego-Cordero et al. showed that spirituality/religion is used as a common strategy by nurses to cope with stress and BO. Nurses' spiritual and religious beliefs correlate with their lower levels of BO [7]. Te study results of Doraiswamy and Deshmukh showed a negative and signifcant relationship between WPS and stress [13]. According to the study results of Fan et al. in China, a negative and signifcant relationship was between WPS and BO of nurses [14]. Te study results of Darvehi et al. in Iran showed that the self-compassion training plan in nurses efectively increases CS and reduces STS, and BO [27]. Tis is while the study results of Polat et al. showed no signifcant relationship between spiritual orientation and BO, CS, and CF [15]. Putri et al. showed no signifcant relationship between spirituality and nurses' burnout in Indonesia [16].
In Iranian Islamic culture, WPS is rooted in religion, and religion is considered the main factor in strengthening and encouraging spirituality in individuals and organizations [28]. It seems that in such a society, spirituality plays a greater role in infuencing people's psychological health so that people strive for their inner and spiritual growth. Tere is a spiritualistic view of profession in Iranian Islamic society. Nursing as a holy profession is a divine blessing. Naturally, such a point of view causes satisfaction in patient care. So a nurse endures care problems and keeps calm [29]. Having religious beliefs enables employees in assistive jobs to consider helping patients to fnd meaning in their professional life and gain high job satisfaction. Religious employees think of helping others as a way of worshiping God and believe that their job is a divine duty from God, who will help them in their lives. Terefore, religious people use religion as a defense mechanism to cope with job problems and fnd meaning in their jobs [30].
Te second aim of the current study was to identify the impact of WPS components on CS, BO, and STS while controlling for demographic variables. In this study, higher "meaningful work" is associated with higher CS and lower BO and STS among nurses. Participants higher in "sense of community" had higher CS scores. Higher "alignment with organizational values" is associated with higher STS. A similar study was not found to compare the WPS components' efect on the ProQOL of nurses.
Meaningful work refects the extent to which employees experience a sense of meaning and purpose. Te meaning is beyond the material rewards and creates a sense of joy and energy at work [9], and then ProQOL would improve. A sense of community involves having a deep connection with others, related to the interactions between nurses and their colleagues. Tis component of WPS includes mental, emotional, and spiritual connections among nurses in teams or groups in the workplace. Experiencing such pleasurable interactions in the workplace can be accompanied by support, freedom of expression, a sense of belonging, and genuine caring, which ultimately lead to greater satisfaction than compassion [9]. Surprisingly, the fndings of the present study showed that the component of alignment with the organization's values is directly related to STS. It is possible that for people who experienced more STS, the organization valued their wellbeing and met their needs to support them. Also, they tried to get organizational support to reduce negative feelings such as stress and depression. Terefore, the existence of this two-way relationship has caused this fnding.

Limitations
As for the study's limitations, a causal relationship could not be determined because of the cross-sectional study design. In addition, although the research sample was representative of nurses in fve teaching hospitals in Arak, Iran, the fndings may not be generalizable to all nurses in Perspectives in Psychiatric Care Iran and nurses in private hospitals. Data collection through the self-report method might have resulted in recall bias. Despite these limitations, this study provides some evidence about the relationship between WPS and the ProQOL of nurses.

Conclusion
In this study, we examined the infuence of WPS on nurses' ProQOL. We conclude that positive WPS leads to improved "compassion satisfaction" and low "burnout." "Meaningful work," as the most important component of WPS, had a signifcant impact on the ProQOL. Results of multiple regression analyses indicate that the model of WPS components and control variables explains 42.7, 34, and 8.9 percent of the variance of CS, BO, and STS, respectively. Te fndings also support the conclusion that female nurses had a higher CS than male nurses.
Organizational spirituality efects on the attitude, feelings, and behavior of employees. Spiritual people clearly experience less BO. Tese people have an acceptable justifcation for their problems and pressures. Even some religious people consider life's problems to be a test by God. Surprisingly, some consider it a divine gift, which makes spiritual people sufer less pressure and problems. Since the improvement of professional life is one of the efective factors in attracting and retaining employees and considering the role of nurses in the prevention and treatment of diseases in medical centers and the efective role in improving health quality, the improvement of ProQOL is recommended in improving the performance of nurses. Considering the confrmation of the relationship between WPS and ProQOL, future research can emphasize the mechanisms of improving the WPS of nurses. Also, WPS should be supported and encouraged by the nursing managers.

Data Availability
Te data that support the fndings of this study are available from the corresponding author upon reasonable request.