Suicidality, resilience and burnout in a population of oncology nurses
Oncology care gives employees the opportunity to take care of people during the most difficult times of their lives, which can affect the psychological well-being of nurses. The specific characteristics of the workplace often involve palliative care as well. According to the data of the World Health Organization, in 2022 a total of 9.7 million deaths were recorded as a result of cancer, and so far cancer has been one of the leading causes of death at the global level . Searching the available scientific literature, numerous studies mainly focused on the mental well-being of employees in oncology departments. They revealed that working in the highly stressful environment of an oncology care departments represented significant risk for psychological status of employees. Some researchers found that, closeness allows oncology nurses the ability to show a level of compassion that is often helpful to patients and their families while struggling with the disease. However, it can also lead to the raising a feeling of pain in employees, if the patient has lost the fight . A study by other scientists showed that oncology staff were at greater risk of professional empathy fatigue compared to the professionals who work in other departments . Oncology nurses take care of patients in the terminal stages of the disease almost every day, and they are often the ones who are with the patients at the very end of their lives. This context brings special challenges, so suicidality in cancer patients is a frequently investigated phenomenon: some data show that one quarter of cancer patients have suicidal thoughts , . On the other hand, the occurrence of suicidality in oncology nurses and the factors that influence it remain unexplained and insufficiently investigated. Suicide is considered to be one of the most challenging public health problems worldwide. It is defined as self-inflicted death with proven intention to die . Suicide attempts are often related to the existence of suicidal thoughts and ideas, however, it is important to know that two thirds of people with suicidal ideas never make any suicide attempt, nor all suicide attempts are fatal . In this light, authors speaks about nonfatal suicidal thoughts and behaviors which are classified into three categories: suicidal ideation which refers to process of having rumination about ending one’s life, suicide plan which includes thinking about specific method through which one person desire to die, and suicide attempts which is related to conscious engaging in self-injuring acts and behaviors with at least some intent to die . Modern scientific literature often uses the term suicidality when describing a large group of psychopathological behaviors ranging from suicidal ideations, ambivalent suicide attempt, suicide attempt and suicide . Some authors speak of suicidality as the appearance of ideas, thoughts, contemplation, related to potential suicide, rather than suicide attempts . American psychological association defines suicidality as “the risk of suicide, usually indicated by suicidal ideation or intent, especially as evident in the presence of a well-elaborated suicidal plan” . Healthcare professionals are in high risk for suicide. In general, suicidality among nurses is often associated with risk factors such as psychiatric difficulties, health problems, but also occupational factors . In general, suicidality among nurses is often associated with risk factors such as psychiatric difficulties, health problems, but also occupational factors . Healthcare professionals are in high risk for suicide. An American study showed that 5.5% of nurses experience suicidal thoughts related to burnout syndrome - an individual response to chronic stress related to work conditions, which can cause certain health problems and psychological problems . On the other hand, the question of protective factors arises. Some authors believe that greater psychological resistance to stress correlates with a lower degree of suicidality . Resilience is actually a person’s ability to successfully resist the negative impact of stressors, adapt to changes and quickly return to their pre-crisis state. Resilient individuals are more resistant to the impact of stressful events and more easily reach positive outcomes after a crisis situation , . The aim of this work is to examine is suicidality connected with resilience and burnout in the populations of oncology and non-oncology nurses, nursing students and administrative workers, as well as to determine if oncology nurses differ from other groups. 

This cross-sectional study included a total of 75 oncology nurses from six healthcare centers, as well as 74 non-oncology nurses working in traditionally highly stressful and challenging settings: psychiatric, intensive care, surgical, and orthopedic departments, 70 nursing students, and 71 administrative workers. The student group included 70 nursing college students, currently completing their 2nd or 3rd year of studies, without history of employment in healthcare, with very little clinical exposure, their clinical experience was limited on student practice with supervision, few hours a month. The group of administrative workers consisted of adult citizens, selected using a random sample method, who, in terms of characteristics such as gender, age, and level of education, correspond to the group of nurses, and works in office setting: making schedules, managing finances, filling documentation. The research was conducted in 2022, anonymously. Informed consent was obtained from all subjects involved in the study. The research question was to answer if suicidality is connected with resilience and burnout in the population of nurses, nursing students and administrative workers, as well as to determine if oncology nurses differ from the other groups. The respondents filled out the following instruments: the Serbian version of the RASS—Risk Assessment Suicidality Scale , the Serbian version of the Brief Resilience Scale—BRS , the Maslach Burnout Inventory . Respondents also filled out specially designed sociodemographic questionnaire, that except basic sociodemographic data included question on family functioning, occupational factors as well as health related factors. Data included question on family functioning, occupational factors as well as health related factors. Suicidality was measured by the Risk Assessment Suicidality Scale (RASS) . This scale contains a total of twelve items. They can be graded by four statements: not at all, somewhat, a lot and very much. The scale is scored based on the frequency of responses and was tested in the Serbian population. To assess burnout, the Maslach Burnout Inventory—Human Services Survey (MBI-HSS) and Maslach Burnout Inventory for general population (MBI) were used, with oncology nurses and non-oncology nurses filling out MBI-HSS. MBI-HSS consists of three three subscales that measure: Emotional exhaustion (9 items), Depersonalization (5 items), Personal accomplishment (8 items). The population of students and administrative workers filled out a general questionnaire containing subscales: Exhaustion, Cynicism and Professional efficacy. In order to measure resilience, we used the Brief Resilience Scale- BRS , which consists of six items, namely three positive and three negative statements. All six relate to an individual’s ability to cope with stressful events. The scale was translated from English to Serbian, and then from Serbian to English, so that the new version was sent to the author who approved the translation and use of the scale. Statistical analysis was performed using the SPSS 19.0 (Statistical Package for Social Science for Windows 19). The Kolmogorov-Smirnov test and Shapiro–Wilk test were used for determination of quantitative data distribution. Continuous variables were presented as mean ± SD or median (25-th percentile–75-th percentile). Comparisons between two groups were analyzed by Mann–Whitney test. Comparisons between more than two groups were analyzed by Kruskal–Wallis test. The relationship between the observed categorical variables was examined by Spearman’s Rho correlation. Differences were considered significant at p < 0.05. The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of University Clinical Center, Kragujevac, Serbia (protocol number: 01/18-3739, date of approval 25 September 2018). 

The demographic and numerical characteristics of the respondents are given in Tables and . Differences in the levels of suicidality between occupations are not statistically significant. Differences in levels of suicidality between the categories of education, family relations satisfaction, patient’s behavior satisfaction, socio-economic satisfaction, thinking about going abroad, growth opportunities at work and sleep problems are statistically significant. Respondents with high school/secondary education have a higher level of suicidality compared to respondents with college or university degree. Higher family relationships satisfaction reduces the level of suicidality. Respondents who are very dissatisfied with the patient behavior towards them have a lower level of suicidality compared to other respondents. Respondents who are dissatisfied with their socio-economic status have a higher level of suicidality compared to other respondents: it is interesting that respondents who are very dissatisfied have twice as lower level of suicidality than those who are ‘only’ dissatisfied. Respondents who are working on going abroad have a higher level of suicidality compared to other respondents. Respondents who believe that they have growth opportunities at work are less suicidal than other respondents. Respondents who do not have sleep problems are far less suicidal than other respondents. See Table . Our research showed that in the group of oncology and non-oncology nurses, suicidality and resilience are negatively correlated, while there is no correlation in the groups of administrative workers and students (Table ). In the group of oncology nurse’s resilience and suicidality are negatively correlated (ρ = − 0.375, p = 0.001), i.e. greater resilience reduces the occurrence of suicidality. In the group of non-oncology nurses, resilience and suicidality are negatively correlated (ρ = − 0.306, p = 0.008), i.e. greater resilience reduces the occurrence of suicidality. In the group of oncology nurses, suicidality is not correlated with personal accomplishment, emotional exhaustion and depersonalization. In the group of non-oncology nurses, suicidality and personal accomplishment are negatively correlated (ρ = − 0.326, p = 0.005), and suicidality and emotional exhaustion are positively correlated (ρ = 0.311, p = 0.007), as well as suicidality and depersonalization (ρ = 0.270, p = 0.020) (Table ). Our results show that in the population of administrative workers, suicidality and professional efficacy are negatively correlated (ρ = − 0.296, p = 0.012), and suicidality and exhaustion are positively correlated (ρ = 0.236, p = 0.048). In the student population, suicidality and cynicism are positively correlated (ρ = 0.351, p = 0.003) (Table ). 

The aim of this work was to examine if suicidality is connected with resilience and burnout in the population of nurses, nursing students and administrative workers and to determinate if oncology nurses differ from other groups. Secondary school education, dissatisfaction with socio-economic status and active working on going abroad are the factors connected with higher level of suicidality in total sample. Family relations satisfaction, growth opportunities at work and lack of sleep problems correlate with lower levels of suicidality. Respondents who were very dissatisfied with the patient behavior towards them had lower level of suicidality compared to other respondents. One of the possible reasons for this might be that those respondents are better in recognizing and understanding negative emotions and are not prone to suppressing negative experiences which can further lead to better personal mental health strategies. Our results also showed that respondents who are very dissatisfied with their socio-economic status have twice as lower level of suicidality than those who are ‘only’ dissatisfied. Considering that socio-economic status is a subjective category, the reason for this result might lie in personal/individual differences and other subjective factors. Previous researches confirmed the influence of various personal, demographic and social factors on suicidality. One study from Turkey found that the female gender, psychological distress and history of suicide attempt are connected to increased risk of suicide, while age, positive perception of God, self-esteem and positive communication with parents-which speaks in favor of family relations satisfaction as in our study, decreased the risk . According to Bakken and coworkers, less emotion-orientated coping, greater levels of physical activity, higher self-perception and higher school wellbeing were considered to be protective factors for suicidal ideations, while higher family function and secure attachment were protective factors for women . Madigan and Daly explain the link between subjective socioeconomic status and suicidality: the authors report 51% of the relationship between socioeconomic status and suicidal ideation, and 37% of the link between socioeconomic status and suicide attempts on average . Our research found that in the population of oncology nurses, resilience and suicidality are correlated - greater resilience reduces the occurrence of suicidality. This relationship was also proven in the population of non-oncology nurses, while the link was not found in the populations of students and administrative workers. Oncology nurses do not seem to differ from non-oncology nurses, but both of these groups are different from other two groups. The reasons for this can be seen in the specifics of the nursing profession, certain working conditions, the fact that our research was conducted during the COVID-19 pandemic, which significantly affected the functioning of the health system. Also, the group of students is significantly younger than the other control groups, while the population of administrative workers performs the office tasks during the day shift, which is certainly differs from work performed by the nurses, who often bear responsibility for other people’s lives. Searching the available databases, we haven’t found researches that directly addressed the relationship between suicidality and resilience in same study population. However, researches pointed out that trust in information and resilience were significant factors contributing to mental health outcomes, including suicidal thoughts, among outpatients, healthcare workers and the general population during the COVID-19 pandemic. They stated that special attention should be paid to nurses, who seem to bear a disproportionate share of the psychological burden . Another research group studied a population of German nurses. The research was conducted during the COVID-19 pandemic. It found that resilience significantly reduces feelings such as of hopelessness, depression, anxiety, agitation, stress, and perceived frustration. The same study found that nearly half of subjects had suicidal thoughts during the past four weeks . Although the link between suicidality and resilience has not been directly investigated, this research raises the question of potential consideration of this link, which favor the importance of our results. Searching the available literature, no research that studied the relationship between resilience and suicidality in Serbia or the countries of Balkans region was found. On the other side, the relationship between resilience and suicidality was investigated in other part of the World. For example, one study conducted in a population of Korean workers aged 18 to 63 found that a high level of resilience was associated with a low frequency of suicidal ideation. The same research found no link between resilience and suicide planning and attempts. Considering the results, these authors emphasize the necessity of developing new strategies for strengthening resilience at work and overcoming stress, in order to prevent the emergence of suicidal ideas in the population of workers . It should be noted that our research also recognized the importance of the resilience of specific professional groups, related to working conditions. The association between resilience and social engagement and initial severe suicidal ideation associated with PTSD was investigated in a cohort of US veterans. The study concluded that psychological resilience and social engagement helped to mitigate suicidal thoughts in this population . Another study conducted in Australia examined the association between resilience and suicidality across the lifespan, in the general population. The results showed that low resilience is associated with suicide risk. In addition, the resilience was associated with suicidality at all ages, but only those in middle age continued to report an increased likelihood of suicidality in fully adjusted models . The Nigerian authors conducted a study in a population of 505 students from three universities in southern part of their country. The study reported that psychological resilience was significantly and negatively associated with suicidal ideation, while academic stress was positively associated with suicidal ideation. On the other hand, our results did not prove the significant correlations in the student population, which can be explained by cultural factors, the difference in sample size, and the difference of study designs . We haven’t found the link between the dimension’s suicidality and burnout in the population of oncology nurses, in contrast to all other groups. Such results may seem confusing and unexpected, and therefore their interpretation requires a deeper analysis. In the group of non-oncology nurses, we found a positive correlation between suicidality and depersonalization and emotional exhaustion and a negative correlation between suicidality and personal accomplishment. Research conducted in the population of Spanish primary care nurses established a relationship between suicidal risk and professional burnout, i.e. the dimensions of emotional exhaustion and personal accomplishment, which to some extent corresponds to our results . The relationship between suicidality and burnout was also the subject of the research conducted in a population of nurses in Bangladesh. This study found that burnout in this population is significantly related to suicidality . In addition, Taiwanese researchers found an association between a high degree of burnout and suicidal thoughts in a population of nurses, in the context of the psychological environment at work . Our study showed that in the nursing student population, suicidality and cynicism are positively correlated. Cynicism describes indifference or detachment of individuals in relation to their work and is not necessarily related to working with people. Given that loss of interest and lack of interest may be one of the indicators of tendency towards depression, this relationship should be further investigated. In this regard, it is important to pay particular attention to specific working conditions and determine whether and in what way they affect the individual capacities of nursing students. One study conducted in the population of dental students attempted to determine the relationship between suicidality, depression, and professional burnout. The results showed that in this population a statistically significant relationship was observed between the dimension of personal accomplishment and suicidality . There is the evidence that high rates of burnout may be related to the occurrence of suicidal ideation in medical students . Contrary to this, a group of researchers who conducted a study among students of Tehran University of Medical Sciences concluded that hopelessness, loneliness and stress were factors independently associated with increased odds of suicidal ideation among students, while burnout was not an independent factor associated with suicidality . Our results showed a negative correlation suicidality and professional efficacy was, as well as a positive correlation between suicidality and exhaustion, in the population of administrative workers. The influence of occupational factors on suicidality is a phenomenon that we encounter within different occupational group. The importance of emotional exhaustion in the group of non-oncology nurses, regardless of various factors of professional settings has also been recognized. When it comes to our research, both oncology and non-oncology nurses face daily responsibility for other people’s lives, unexpected situations and the need to react urgently. What differentiates work in the oncology departments from work in the other departments is the fact that deaths are more common, and palliative care services are often practiced. The work of oncology nurses is also related to the provision of mental health services, counseling and psychological empowerment, but contrary to psychiatric nurses, it is not their specialty. The need for additional education of nurses in this segment is also recognized by other authors. The high prevalence of depression in oncology patients means that the medical staff working with such patients must understand and follow the processes related to access, screening and non-pharmacological treatment of depression . Provision of such services requires a high degree of self-awareness, good emotional control, psychological stability, composure and responsibility at all times during working hours. Oncology care is often performed in the last moments of patient’s life, when people are approaching the death, and the prognosis for recovery and improvement of health condition are minimal. In this sense, we cannot talk about sudden and unexpected outcomes, which can be the case in other departments as well. Also, in such an environment, professionals are more often forced to develop individual protective strategies and incorporate them into daily practice. This leads to usage of four protective strategies: proactive coping, which refers to practicing activities to control emotions and increase self-confidence, coping based on self-awareness and self-protection, coping in terms of self-transformation, which focuses on accepting limiting factors, and finally, finding of deep professional importance . Therefore, specific working conditions and the necessity of developing individual protective mechanisms as a response to the consequences of burnout, in order to function adequately in the work environment, must be taken into account when we talk about the absence of a connection between suicidality and burnout among the oncology nurses. First limitation of our study is in relevant, but relatively small sample size of groups, which can lead to limited generalizability. Another limitation lies in the fact that in this study, we separated oncology nurses from non-oncology nurses, focusing on specificities of oncology care. The group of non-oncology nurses contains of nurses of more than one specialty, so the role of each specialty is unclear. Also, we used cross-sectional design which makes it difficult to establish causality. However, based on the search of the available scientific literature, a single study that dealt with the issues of suicidality, resilience and burnout in Serbia was not found altogether. The number of similar studies conducted in the world is very small, they are focused on different populations and different instruments are used, which makes it somewhat difficult to compare the results. Nevertheless, this fact reveals the importance of our study itself, as it represents a good starting point for new researches and to some extent clarifies the issue of suicidality in the examined populations. Future studies should include larger sample, other medical professional groups such as physicians, longitudinal design to assess changes in suicidality, resilience and burnout over time, as well as qualitative studies to explore the lived experiences of studied population in greater depth. 

In the population of oncology nurses there is a statistically significant connection between resilience and suicidality, greater resilience reduces suicidality. The same correlation was proven in the control group of non-oncology nurses, which speaks in favor of the importance of strengthening the resilience of employees in the healthcare sector, through various programs and trainings. Yet, our research did not show a relationship between suicidality and occupational burnout according to the Maslach scale in the oncology nurses, but it did in all other groups, which speaks in favor of the work specificities in oncology departments and opens up space for new researches. Based on our results, we emphasize importance of practical resilience trainings in nursing profession and continuous education which covers suicidality issues in order to strengthen resilience and lower suicidality among both groups of nurses. Oncology nurses should be especially guided. Nursing schools should provide their students lectures on suicidality risk and protective factors in the light of future workplace setting. In order to prevent suicidality, public health policies should include burnout prevention strategies not only in a relation to healthcare workers, but also the general population. 

