The Association Between Adaptive Reserve, Burnout, and Stress Among Rehabilitation Counselors During the COVID-19 Pandemic

The final section of the special issue presents a pair of articles which look at human services responders and professional pressures. In the first of these, our study focused on understanding rehabilitation counselors’ perceptions of the likelihood that their workplace can adapt to new challenges and make sustainable changes and how this perception is reflected in their level of emotional exhaustion, feelings of depersonalization, and the likelihood of achieving personal accomplishments. A total of 72 rehabilitation counselors completed a survey consisting of five measures, including a demographic questionnaire. The study’s results suggest that the more confident rehabilitation counselors are that their workplace can adapt to new challenges, the less burnout and stress they will experience, and the lower their job turnover intentions. Our study also examined whether rehabilitation counselors’ turnover intentions are related to the COVID-19 pandemic. The findings can help administrators provide appropriate training to improve teamwork, decrease counselors’ burnout and stress levels, and ultimately enhance quality service delivery.


Introduction
On March 11, 2020, the World Health Organization (WHO) declared COVID-19 a pandemic caused by the SARS-CoV2 novel coronavirus (WHO, 2020). As the preceding articles have thoroughly discussed, since then, the COVID-19 pandemic has presented unique challenges. It has disrupted people's daily living routines, causing increased anxiety, stress, and strain-physically, mentally, and financially (Park et al., 2020). Among mental health needs, fear (Brooks et al., 2020;Park et al., 2020); frustration (Brooks et al., 2020;Park et al., 2020); anxiety (Arslan et al., 2020;Zhang et al., 2020); and depression (Ashtari et al., 2020) have commonly reported. The Centers for Disease Control and Prevention (CDC, 2020) emphasized the need for all individuals to manage stress and protect their mental health during this highly uncertain time, recognizing that increased stress and anxiety could lead to maladaptive coping behaviors. Frontline workers in the US have reported experiencing many stressors in all aspects of their lives, such as concerns about the spread of the disease, uncertainty, changes in routines, financial worries over job security, and a lack of resources (Park et al., 2020).
Human service providers have been navigating uncharted waters since the pandemic began while finding creative ways to work and interact. These unexpected yet significant changes highlight the need to take care of mental health and well-being. Human service providers also have started to telecommute full-time for the first time, isolated from coworkers, friends, family, and clients. According to a nationwide survey in May 2020, more (Cohen & Williamson, 1988). Launer (2020) further concluded that burnout is a consequence of a combination of different environmental factors. Feeling burnout on the job can lead to undesirable job performance, such as low productivity, ineffectiveness, poor service quality, and high absenteeism and turnover rates (Bradley & Chahar, 2020;Layne et al., 2004;Maslach & Florian, 1988;Maslach & Jackson, 1981;Maslach et al., 2001). Another study focused on mental health counselors' levels of burnout (Lee et al., 2010), and the researchers pointed out that counselors who received the lowest pay among the participants had the lowest job satisfaction, the worst self-esteem, and the highest depersonalization feelings among all research participants.
Multiple stressors that come along with COVID-19 (e.g., high infection rate and death count, social isolation, economic impact, heightened stress and exhaustion, lack of protective gear, and fear of personal safety) would exacerbate the burnout (Bradley & Chahar, 2020;Launer, 2020;Restauri & Sheridan, 2020;Yıldırım & Solmaz, 2020). Especially when burnout is a job-related construct, patient care and productivity are affected (Bradley & Chahar, 2020). Before the COVID-19 pandemic, rehabilitation counselors who worked with individuals with various physiological and psychological disabilities had historically reported a great deal of emotional exhaustion given their large caseload (Kahill, 1988;Maslach & Florian, 1988). Recent research on the VR professionals in the Republic of Slovenia also identified organizational stressors, such as not being valued at work, relationships with the organization, and the amount of administrative work (Tabaj et al., 2015).
In addition, work settings can affect the level of burnout that rehabilitation counselors experience. For example, Maslach and Florian (1988) identified that dissatisfaction with administrators, limited opportunities for job advancement, and the physical work settings could lead to low satisfaction rates. When compared to others, Certified Rehabilitation Counselors (CRCs) who worked in state VR settings had the lowest satisfaction rate and highest turnover intention rate (Armstrong et al., 2008). The low pay and lack of opportunities for career advancement could be the leading contributors to this low satisfaction. Another study focusing on turnover intentions among rehabilitation counselors found that when counselors face increased stress, their intentions to change careers also increased (Layne et al., 2004). Lee et al. (2010) highlighted that a negative work environment relates to high emotional exhaustion, negative personal life, and feeling incompetent and devalued by their clients. Clientele, large caseload, work settings, low salary, and lack of career advancement were all related to rehabilitation counselors' burnout and their intention to quit before the COVID-19 pandemic. However, none of the studies we reviewed discussed the correlations between rehabilitation counselors' low satisfaction/turnover intentions and their administrators' ability to adapt to change before or during the pandemic.
Since adaptive reserve and burnout are correlated with a lower quality of service provision and the ineffectiveness of job performance among rehabilitation counselors, it is appropriate to assess whether the counselors believe that their offices can adapt to continuous changes, especially during the COVID-19 pandemic. Previous studies have focused on health care providers in different specialized disciplines globally. For example, Matsuo et al. (2020) examined health care workers' levels of burnout during COVID-19 in Japan, and Lasalvia et al. (2020) focused on the level of burnout and associated factors in the most impacted area in northern Italy. Both studies showed a much higher burnout prevalence among healthcare workers during the pandemic. However, there is no research available on how COVID-19 has affected rehabilitation counselors before this date. Thus, our study aimed to examine whether rehabilitation counselors perceive their work environments during the COVID-19 pandemic as adaptive to change and assess the association between AR and burnout among rehabilitation counselors.
The study had the following research questions: 1. Do rehabilitation counselors perceive their work environment as having "adaptive reserve (AR)" during the pandemic? 2. Is there a correlation between AR, burnout, and perceived stress during the pandemic? 3. Is there a correlation between burnout and perceived stress among rehabilitation counselors during the pandemic? 4. Are there any statistically significant relationships between each of the participants' demographics (i.e., age, gender, the highest level of education, certification status, length in the current office, length employed as a full-time rehabilitation counselor, job title, caseload size, agency size, primary diagnosis of the current caseload, and turnover intentions); burnout; and their perceived stress level during the pandemic? 5. How likely are rehabilitation counselors to leave their current positions due to COVID-19? 6. Is there a difference in perceived stress between the participants who have a turnover intention and those who do not during COVID-19?
We hypothesized that rehabilitation counselors would recognize their offices have a certain degree of AR, and their turnover intention would be positively correlated with their levels of burnout related to emotional exhaustion, depersonalization, and personal accomplishment, as well as their level of perceived stress. We also hypothesize that their turnover intention would be positively correlated to the pandemic. That is, there would be a statistically significant difference in perceived stress between the participants who wanted to quit their jobs and those who did not.

Method Participants
The inclusion criteria for participants were as follows: (a) being aged 18 or above; (b) self-identifying as a vocational rehabilitation counselor, regardless of certification status; and (c) being employed in a vocational rehabilitation-related setting during the time of the survey.

Measures
Participants completed a survey on an online survey platform (Qualtrics.com). The survey consisted of a series of measures, including a demographic questionnaire, the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), the Adaptive Reserve Scale, the Perceived Stress Scale, and a turnover intention scale.
The demographic questionnaire collected basic information from participants, such as their age, gender, highest level of education, CRC status, length of time working in the current office, length of time employed as a full-time rehabilitation counselor, job title, caseload size, agency size, primary diagnosis of the current caseload, and turnover intentions. We also included a 1-item turnover intention scale (Spector et al., 1988), with a follow-up question to observe whether participants' intentions to resign were related to COVID-19.
The MBI-HSS (Maslach & Jackson, 1981) is a psychological assessment instrument comprised of 22 items related to occupational burnout, specifically among those in the human services professions. This scale assesses the psychological factor of the participants' burnout level related to their emotional exhaustion, the depersonalization they felt on the job, and their sense of personal accomplishment. We used each subscale's scores and examined three different constructs (emotional exhaustion, depersonalization, and personal accomplishment) rather than the overall scale score, The Adaptive Reserve Scale  has 23 questions. We used it with slight modifications (e.g., the term "practice" was changed to "agency"). This scale includes six components of an agency's ability to adapt and make a sustainable change: the relationship infrastructure, facilitative leadership, sense making, teamwork, the work environment, and learning culture. This scale had a Cronbach's alpha of .97. A higher score indicates a workplace has healthy and flexible leadership and the likelihood to value teamwork (Henderson et al., 2018).
The 10-question Perceived Stress Scale (Cohen et al., 1983) measures events in an individual's life that are perceived as stressful during the last month. For example, Question 1 reads, "In the last month, how often have you been upset because of something that happened unexpectedly?" The internal consistency and test-retest reliability of this scale were both above .70. We used this scale to assess participants' perceived stress levels.

Procedure
After obtaining approval from our Institutional Review Board, we sent out recruitment announcements via the National Council of Rehabilitation Education listserv and posted on a rehabilitation counselor Facebook group. Interested participants then used the direct link included in the listserv email or Facebook post to participate. The participants were anonymous, and the surveys did not collect identifiable information. After reviewing the research statement through the survey link from Qualtrics.com, participants could complete the survey or decline to do so by closing the website. Data were collected during August 2020. Participants reflected on their perceived stress during July 2020, the month before the data collection.

Data Analysis
Data were downloaded directly from Qualtrics and analyzed using IBM SPSS (version 26) predictive analytics software. We used a cross-sectional descriptive correlational design to examine the relationships between the demographic variables (i.e., age, gender, highest level of education, CRC status, length worked in the current office, length employed as a full-time rehabilitation counselor, job title, caseload size, agency size, primary diagnosis of the current caseload, turnover intentions); participants' psychological factors (i.e., emotional exhaustion, depersonalization, personal accomplishment, and perceived stress); and the outcome measure (i.e., AR). We used each outcome measure's average scores to generate inferential statistics. Binomial probability confidence interval analysis was conducted to determine the confidence interval of the likelihood that rehabilitation counselors would want to quit their jobs because of COVID-19. We also used a one-way analysis of variance (ANOVA) to test the significance of rehabilitation counselors' perceived stress and turnover intention related to COVID-19.

Results
We collected a total of 72 valid responses for data analysis. Most participants self-identified as female (94%), middle-aged (M = 40.75 years old, SD = 11.67), and had the job title of Rehabilitation Counselor (83%). About 93% held at least a master's degree, and 68% were CRCs. About 44% worked 1-5 years in the current office, while 22% stayed more than 10 years. About 65% considered quitting their current job in general, and 49% of those who indicated turnover intention specified that it was related to COVID-19.
Regarding participants' psychological factors, it was clear that they were undergoing significant burnout and stress. The three subscales of the MBI-HSS have different cutoff scores: high scores for the emotional exhaustion and depersonalization subscales are >27 and >12, respectively; the personal accomplishment subscale indicates that low is >38. The results showed high levels of emotional exhaustion (M = 37.74), depersonalization (M = 12.99), and a low level of personal accomplishment (M = 43.69).

Correlational Analysis
We used Pearson and Spearman correlation analyses to answer Research Questions 2, 3, and 4 (see Table 1 and Table 2). Specifically, we performed a series of Pearson correlation analyses to examine the association between the continuous variables (i.e., age); psychological factors (i.e., emotional exhaustion, depersonalization, personal accomplishment, and perceived stress); and the average score of the outcome measure (i.e., AR). The results showed that the participants' age did not correlate with the outcome variable or other psychological factors. However, the higher the level of stress a participant perceived, the higher their emotional exhaustion (r = .57, p ≤.01) and depersonalization (r = .57, p ≤.01), and the lower their personal accomplishment (r = -.23, p ≤.01). Moreover, the AR score was significantly negatively correlated with emotional exhaustion (r = -.56, p ≤.01), depersonalization (r = -.36, p ≤.01), and perceived stress (r = -.33, p ≤.01). It was positively correlated with personal accomplishment (r = .31, p ≤.01).
Spearman correlation analysis was conducted to determine the relationship between the categorical variables (i.e., gender, the highest level of education, CRC status, length of time being a CRC, length of time working in the current office, length of the time employed as a full-time rehabilitation counselor, job title, caseload size, agency size, primary diagnosis of the current caseload, and turnover intentions); psychological factors (i.e., emotional exhaustion, depersonalization, personal accomplishment, and perceived stress); and the outcome measure (i.e., AR). Only a few significant correlations existed among the variables (Table 2). Most importantly, participants' turnover intentions were negatively correlated with AR (r = .6, p ≤ .01) but positively correlated with emotional exhaustion (r = .52, p ≤ .01), depersonalization (r = .44, p ≤ .01), and perceived stress level (r = .29, p ≤ .05). Lastly, the turnover intention related to COVID-19 was significantly related to the rehabilitation counselors' perceived stress (r = .44, p ≤ .01).

Binomial Probability Confidence Interval
The binomial probability confidence interval (CI) analysis showed that 31% of respondents indicated that their intentions to resign from their current job were related to 44.0]).

One-Way ANOVA
We a single one-way ANOVA to test the significance of respondents' perceived stress and intention to leave their jobs related to COVID-19. The test showed no significance between turnover intention related to COVID-19 and perceived stress level, F(2,67) = 1.43, p = .148.

Discussion
The purpose of this study was to examine the following: (a) rehabilitation counselors' perceptions of their agency's ability to adapt to new changes; (b) the relationship between perceived adaptive reserve, participants' level of burnout related to emotional exhaustion, depersonalization, personal accomplishment, their perceived stress level, and their intentions to quit their jobs; and (c) the correlation between turnover intentions and COVID-19. This study supports the hypothesis that vocational rehabilitation counselors had some confidence in how their agency handled the crisis. Still, they were somewhat burnt out at their jobs, as indicated in their level of emotional exhaustion, feelings of depersonalization, and low levels of personal accomplishment. They were also experiencing a high level of stress. However, the more confident they were in their agency's ability to adapt to new changes, the lower their likelihood of quitting their jobs. Results also confirmed the hypothesis that higher levels of burnout and stress correlated with participants reporting they were more likely to want to change jobs.

Relationships Between the Demographic Variables and the Outcome Measure
The Adaptive Reserve Scale is a Likert scale in which participants rank whether they agree with statements, with response options ranging from 1 (strongly disagree) to 5 (strongly agree). The scale's average score was neutral (M = 3). This result could indicate that repsondents were neither dissatisfied nor satisfied with their current agency/office. Most self-identified respondents agreed that their employers had some capacity to respond to changes amid the pandemic. However, we also anticipated finding that some rehabilitation counselors would identify some burnout levels and possibly find employment elsewhere for different reasons. The turnover intention could result from the pandemic's overall situation or some emergency measures with which they disagreed.
Educational level, certification status, length of time being certified, and length of employment were not associated with AR. These factors did not associate with levels of burnout due to emotional exhaustion, depersonalization, personal accomplishment, or turnover intentions. This result is very similar to Layne et al.'s (2004) findings that certification level and years of certification had no statistically significant relationship with stress or turnover intentions.
Not surprisingly, the participants' age correlated positively with their educational level. Their length of employment in the current office was also positively correlated with their job title (rehabilitation counselor or administrator). A higher educational level was also associated with participants' CRC status. This finding indicates that most participants who held a master's degree or above were also likely to be certified. A total of 70.9% of those who had a master's degree also held CRC status, and 75% of those who held a Ph.D. degree also held CRC status. However, there was no association between the participants' education and their job turnover intentions, levels of burnout due to different causes, or perceived stress.

Results from the Outcome Measure
The Adaptive Reserve Scale results were significantly negatively associated with participants' burnout and perceived stress levels. This finding means that if respondents felt that their work environment was not trustworthy and that it did not provide a respectful space for communication, they experienced a higher level of stress and burnout because of emotional exhaustion. Along with the burnout, individuals felt depersonalized in the workplace and could not gain a sense of personal accomplishment. Such feelings might also increase their likelihood of finding new employment opportunities. A previous study pointed out that one way of reducing rehabilitation counselors' job turnover intentions is to have a work environment where their feedback could be valued by others (Layne et al., 2004). An early article also highlighted the importance of keeping open communication channels among supervisors, rehabilitation counselors, and team members (Payne, 1989). Providing honest feedback and support could create a pleasant environment that enhances job satisfaction and professional growth (Payne, 1989).

Turnover Intentions, Burnout, and COVID-19
Turnover intentions correlated with AR positively and correlated with burnout levels negatively related to emotional exhaustion, depersonalization, personal accomplishment, and the Perceived Stress Scale score. This result echoes Layne et al. (2004), showing that stress is associated with turnover intentions. In our study, 23 out of 72 participants (31.9%) indicated that their reasons for resigning from their current job were related to 44.0]). When using single one-way ANOVA further to examine the differences in perceived level of stress, we did not find statistical significance between those who had turnover intention related to COVID-19 and those who had none.
With quarantine in place, this pandemic is a global health crisis that has challenged every organization's capacity to offer facilitated leadership, improvise, and remain in communication while continuing to offer services to citizens. In our study, participants recalled their personal experiences during the second wave of the pandemic in July 2020 when confirmed COVID-19 cases, hospitalization, and death related to COVID-19 were all at their peak since the first wave in Spring 2020 ("Coronavirus in the US: Latest Map and Case Count," 2020). In addition, during late June 2020, around 40% of adults in the U.S. had reported having mental health issues or substance use triggered by COVID-19 (Czeisler et al., 2020). According to the Census Bureau's Household Pulse survey (August 19-31, 2020), when our study took place, 36.4% of adults in the U.S. indicated that they had symptoms of anxiety or depression disorder (Kaiser Family Foundation, 2020). The rehabilitation counselors in our study reported higher levels of burnout on the job in all three dimensions during this heightened period. Although their levels of burnout did not have a statistically significant relationship with turnover intention due to COVID-19, it did indicate overall how exhausted these counselors were.
In this study, the average AR score of 3 indicates that participants were neutral regarding their agency's ability to adapt to the process of change during the COVID-19 pandemic. Additionally, the more the rehabilitation counselors felt that their current agency could adapt to the crisis and make sustainable change, the lower the likelihood that they intended to quit their jobs and the less burnout and stress they experienced. It is also worth noting that we found no significance between perceived stress level and turnover intention due to COVID-19. Despite being under a lot of stress, respondents did not show intentions to change their career amid the pandemic; we hypothesize that possible explanations for this are that they may have had some level of confidence in how their employers adapted to the crisis, and/or they felt uncertain about the future and economics.
Although fewer than half of the participants stated that they intended to quit their current job because of COVID-19, several reasons warrant discussion. First, some participants commented that they were not satisfied with how their agencies handled the crisis. Some recognized that COVID-19 had exacerbated issues that already existed. Additionally, some commented that their workload had increased due to working from home. They struggled to balance work and family, and no support staff was available while performing the job remotely. Program funding cuts and the inability to obtain accommodations were also mentioned. Similar results from Prudential's (2021) Pulse of the American Worker Survey showed that 26% of all workers expected to change jobs when the pandemic has subsided. Of these workers, 80% were concerned about their career growth. Although COVID-19 is an unforeseen and unpredictable pandemic, it presents a learning opportunity to develop well-rounded emergency plans that promote agencies' AR should any disaster of this magnitude happen in the future.

Limitations and Future Research
Although this study is unique in exploring the relationships between rehabilitation counselors' perception of their work environment's adaptability to change, job burnout and stress, and job turnover intentions, it is not without limitations. First, the sample size (n = 72) was relatively small, impacting the power of statistical analyses and the reliability of the survey results. Second, the fact that all questionnaires were self-reported could also influence the validity of the results. Third, we conducted cross-sectional analyses with data collected in August 2020, which was at the height of the pandemic. The overall environment stressed people, but they might not have wished to change their jobs amidst the uncertainty of this period. Fourth, by employing simple correlational analysis, we could not establish causal relationships between the variables. Additionally, due to the scope of the current study, we did not explore how the six different components of the Adaptive Reserve Scale were differently affected by perceived stress, burnout, and turnover intentions. Finally, we did not examine the differences between geographic locations, as some areas were affected by the COVID-19 pandemic more than others.
Readers should be cautious in interpreting these data, and the results cannot be generalized to rehabilitation counselors due to the above-mentioned limitations. Future research might examine the resilience factors or personal traits that mediate the effect of burnout and turnover intentions despite the perceived high stress or low scores on specific components of the Adaptive Reserve Scale. The mediating factors explored in other fields include emotional competence (Rey et al., 2016); cognitive appraisal in evaluating the ability to cope (Gomes et al., 2013); coping resources (cognitive restructuring and functional beliefs; Gnilka et al., 2017); and relatedness satisfaction (Harmon-Darrow & Xu, 2018). In the context of the COVID-19 pandemic, meaningful living positively correlates with resilience and psychological wellbeing (Arslan et al., 2020). Future researchers can consider supporting strategies that incorporate explorations of individuals' life meaning and purpose to build resilience and positive affective experiences and foster their psychological health. Moreover, future researchers might use different statistical analyses (e.g., multivariate ANOVA) to examine the effect of individual factors and demographics on COVID-19-related turnover intention.
Due to the length of the survey, we chose a one-item turnover intention (Spector et al., 1988) instead of a longer questionnaire to address COVID-19 explicitly. Additionally, we included the 10-question Perceived Stress Scale to measure life events that are perceived as stressful during the last month. As the U.S. continues to recover from the COVID-19 health crisis, individuals could perceive their stress very differently from our participants. In our study, there was no association between education and job turnover intentions or between education and perceived stress. Other professional dispositions or characteristics of the counselors likely mediated the effects of burnout. Finally, we recommend that future researchers add more demographic factors, such as race/ethnicity, and include more male participants to explore how those factors could affect burnout and turnover intentions.

Conclusion
In this study, we explored selected rehabilitation counselors' perceptions of the likelihood that their workplace can adapt to new challenges and how these perceptions reflected their burnout level. Respondents had some confidence in how their agencies had been handling crises and adapting to changes. However, they were somewhat burned out in their jobs, as indicated by their level of emotional exhaustion, feelings of depersonalization, and low level of personal accomplishment; they also reported experiencing a high level of stress. The more confident they were in their agency's ability to adapt to new changes, the lower the likelihood that they intended to quit their jobs.
AR indicates an agency's ability to adapt and make sustainable change. Understanding how rehabilitation counselors view their employers' AR is crucial when an agency recruits new administrators and considers administrators' characteristics. To enhance agencies' AR, training should be designed for leadership teams to increase cohesion, creativity, and multicultural competency or humility. Doing so will decrease burnout, as service providers will perceive a sense of positive working relationships with their colleagues (Savicki & Cooley, 1987); feel supported by their administrators (Kalimo et al., 2003;Savicki & Cooley, 1987); and feel heard and appreciated (Layne et al., 2004). Additionally, training to increase an agency's overall AR should consider the six factors of AR: relationship infrastructure, facilitative leadership, sensemaking, teamwork, work environment, and culture of learning.
The perceived stress of rehabilitation counselors during challenging times, and these professionals' ability to cope, both affect their abilities to serve effectively as public's frontline workers who can instill hope and stability among their consumers. However, it is known that state VR agencies have high turnover rates (Armstrong et al., 2008). Constantly changing staffing could affect clients' willingness to engage in therapeutic relationships and decrease their capacity to find gainful employment. Clients must perceive a sense of stability and feel safe while receiving continuous support from service providers, without fear of losing their progress due to the counselors' high turnover rate. The office culture is another determining factor in counselors' turnover intentions. From the AR perspective, cultivating a culture that values teamwork, appreciates individual differences, supports continuous learning, and harnesses creative problem solving will enhance an agency's capacity to respond to quickly changing events and crises such as the COVID-19 pandemic. This capacity building, in turn, will provide high-quality service outcomes.