## Abstract

Direct support professionals (DSPs) are instrumental to the daily operations of organizations that support people with intellectual and developmental disabilities (IDD). With extensive responsibilities, DSPs often experience high levels of stress and burnout that can result in turnover and vacant positions. Self-care is the practice of behaviors that promote well-being, counter work-related stress, and foster resilience. The current study explored self-care and resilience, and their relationship with professional quality of life (i.e., satisfaction, burnout, and secondary traumatic stress) among DSPs. Using a convenient sample, 153 DSPs (71% female) completed an online survey comprised of multiple measures. Results indicated that DSPs often engaged in self-care behaviors across physical, psychological, emotional, spiritual, relational, and workplace domains, however, less than 40% engaged in self-care behaviors directly related to work. On average, DSPs reported high levels of resilience. Collectively, self-care and resilience accounted for 12% to 28% of variance in DSPs' professional quality of life. Given the contribution of self-care to resilience and professional quality of life, an active approach by IDD organizations to foster self-care among DSPs may help promote their longevity and retention.

Direct support professionals (DSPs) are the “most costly and valuable resource” for organizations supporting individuals with intellectual and developmental disabilities (IDD; Devereux et al., 2009, p.561). They are paid personnel who provide one-on-one support to individuals across a myriad of environments, including residential, day, employment, and community settings. Although the DSP position frequently has minimal education requirements (i.e., high school diploma or its equivalent), DSPs have extensive responsibilities: (a) to meet individuals' basic health, safety, and care needs; (b) to support the development and achievement of individuals' personal goals and relationships; and (c) to support individuals in becoming active community participants (Bogenschutz et al., 2014; Hewitt & Larson, 2007).

Given the scope of responsibilities, stress and burnout are common among DSPs and present a significant risk to the quality of services for individuals (Chung & Harding, 2009; Devereux et al., 2009; Lernihan & Sweeney, 2010). Despite vast knowledge regarding burnout, additional attention is warranted regarding positive aspects of DSP experiences (Lunsky et al., 2014) and strategies to combat burnout. The present study explores self-care behaviors among DSPs and seeks to understand the relationship between self-care behaviors and professional quality of life, a construct that includes burnout, secondary traumatic stress, and compassion satisfaction (Stamm, 2010). Furthermore, this study seeks to understand the influence of resilience on the relationship between self-care and professional quality of life, which may be instrumental in buffering the impact of work-related stress.

### Stress and Burnout

Direct support professionals experience high rates of stress, burnout, and emotional exhaustion amid a low sense of personal accomplishment, dissatisfaction with compensation and opportunities for advancement, and feelings of underbenefit (Disley et al., 2009; Hensel et al., 2012; Skirrow & Hatton, 2007; Tartakovsky et al., 2013). Stress and burnout can have a significant negative impact on service delivery, either indirectly through (a) high staff sickness and poor mental health (e.g., depression and anxiety); (b) reduced job satisfaction and commitment, absenteeism, and turnover; or (c) directly through a reduction in positive interactions between staff and individuals (Devereux et al., 2009; Mutkins et al., 2011; Skirrow & Hatton, 2007; Willems et al., 2010). As requirements for DSP employment have remained stagnant amid increased responsibilities, organizations contend with annual turnover rates ranging from 45%–70% (Bogenschutz et al., 2014; Braddock et al., 2011; Schuengel et al., 2010). High turnover and the inability to hire qualified employees often result in recurrent job vacancies and increased organizational strain such as additional responsibilities for remaining DSPs and disrupted services for individuals with IDD (Hamilton et al., 2005; Larson et al., 2004).

There is a lack of clarity regarding which aspects of direct support work are most stressful (Mutkins et al., 2011), however, various factors have been related to stress and burnout, including (a) personal characteristics (i.e., coping strategies, personality type, perceived inability to make a difference and work-private conflict), (b) work conditions (i.e., excessive workload, understaffing, lack of collaboration; lack of support from colleagues and management, inadequate training and role ambiguity; lack of influences on administrative decisions), and (c) the nature of the job (e.g., individuals' challenging behaviors; minimal employment requirements; low pay and low status; Chung & Harding, 2009; Hewitt et al., 2008; Kowalski et al., 2010; Mills & Rose, 2011; Mutkins et al, 2011; Skirrow & Hatton, 2007; Sondenaa et al., 2015; Thompson & Rose, 2011). Given that many aspects of direct care work are influenced by external factors, there is opportunity to consider the utility and implications of more individualized and internal resources such as self-care and resilience to buffer the impact of the work environment and to augment one's perspective of their work. Self-care and resilience will be explored later in this article.

### Professional Quality of Life

Some researchers in the IDD field have called for greater emphasis on positive aspects of direct support work (Lunsky et al., 2014). Stamm (2010) put forth a model and measure for professional quality of life (ProQOL) that encompasses positive and negative outcomes of work experiences in helping professions: compassion satisfaction and compassion fatigue (Lawson & Myers, 2011; Stamm, 2010). The construct of ProQOL has utility in understanding the experiences of DSPs as it expands upon burnout. Furthermore, it responds to the call for a greater emphasis on positive experiences through a measure of compassion satisfaction.

Compassion satisfaction reflects the degree to which a person derives benefit, pleasure and satisfaction from helping others. It is associated with overall wellness, job satisfaction, invigoration, and belief that one can contribute to their workplace and society (Lawson & Myers, 2011; Stamm, 2010; Zeidner & Hadar, 2014). In contrast, compassion fatigue is comprised of two subscales: burnout and secondary traumatic stress. With empathy and emotional energy as driving forces in effective service delivery (Figley, 2002; Stamm, 2010), burnout is the result of chronic strain associated with insufficient resources, unclear professional boundaries and roles, employee relational challenges, and excessive work demands (Lawson & Myers, 2011; Yan & Beder, 2010). Burnout manifests in increased anger, frustration, rigidity, poor job performance, tardiness, and absenteeism (Bridgeman et al., 2018; Newell & MacNeil, 2010). Secondary traumatic stress results from indirect exposure to trauma and is a sudden adverse reaction to helping or wanting to help someone who has experienced trauma (Bride et al., 2007). Secondary traumatic stress is characterized by re-experiencing the person's traumatic event, avoidance of reminders and numbing, and hyper-arousal (Bride et al., 2007). It negatively influences both the wellbeing of the worker and the quality of care received by the client (Bloomquist et al., 2015).

As previously stated, the ProQOL measure was developed for use among helping professions, yet it has rarely been used in the field of disabilities (Booker et al., 2013; Sondenaa et al., 2015). When it has been used among workers in the disability field, research findings are limited by the lack of population specificity (i.e., type of disability services; Booker et al., 2013) and potential regional differences (i.e., Norway and nursing staff; Sondenaa et al., 2013, 2015). However, limited use of the ProQOL in IDD research may be influenced by the measure's sensitivity to trauma, an area that has only recently emerged in the IDD field (Keesler, 2018; Wigham et al., 2011). Thus, when considering compassion fatigue, it is unclear the extent to which DSPs may experience secondary traumatic stress, however, DSPs do have experiences that are often at the root of secondary traumatic stress. Research suggests that DSPs are exposed to violence in the workplace and have their own adverse histories (Hensel et al., 2012; Keesler, 2018). In addition, DSPs have access to individuals' documented histories and may be involved with organizational investigations of abuse. Documentation and investigations may involve exposure to details of traumatic experiences—a precipitant to the development of secondary traumatic stress (Bride et al., 2007).

### Self-Care

Research has identified a relationship between self-care and professional quality of life, with poor self-care associated with greater compassion fatigue (Butler et al., 2017; Figley, 1995). Self-care is the practice of behaviors that promote well-being and counter work-related stress among the helping professions (Lee & Miller, 2013). Self-care ensures that the fundamental needs of a person are met, such as food and sleep, and enables one's ability to respond to conflict, overcome challenges, and cope more effectively with stress (Barker, 2010). With the impact of burnout well-cited (e.g., Lawson & Meyers, 2011), self-care is a “critical issue” as organizations seek new ways to foster employee retention amid growing demands to do more with less (Lee & Miller, 2013, p. 96).

The purpose and conceptualization of self-care differs across the literature. For example, in the medical field, self-care developed in response to a neglect of basic needs among providers in favor of focusing on patient treatment (Lauder, 2001), whereas in nursing self-care embraces a holistic approach to wellness and the acquisition of health-promoting behaviors (Denyes et al., 2001). Barker (2010) and Lee and Miller (2013) provide two conceptualizations of self-care, both suggesting two different domains. Barker (2010) defined self-care as a combination of reflective (i.e., focusing on a specific conflict or how one is being) and kind (i.e., soothing or nurturing practices) behaviors and suggested that a balance was important to foster positive interactions with others. Lee and Miller (2013) identified a conceptual framework for self-care comprised of personal (i.e., physical, psychological, emotional, social, leisure, and spiritual dimensions) and professional (i.e., work-related dimensions such as time management, role, professional support, and professional development) dimensions.

Self-care has been explored among various helping professions, including counselors, social workers, and childcare workers. It has been associated with increased compassion satisfaction and wellness, and lower levels of burnout and secondary traumatic stress (Bloomquist et al., 2015; Lawson, 2007; Lawson & Myers, 2011). Results have shown that behaviors such as a hobby, taking trips or a vacation, feeling supported outside of work, and reading for pleasure are associated with lower compassion fatigue (Eastwood & Ecklund, 2008).

Self-care is most effective when practiced “proactively and intentionally” (Lee & Miller, 2013, p. 98), and is reinforced by self-awareness and a positive perspective of self-care such that those who hold a favorable view of self-care engage in self-care and intentionally allocate time to self-care (Bloomquist et al., 2015; Devenish-Meares, 2015; Eastwood & Ecklund, 2008; Lawson & Meyers, 2011; Orellana-Rios et al., 2018). Although employees may not independently or routinely engage in self-care, research has demonstrated the efficacy of work-based programs in promoting employee self-care. For example, Orellana-Rios et al., (2018) implemented a 10-week compassion-based meditation program for palliative care providers. The program was well-received and resulted in improved self-care and interpersonal skills with reductions in stress, anxiety, and burnout, and increased job satisfaction (Orellana-Rios et al., 2018).

### Resilience

Resilience, as a correlate of self-care (Rees et al., 2016; Sondenaa et al., 2015), has merit in the discussion of DSP retention and job satisfaction, yet it has been largely absent from the IDD literature. Resilience is a dynamic and multidimensional construct, influenced by individual, biological, cognitive and interpersonal factors, that refers to the adaptive ability to withstand adversity and stress (Foureur et al., 2013; Poole et al., 2017). It buffers the effects of stressful situations and lends to the experience of positive emotions amid adversity (Masten, 2001; Poole et al., 2017; Tugade & Fredrickson, 2004).

There is a dearth of research focusing on resilience among DSPs. Noone and Hastings (2009) explored the efficacy of a brief intervention to combat work stress and promote resilience among DSPs. The 2-day training focused on the impact of negative thoughts and emotions, coping strategies and avoidance reduction, and how to be mindful. A booster session was provided several weeks later. The training was associated with a significant reduction in DSPs' psychological distress, despite a small increase in perceived work stressors (Noone & Hastings, 2009). Noone and Hastings (2009) suggested that if DSPs can develop greater resilience and increase capacity to cope effectively with stress, they are likely to show more positive interactions with the individuals they support.

To augment the discussion of resilience, it is necessary to consult the literature from related fields. Among college students, resilience has been correlated with self-esteem, self-care, self-efficacy, and lower levels of anxiety (Bender & Ingram, 2018; DeRosier et al., 2013). Among nurses, resilience—characterized by personal strength, the ability to plan, sociability, and social resources—has been associated with increased quality of patient care and greater respect for clients (Williams et al., 2016). Further, increased resilience has been associated with positive coping strategies among nurses, as well as increased compassion satisfaction, decreased burnout, and decreased secondary traumatic stress (Hegney et al., 2015; Rees et al., 2016).

Research has demonstrated the efficacy of trainings to increase resilience, as was similarly noted with self-care. Foureur and colleagues (2013) explored the implications of a mindfulness-based stress reduction program for nurses and midwives. Comprised of a 1-day training and daily meditation practices for 8 weeks, the program was associated with significant improvements in general health and ability to cope with stress, as well as decreased self-reported stress. Similarly, Slatyer, Craigie, Heritage, et al. (2018) conducted a controlled trial with nurses to determine the impact of a resiliency training. The brief mindful self-care and resiliency (MSCR) intervention consisted of a 1-day training followed by three weekly mindfulness exercises and home-based practice exercises. Nurses who participated in the training experienced a significant decrease in burnout with small-to-moderate effect that persisted 6 months after the intervention. In addition, the nurses experienced increased compassion satisfaction and quality of life.

### Purpose

DSPs are critical to the quality of life for many individuals with IDD, yet organizations continue to struggle with their recruitment and retention amid various systemic challenges. Additional and alternative methods are needed to increase organizational capacity and to respond to the ongoing and historic challenges with DSP turnover. The present study is a preliminary effort to explore self-care behaviors among DSPs and the relationship between self-care, resilience, and professional quality of life. More specifically, the research sought to answer the following questions: (a) In what self-care behaviors do DSPs engage? (b) How is self-care related to DSPs' professional quality of life? (c) If there is a relationship between self-care and professional quality of life, does resilience moderate this relationship?

## Methodology

### Overview

The present study was conducted in a not-for-profit agency in a midwestern state in the United States. The agency provides supports to over 2,000 individuals with IDD and their families through residential programs, employment and day services, as well as outpatient psychiatric and other clinical services. The agency has an operating budget of approximately $21.5 million with approximately 50% of its income generated from the HCBS waiver. The agency has an estimated annual turnover rate of 60%. At the time of this study, the primary researcher was developing a relationship with this community agency. The agency's director of human resources assisted the researcher by creating an online survey using an internal electronic platform. The online survey included information for informed consent and multiple measures, including demographic items, self-care behaviors, resilience, and professional quality of life. The survey was comprised of 108 items and took approximately 15–20 min to complete. After review by the researcher's university institutional review board and the agency's human subjects review board, the survey link was emailed to 392 employees, including residential site managers, whose jobs were categorized as DSPs. Respondents were eligible to receive a$5 e-gift card as an incentive and were prompted to provide their contact information via a separate link at the end of the survey to ensure anonymity of responses. Recruitment lasted for approximately two months during which time a recruitment email with the survey link was sent a total of four times. The results of the study are from 153 DSPs and represent a 39% response rate.

### Measurement

#### Demographics

Several items were constructed by the primary researcher to query respondents' demographic information, including gender, level of education, and length of time as a DSP. Demographic items were limited (e.g. ethnicity was not solicited) to protect the identity of respondents given the lack of diversity in the organization.

#### Self-Care Behaviors

Self-care behaviors were assessed using an adaptation of the Self-Care Assessment (Saakvitne & Pearlman, 1996). It is comprised of 71 items across seven domains (i.e., physical, psychological, emotional, spiritual, relational, workplace, and overall balance) and an additional “other” option after five of the domains (i.e., physical through relational) which afforded respondents the opportunity to identify any behaviors in which they engaged that were not included on the measure. Examples of items include “get regular medical attention,” “say no to extra responsibilities,” “read/listen to inspirational material,” and “ask for help when I need it.” Items are scored using a Likert-type scale ranging from I never do this (1) to I do this a lot (5). No psychometric properties are available on this measurement. For the present study, two items (i.e., be curious and access psychotherapy) from the psychological domain were omitted by error from the online survey and the “other” option was presented only once after all items were listed in the current survey to decrease repetition. Domains were not specified in the online survey to avoid potentially influencing responses.

Scores were calculated for each domain using the mean of individual item scores. Domain scores were moderately (r = .541, p < .001) to strongly (r = .741, p < .001) correlated. Given the preliminary nature of this study and the number of self-care behaviors, principal component analysis was used to assess the viability of data reduction and resulted in a scree plot suggesting one or two factors. Thus, a composite self-care score was calculated from the mean of all items on the measure. Preliminary evidence indicates strong reliability (α = .96), however limitations of Cronbach's alpha are noted (Agbo, 2014).

#### Resilience

Resilience was measured using the Response to Stressful Experiences Scale-4 (RSES-4; De La Rosa et al., 2016). This 4-item instrument is a brief version of a 22-item instrument with preliminary psychometric testing supporting its validity and reliability (α = 0.877). With a lead-in statement of “During and after life's most stressful events…” the four items include: “I tend to find a way to do what's necessary to carry on.”; “I tend to know I will bounce back.”; “I tend to learn important and useful life lessons.”; and, “I tend to practice ways to handle it better next time.” Likert-type scaled responses range from 1 not at all like me to 5 exactly like me. Reliability for the RSES-4 in the present study was acceptable (α = 0.788).

#### Professional Quality of Life

The Professional Quality of Life (ProQOL) is a manualized instrument comprised of 30 items across three subscales: (a) compassion satisfaction (CS; i.e., the pleasure one derives from work), (b) burnout (BO; i.e., exhaustion, frustration, anger and depression), and (c) secondary traumatic stress (STS; i.e., negative feelings driven by fear and work-related trauma; Stamm, 2010). The latter two subscales comprise compassion fatigue. Each subscale is comprised of 10 items with a total of five reverse scored items. Items are scored using a Likert-type scale ranging from never (1) to very often (5). Examples of items include: “I am preoccupied with more than one person I help” and “I jump or am startled by unexpected sounds.” Five items are reverse scored. Each subscale has a mean of 50 and a standard deviation of 10, with acceptable reliabilities (CS: α = .88; BO: α = .75; and, STS: α = .81). The measure has demonstrated good construct validity with each scale measuring separate constructs. However, the BO and STS subscales have shared variance of 34% (r = .58). For the present study, subscale scores were computed according to the manual (i.e., the sum of scores for items on each subscale are converted to z scores and then to t scores; Stamm, 2010). Reliability of the scales using data from the present study were acceptable (CS: α = .93; BO: α = .80; and, STS: α = .83).

### Data Analysis

All data were analyzed using IBM SPSS Statistics 25. All respondents completed the survey in its entirety with no missing data. Univariate analyses of demographics, self-care behaviors, resilience, and ProQOL subscale scores (i.e., CS, BO, and STS) included frequencies and measures of central tendency. Bivariate analyses included correlations among mean self-care, mean resilience, and ProQOL subscale scores.

After ruling out any possible multicollinearity between variables, a series of analyses were conducted to investigate if resilience mediated the relationship between self-care and professional quality of life. Generally, mediation is thought to occur when the effects of the independent variable (i.e., self-care) on the dependent variable (i.e., professional quality of life) decreases when a control variable (i.e., resilience) is added to the regression model. The authors followed the analytic procedures recommended by Baron and Kenny (1986) to examine this relationship. First, a regression analyses was conducted to analyze the effect of self-care behavior on resilience. Next, hierarchical regression analyses were conducted to examine the mediating effects of resilience on DSPs' professional quality of life. Three models were estimated to account for each ProQOL subscale (i.e., CS, BO, and STS). The accuracy of the mediation effect was further tested using R 3.4.3 using sem() function in the lavaan package for mediation analysis (Rosseel, 2012). The Sobel test was used to test the significance of any mediation effects, that is, to determine if the reduction in the effect of the self-care, after including resilience, is a significant reduction (Sobel, 1982).

## Results

### Demographics

The total sample was comprised of 153 DSPs. Demographic information is displayed in Table 1. Respondents were predominantly women (71.2%) with an average age of 36.4 years old (SD = .483). Most had less than a 2-year college degree (68%) and had been working as a DSP for at least 1 year (72.9%).

Table 1

Demographics

### Self-Care Behavior

Self-care behaviors are described in Table 2. Percentages reflect DSPs who rated each behavior as a 4 frequently or 5 a lot. On average, DSPs engaged in 25 behaviors (M = 24.96, SD = 14.64), and ranged from one to 60 behaviors across the physical, psychological, emotional, spiritual, relational, and workplace domains. Fifteen self-care behaviors were endorsed by more than one half of DSPs, including (a) wearing preferred clothing (71.2%), (b) finding things that make them laugh (63.4%), (c) identifying what is meaningful to self (63.4%), (d) staying in contact with others (62.7%), (e) being aware of nonmaterial aspects of life (60.8%), (f) spending time with pets (58.2%), (g) setting limits with clients and colleagues (58.2%), (h) singing (56.9%), (i) spending time with others (56.2%), (j) listening to one's self (55.6%), (k) being open to not knowing (54.9%), (l) being open to inspiration (53.6%), (m) cherishing optimism (51.6%), (n) getting needed medical care (51.0%), and (o) calling or visiting relatives (50.3%). The largest number of behaviors (n = 6) are within the spiritual domain. When considering self-care behaviors related to work or those behaviors that have the potential to impact the workday, less than one half of DSPs indicated that they (a) get enough sleep (37.9%), (b) ask for help when it is needed (31.4%), (c) get regular supervision (24.8%), (d) take a break during the work day (21.6%), (e) take time off when sick (20.3%), (f) take vacations (16.3%), and (g) say no to extra responsibilities (17.0%).

Table 2

Self-Care Behaviors Among Direct Support Providers

In addition, means and standard deviations are presented in Table 2 for each self-care domain. The mean is the sum of scores for each behavior (i.e., 1–5) divided by the total number of behaviors in the domain. The means ranged from 2.86 (SD = .69) in the relationship domain to 3.31 (SD = .79) in the spiritual domain. The mean score for striving to balance work responsibilities during the work day and work life with personal life was 3.44 (SD = .99). Thus, on average, DSPs occasionally to frequently seek a balance in their life.

### Resilience

The mean resilience score was calculated from the sum of scores for each item divided by the total number of items on the scale. The mean resilience score for DSPs was M = 4.14 (SD = .64), thus suggesting that DSPs believed that the items were very consistent with their practices. A statistically significant positive correlation was noted between resilience and self-care (r = .34, p < .01).

### Professional Quality of Life

The compassion satisfaction (CS), burnout (BO), and secondary traumatic stress (STS) scores were standardized (M = 50; SD = 10) according to the manual (Stamm, 2010). The range of scores, as well as percentages for DSPs in lower and upper quartiles, for each subscale are presented in Table 3. Although 28.8% of DSPs derive considerable satisfaction from their work, 26.8% of DSPs identified feelings of burnout and 23.7% of DSPs identified concerns related to secondary traumatic stress.

Table 3

Professional Quality of Life

Correlations between ProQOL subscale scores, self-care, and resilience are displayed in Table 4. All correlations were statistically significant (p < .01). Compassion satisfaction was positively correlated with self-care (r = .35) and resilience (r = .49). In contrast, BO and STS were negatively correlated with self-care and resilience.

Table 4

Correlations Among Self-Care, Resilience, and Professional Quality of Life

### Mediation Analyses

The initial step of mediation analyzed the effect of self-care on resilience. Self-care significantly predicted resilience, β = .36, t(151) = 4.49, p < .001, and explained a significant proportion of variance in resilience, R2 = .12, F(1, 151) = 20.14, p < .001. Next, hierarchical regression analyses were conducted to ascertain if the relationship between self-care and each ProQOL subscale (i.e., CS, BO, and STS) was mediated by resilience. The mediation models are displayed in Figure 1.

Figure 1

Mediation Models for Self-Care and Professional Quality of Life (ProQOL). The above figure depicts the mediation models for self-care and the three subscales of ProQOL, incorporating resilience as a mechanism. In the paths from self-care to each of the ProQOL subscales, the first coefficient represents the direct path (a); the coefficient in parentheses represents the relationship once the indirect path is added to the model. **p < .01. ***p < .001.

Figure 1

Mediation Models for Self-Care and Professional Quality of Life (ProQOL). The above figure depicts the mediation models for self-care and the three subscales of ProQOL, incorporating resilience as a mechanism. In the paths from self-care to each of the ProQOL subscales, the first coefficient represents the direct path (a); the coefficient in parentheses represents the relationship once the indirect path is added to the model. **p < .01. ***p < .001.

The analyses for CS are displayed in Table 5. Model 1a indicates that self-care is significantly associated with higher CS (p < .001). Model 1b indicates that resilience mediated the effects of self-care on CS (p < .001). The results of the Sobel test indicate that the association between CS and self-care is significantly mediated by resilience with the indirect effect of 2.381 (z = 3.550, p < .001). The direct effect of self-care, however, is still significant (z = 2.870 and p < .01). Thus, resilience is a partial mediator. The results indicate the two predictors, self-care and resilience, explained 28% of the variance in CS scores.

Table 5

Hierarchical Regression Predicting Compassion Satisfaction (CS)

The analyses for BO are displayed in Table 6. Model 2a indicates that self-care is significantly associated with lower BO (p < .001). Model 2b indicates that resilience mediated the effects of self-care on BO (p < .001). The results of the Sobel test indicate that the association between BO and self-care is significantly mediated by resilience with the indirect effect of −1.549 (z = −2.883, p < .01). The direct effect of self-care, however, is still significant (z = −5.134, p < 0.001). Thus, resilience is a partial mediator. The result indicates the two predictors, self-care and resilience, explained 28% of the variance in BO scores.

Table 6

Hierarchical Regression Predicting Burnout (BO)

The analyses for STS are displayed in Table 7. Model 3a indicates that self-care is significantly associated with lower STS (p < .01). Model 3b indicates that resilience mediated the effects of self-care on STS (p < .01). The results of the Sobel test indicate that the association between STS and self-care is significantly mediated by resilience with the indirect effect of −1.556 (z = −2.713, p < .01). The direct effect of self-care is not significant (z = −1.697, p > .05). Thus, resilience is a full mediator. The result indicates the two predictors, self-care and resilience, explained 12% of the variance in STS scores.

Table 7

Hierarchical Regression Predicting Secondary Traumatic Stress (STS)

## Discussion

To the authors' knowledge, this is the first study to explore and describe self-care behaviors, and the relationship of self-care to DSPs' professional quality of life. Findings suggest considerable variability and frequency in self-care behaviors among DSPs. Spiritual behaviors were among the most prevalent self-care strategies. It can be argued that many of the behaviors identified in the spiritual domain are of critical importance to the nature of DSP work. For example, being open to not knowing and being hopeful might translate into greater patience when working with individuals with IDD who exhibit challenging behavior or who might struggle to achieve their goals. A sense of optimism, an additional behavior within the spiritual domain, might sustain DSPs and provide them with a different lens through which to interpret work experiences. Chang and Chan (2015) noted that nurses who were more optimistic reported less burnout. Optimism was associated with greater likelihood of utilizing resources to contend with stress and less vulnerability to the impact of stress.

DSPs least often endorsed getting supervision, taking a break, taking time off when ill, and declining additional responsibilities—factors that are directly related to work experiences. It is possible that supervision was not readily available for DSPs (AAIDD, 2016). Further, a growing number of DSPs work by themselves in family and individual homes, with increased distance from other DSPs or managers who, in other settings like group homes or day programs, might otherwise be able to provide support (Braddock et al., 2017). In addition, DSPs frequently fill the gaps created by vacant positions (Bogenschutz et al., 2014). Requests from management to fill open shifts and DSPs' commitment to the individuals might compromise or limit opportunities to take time off or a break during their shift. Such considerations provide a broader contextualization for the lack of engagement in work-related self-care among DSPs in the current study.

As previously discussed, burnout results from an imbalance between an employee and the demands of work and can have significant implications for one's professional and personal life (Lawson & Myers, 2011). Lack of supervision and support, taking on additional responsibilities, and the lack of personal resources have the potential to result in increased burnout and turnover (Willems et al., 2010). Self-care is one strategy to increase personal resources, promote a sense of agency in managing stress, and an opportunity for DSPs to take “ownership of their health and well-being holistically…[in their] personal and professional lives” (Lee & Miller, 2013, p. 96). However, research has highlighted the importance of promoting self-care at the organizational level and fostering opportunities for workers to engage in self-care (Lee & Miller, 2013; Orellana-Rios et al., 2018).

The present study highlights the importance of self-care toward wellbeing and buffering the impact of burnout and secondary traumatic stress among DSPs. In the broader literature, research has found a similar relationship between self-care and professional quality of life (Bloomquist et al., 2015; Butler et al., 2017; Figley, 1995; Orellana-Rios et al., 2018). Although self-care contributed to DSP wellness, the relationship between self-care and compassion satisfaction, as well as self-care and burnout, was partially mediated by resilience. Self-care and resilience accounted for 28% of the variance in compassion satisfaction and in burnout. In contrast, the relationship between self-care and secondary traumatic stress was fully mediated by resilience, thus suggesting that the relationship between self-care and secondary traumatic stress was best explained by resilience. Together, self-care and resilience accounted for 12% of the variance in secondary traumatic stress. Although much is known about burnout, there is a dearth of research on secondary traumatic stress among DSPs. With a growing interest in trauma and trauma-informed care in the IDD field (Keesler, 2014; Wigham & Emerson, 2015), secondary traumatic stress is a corresponding area for further inquiry.

The contribution of self-care to professional quality of life is greatest for burnout, and to a lesser degree compassion satisfaction and secondary traumatic stress. From a definitional perspective, this makes sense given that self-care refers to practices and behaviors intended to counter work-related stress and overcome challenges (Barker, 2010; Lee & Miller, 2013). It is likely that self-care contributes to compassion satisfaction such that those who engage in self-care are investing and nourishing themselves. When people take time for themselves, do things that they enjoy, and strive for balance, they are likely to have an increased sense of well-being (Lee & Miller, 2013). Notably, engaging in self-care is both preventative and restorative (Butler et al., 2017).

Secondary traumatic stress, although related to burnout, is specific to indirect exposure to trauma. Although little is known about the prevalence of secondary trauma among DSPs, the present study suggests evidence that warrants further inquiry. Findings indicate that the relationship between self-care and secondary traumatic stress is different from the relationships between self-care and compassion satisfaction or burnout. The relationship between self-care and secondary traumatic stress is best explained by resilience. Resilience is a complex construct influenced by individual, biological, cognitive, and interpersonal factors that not only buffers stress, but also lends to positive emotions amid adversity (Foureur et al., 2013; Poole et al., 2017). It is plausible that as DSPs are indirectly exposed to traumatic experiences, resilience fosters their ability to acknowledge and contain or frame the adversity and have greater optimism. For example, if a DSP is exposed to details regarding the sexual assault of an individual with IDD that they support, resilience could enable the DSP to move beyond the horrific nature of the experience to recognize the assault as a past event, and identify factors to buffer the emotional charge of the event (e.g., individual received treatment; the individual continues to go to work; the DSP can continue supporting the individual, etc.).

Resilience is an important factor to consider in understanding DSPs' ability to withstand stress and burnout, while experiencing greater satisfaction. Because of this, it warrants further consideration. For example, although self-care contributes to resilience, what else bolsters DSPs' resilience? Preliminary research has noted a higher prevalence of early life adversity among DSPs than in the general population (Keesler, 2018). Relevant literature suggests the potential for adversity to contribute to a persons' resilience and ability to thrive, as well as the ability of resilience to contribute to subsequent well-being (Hamby et al., 2018; Höltge et al., 2018; Poole et al., 2017). In the current study, DSPs had relatively high levels of self-reported resilience.

A large body of literature highlights the implications of burnout on DSP turnover and the quality of services for individuals with IDD. Efforts to promote professional quality of life while also fostering resilience to buffer the stress associated with DSP work are very much needed. Initiatives to increase support to DSPs through additional trainings and professionalization of this line of work have been promoted by various national organizations (e.g., The National Alliance for Direct Support Professionals, 2013; National Association for the Dually Diagnosed, 2018). Further, statements have been issued by the American Association of Intellectual and Developmental Disabilities (AAIDD, 2016), as well as the President's Committee for People with Intellectual Disabilities (2017), that highlight factors contributing to the stability of the DSP workforce: (a) low wages and limited benefits, (b) limited training and opportunities for credentialing, and (c) lack of good supervision and organizational support. Although efforts are being made at local, state, and federal levels, each organization is responsible for its workforce and its commitment to adequately serve individuals with IDD. As organizations seek ways to bolster their workforce amid broad systemic challenges, the development of trainings to promote self-care and empower DSPs with opportunities to engage in self-care may be additional strategies to buffer the impact of stress.

It is important for those in helping professions, like DSPs, to be emotionally self-aware. With greater insight, workers can identify when they are getting worn down and increase self-care to avoid worsening fatigue and burnout (Killian, 2008). As such, increased self-awareness has been associated with the search for work-life balance and greater work satisfaction (Lawson, 2007). Historically however, “[the] emotional and psychological risks associate(d) with being a provider…to vulnerable populations and professional self-care in response to these risks have been overlooked issues in…practice, training, and education” (Newell & MacNeil, 2010, p. 58). Newell and MacNeil (2010) noted an association between a lack of knowledge regarding risks of direct practice and the benefits of preventative strategies such as self-care increase the vulnerability of service providers to the impact of adverse outcomes like burnout.

The efficacy of trainings to increase self-care and resilience has been noted in the literature (Foureur et al., 2013; Noone & Hastings, 2009; Orellana-Rios et al., 2018; Slatyer, Craigie, Heritage, et al., 2018). Although increasing resilience is critical given its contribution to professional quality of life, focusing on self-care may be more practical to promote through trainings (Bender & Ingram, 2018). In order to increase the potential success of self-care trainings, it is critical for organizations (a) to understand the importance of self-care to professional quality of life, (b) to foster awareness of self-care among DSPs through education, (c) to promote and reward self-care practices among DSPs, and (d) to provide opportunities for the integration of self-care into daily routines (Foureur et al., 2013; Williams et al., 2016). Trainings need to be accessible and organizations need to proactively strategize staff attendance at workshops and ensure coverage of work shifts (Noone & Hastings, 2009). In addition, when developing self-care trainings, it is important to consider individual and workplace factors (e.g., current practices, organizational culture), as well as work-family conflict, which often compromise a worker's ability to cope (Slatyer, Craigie, Rees, et al., 2018). Foureur and colleagues (2013) noted the collective impact of self-care for the individual worker and the organization: “(t)he potential of staff who engage in self-care…and contexts that enable [self-care]…in day-to-day work, is the building of resilience both for the individuals involved and the workplace in general” (p. 122).

### Limitations

Although the present study provides much needed insight regarding DSPs' self-care and professional quality of life, it is not without limitations. The sample was comprised of DSPs from one agency in the Midwest who work with individuals with IDD across various settings, including day habilitation, community living, employment, and agency group homes. It is possible that the present findings do not generalize to DSPs in other settings (e.g., institutional, for-profit, etc.). Similarly, DSPs' self-care behaviors, resilience, and professional quality of life could reflect unique aspects of the specific agency and local culture. For example, spirituality has been found to be more prevalent in the Midwest than in other regions of the United States (Furman et al., 2004). Perhaps this explains the predominance of self-care behaviors in the spiritual domain.

Across the United Sates, more than 50% of DSPs are people of color, and 33% to 66% have a high school level education (Gray-Stanley & Muramatsu, 2011; Hewitt et al., 2008). Given the potential for increased stress and adversity associated with these demographics, and the importance of recognizing the contribution of cultural diversity, a more diverse sample of DSPs is necessary to fully understand the relationship between self-care, resilience, and professional quality of life. However, a more diverse sample may have implications for measurement. For example, although the ProQOL has been used extensively (Stamm, 2010) with studies supporting its psychometric properties across cultures and its sensitivity to cultural differences (Galiana et al., 2017; Shen et al., 2015), some scholars argue for increased exploration of its cross-cultural utility (Heritage et al., 2018). Similarly, self-care and resilience can be influenced by culture, with resilience often presenting with moral, social, and structural factors (Ikeda et al., 2018; Panter-Brick, 2015). Therefore, the findings of the present study should be considered within the context of the respective culture.

Data analysis did not consider the breadth and depth of various factors that could contribute to DSPs' professional quality of life. It is possible that other factors within DSPs' personal lives and the broader context of IDD service delivery contribute to ProQOL subscale scores. Considerations such as length of work shifts, communication styles, worker maturity, supportiveness of management, and social support have been found to contribute to ProQOL scores (Granek et al, 2017; Khan et al., 2016; Mohsin et al., 2017; Sodeke-Gregson et al., 2013). In addition, the self-care measure used in the present study has multiple dimensions that were collapsed into a single score for data analysis. Although a composite score facilitated analysis, it resulted in the loss of nuances associated with individual self-care behaviors. Previous research noted a differential impact of various self-care strategies on professional quality of life. For example, Killian (2008) noted the importance of participating in supervision and social interactions with work colleagues in lowering perceived work stress, as compared with strategies such as venting.

Overall, there is a dearth of research regarding self-care, resilience, and professional quality of life in the broader body of IDD literature which presents some limitation with contextualizing and interpreting the current findings. Findings from related research have been used where feasible and appropriate. Results should be interpreted within the context of the study limitations and understood as a preliminary foundation for subsequent research.

### Conclusions

Organizations supporting individuals with IDD continue to struggle with their DSP workforce due to high rates of burnout and turnover amid low wages, lack of training and supervision, and other organizational and personal factors. Given the integral role of DSPs in promoting the quality of life for individuals with IDD, and the fundamental stress associated with caregiving exacerbated by extensive responsibilities, it is important for organizations to identify ways to promote DSPs' professional quality of life while also urging systemic changes at the state and national levels.

The current study highlighted the relationships between self-care, resilience, and professional quality of life. Organizational strategies to develop a culture that embraces the importance of self-care and empowers DSPs with opportunities to engage in self-care may be one strategy to increase DSP resilience and decrease burnout amid the context of significant stressors. Although DSPs may naturally engage in some self-care behaviors, trainings can be provided by organizations to increase awareness of the importance of selfcare and to promote its use. Given the relationship between selfcare and resilience, and findings from previous research, it is possible that when organizations promote selfcare, DSPs may experience gains that carry over into aspects of their personal lives.

This study is an initial investigation of self-care, resilience, and professional quality of life. It provides a preliminary foundation for subsequent discussion and inquiry within the broader context of challenges associated with the DSP workforce. Multiple and varied strategies at all levels are warranted to address the complexity of problems within the field. Greater attention to self-care and efforts to promote DSP resilience may be a viable strategy to contribute to broader efforts in response to an historic and immediate concern.

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