Compassion fatigue in nursing: A concept analysis

3.1 Defining compassion fatigue

CF and the related terms of burnout, secondary traumatic stress (STS), and vicarious traumatization (VT) were first explored with definitions outside of literary sources.

STS was not found outside of literary sources, and Jenkins and Warren's4 definition of STS was extracted from their concept analysis on CF. Subsequently, theoretical and empirical works from the academic disciplines of nursing, psychology, and social work were analyzed to discover varied uses of CF, provide insight for an operational nursing definition of CF, and discover preventative and mitigating strategies that could benefit helping professions. These works are discussed in additional detail and graded for evidence quality in Appendix B.

Compassion is “sympathetic consciousness of others’ distress together with a desire to alleviate it”.5 Fatigue is described in the form of military manual labor; military uniforms; physical or mental exhaustion; transient impaired response in a receptor or organ from excessive stimuli; and the propensity of an object to break after continued strain.6 CF is “the physical and mental exhaustion and emotional withdrawal experienced by those that care for sick or traumatized people over an extended period of time”.7

Burnout is the “exhaustion of physical or emotional strength or motivation usually as a result of prolonged stress or frustration”.8 STS occurs when one knows about another person's traumatizing event and then experiences stress as a result of wanting to help the trauma victim.4 “Vicarious trauma is a state of tension and preoccupation of the stories/trauma experiences described by clients.”9

3.2 Uses in nursing

CF was examined in the academic discipline of nursing, with all of the reviewed literature written by persons in the discipline.

Coetzee and Klopper10 defined CF as a process that originates as compassion discomfort, progressing to compassion stress, and culminating in CF. Once CF is experienced, there is no hope for recovery due to the complete depletion of compassionate energy.4, 10 Previous concept analyses and other published works on CF in nursing identified an array of physical, emotional, and spiritual manifestations that defined the concept, with the element of exhaustion or decline in energy and lack of empathetic ability being the most common elements.4, 10-13 Physical and emotional symptoms of CF were also described metaphorically as “’just plain worn out’ and ’walking on a tight rope’.”12^{, pp. 4367,4369} Sheppard13 suggested that CF begins with emotional symptoms such as feeling a disconnectedness with the patient and ending with physical symptomatology such as headaches and insomnia.

CF was implied to be an occupational hazard for several reasons. First, simply being in the nursing profession places one at risk.13 Second, CF was described as a natural result of caring.4 Third, Boyle14 noted that nurses differ from other helping professionals because of nurses’ “constancy and proximity to tragedy over time. Nurses can't remove themselves from their source of distress.”14^{, p. 49}

Burnout can manifest similarly to CF, but burnout was associated with work environment4, 11, 13, 15, 16 or workplace stressors14 and excluded an empathetic connection.17 Alternatively, burnout was suggested as a consequence or outcome of CF.10, 13, 18 Ultimately, compassion does not have to exist prior to burnout, but compassion does have to exist prior to CF.11

Antecedents in previous concept analyses were the exposure to suffering, chronic and intense nature of patient contact, high occupational use of self, and prolonged stress exposure.4, 10 Harris and Griffin's11 concept analysis incorporated a spiritual perspective of CF and identified “the degree and length of emotional investment, poor or lack of personal and professional support, minimal or no spiritual commitment, and lack of inner resiliency” (p. 83) as antecedents.

The inability to maintain personal or professional boundaries was a cause of CF,12, 13 as was sacrificing self-care.13 Sheppard13 explained, “Nurses who skip breaks, take extra shifts, or come in on their days off out of a sense of duty may be more at risk for CF” (p. 53).

A shortage of personal or professional support can cause CF,11, 12, 15, 17, 19 as can workplace factors.12 Specifically, workplace factors included an enhanced workload,18 hours per shift,15 and time constraints that hindered quality patient care.19

In nurse residents, repeated exposure to stressful occupational situations early in a nursing career can precipitate early development of CF, as can a personal history of trauma.16 CF was associated with witnessing traumatic events such as child abuse and end of life, along with daily care of critical patients18 and lack of awareness about CF.19 Age was found to be inversely related to CF.15, 17, 18 Sinclair et al's20 meta-narrative review of CF illuminated two conceptual problems with the construct of CF. If CF is the result of additive stress or trauma exposure, the findings that CF are inversely related to age and experience presents a troubling conceptual problem. Second, it is difficult to conclude that CF is present when none of the CF instruments measure compassion. Their concern about the inverse relationship between experience and CF are supported by Kolthoff and Hickman's findings with nurses working with older adults. Duarte and Pinto-Gouveia21 found that beyond a certain level, empathy may lead to irrational (omnipotent and survivor) guilt that is associated with higher CF scores. If this is consistent across populations of nurses, their findings may explain why experience and age may be inversely related to CF.

Consequences of CF included “physical, social, emotional, spiritual, and intellectual effects.”10^{, p. 237} Ethically, CF caused a transformation in clinical values.4 The nurse experiences insufficient performance and holistic health decline.11 One may display poor judgment,10, 11 experience an increase in work errors,11, 13 and become accident prone.4, 10

Absenteeism,10, 13, 14 alcohol or substance abuse,13 and physical weight fluctuations4 may ensue. An individual may have an emotional breakdown,4, 10 and spiritually, one may experience values questioning.14

In the discipline of nursing, a significant consequence of CF was a desire to leave the profession,10-14, 19 thus contributing to the nursing shortage11, 12 and high staff turnover rates.4, 14, 18, 22 CF can negatively impact patient safety and quality care, leading to patient dissatisfactions, decreased reimbursement rates, and institution financial strain.11, 17, 18

Preventative measures in nursing often pertained to the self in the forms of self-care,12-14 self-awareness,14 and self-reflection.12, 13 Maintaining boundaries was also a common preventative strategy.12, 13 Strategies for prevention also included desirable work settings.14 Li et al16 found that high group cohesion was protective against CF, organizational commitment enhanced compassion and job satisfaction, and compassion satisfaction can be achieved through working in stressful situations in nurse residents. Resilience obtained through life years, professional experience, and empowerment via organizations could protect one from CF.18 Bao and Taliaferro22 found that the use of psychological capital can eliminate and prevent self-reported CF while enhancing quality patient care at the same time. Psychological capital encompassed four dimensions that included “self-efficacy, optimism, hope, and resiliency.”22 ^{p. 36} It was also suggested that enhancing knowledge about CF could be protective.12

3.3 Uses in psychology

CF was examined in the academic discipline of psychology, with all of the reviewed literature written by persons in the discipline.

In the discipline of psychology, CF definitions commonly included emotional components, such as an emotional response from client material exposure,23 emotional exhaustion,24 and “the emotional cost of emotional drain that can occur among those caring for those with various disabilities and impairments.”25^{, p. 1} Additional defining characteristics of CF included a decline in empathetic ability,23, 24, 26 hopelessness/helplessness,23, 26 confusion,23 depersonalization,24, 26 distancing oneself from the client and substance abuse,26 and social isolation.23

Jenkins and Baird27 differentiated CF/STS and VT because “CF/STS has emotional and social symptomatology, whereas VT has cognitive symptomatology” (p. 431). Further, STS encompasses a greater variety of scenarios where one is in close contact with a traumatized individual, whereas CF is specific to those in helping professions.25 As in nursing, burnout was suggested to stem from CF, but stringent organization demands must be present for burnout to ensue.26 CF was suggested to be closely related to moral stress.23 “Moral stress refers to the awareness that competing values are at play and that they cannot be resolved due to external constraints.”23^{, p. 2} Moral stress can cause frustration in the mental health professional due to a lack of resolution with conflicting values. The emotional response of CF can trigger frustration as well, as it can develop quickly when repeatedly exposed to others’ anguish.23

Personal trauma history was frequently suggested to be related to CF development.25-27 Personal stress, professional stress, and boundless compassion in the forms of constant self-giving and unhealthy countertransference are additive factors leading to the development of CF.26 Negash and Sahin24 identified CF as an overinvolvement with client suffering and included precipitating factors of a negative work environment, constant exposure to trauma and grief, and interpersonal influences such as having clients with a history of child abuse.

Consequences of CF included spiritual weariness, doubting one's values, and an overall decline in health.26 Ultimately, the first step in CF prevention included acceptance of one's vulnerability to develop CF as a mental health professional.26 Setting boundaries, practicing self-care, and taking time to relax and reflect were also suggested as ways to combat CF.24

3.4 Uses in social work

CF was examined in the academic discipline of social work, with all of the reviewed literature written by persons in the discipline.

Empathy was associated with CF in social work. Working with traumatized persons plus the incorporation of empathetic engagement can lead to CF,28 and CF was defined by a lack of empathetic ability.28-30 Empathy was also discussed by Wagaman et al.,31 who found that “self-other awareness and emotional regulation, which are cognitive components of empathy, appear to be significant contributors to components of CF as compared with the other components of empathy.”31^{,p. 206}

Secondary trauma and job burnout were two components of CF.28 In social workers, CF was found to be related to psychological problems, and secondary trauma was enhanced with client material exposure whereas job burnout was not.28 As in nursing and psychology, burnout was indicated as an outcome of CF and was caused by organizational demands.29 Harr29 defined CF in social work as “negative consequences of working with traumatized individuals and vicariously experiencing the effects of traumatic life events” (p. 73). While this definition overlaps between STS/VT, Harr29 further specified CF by identifying specific emotional and behavioral manifestations that included helplessness, feeling drained, detachment, and sleep disturbances.

While personal trauma history was not a significant cause of CF, working with aggressive clients and children in distress showed an increase in CF symptoms.30 In student social workers, signs of CF were exhibited by those who lacked supervision and knowledge about CF.30 Organizational consequences of CF were high social worker turnover and poor quality of service.29 In the realm of academia, students demonstrated more signs of CF than did their instructors, and students who exhibited signs of CF were more likely to display reluctance in becoming a social worker.30

A call to action regarding CF prevention was encouraged by Kanter,32 who argued that current literature on CF in social workers is more concerned with treating CF after it is discovered, rather than focusing on prevention tools. Since all social workers will deal with traumatized patients and stressful situations, Kanter32 suggested that literature should focus on how the social worker responds to those situations. Kanter32 suggested clinical skills training, setting realistic expectations for client outcomes, and taking steps toward self-awareness to avoid countertransference will help prevent CF. Bourassa33 found that boundary setting could protect social workers from CF, and “Social work education, personal history of crisis, sense of achievement, job experience, and preventative actions, coworker support, and independence aid in boundary-setting”.33^{, p. 1708} Harr29 suggested that a supportive work environment with increased CF education will help combat CF and practicing self-care measures along with having a positive outlook will prevent the formation of CF.

3.5 Antecedents

Six antecedents always occur before the concept of CF (refer to Appendix A for a conceptual model depiction and Appendix B for additional literature support). The antecedents include chronic exposure to the suffering of others,4, 10, 12, 16, 18, 19, 23, 24, 27, 29 compassion,11, 18, 24, 26 inability to maintain professional boundaries,12, 13, 24, 29, 31-33 high occupational use of self,4, 10, 12, 15, 24, 26, 29 high stress exposure,4, 10, 12, 15, 16, 18, 19, 26, 29, 30 and lack of self-care measures.13, 14, 18, 24, 29, 32

3.6 Essential attributes

There are four essential attributes of CF (refer to Appendix A for a conceptual model depiction and Appendix B for additional literature support). The essential attributes that define the concept of CF in all situations include declining empathetic ability,4, 10-12, 14, 23, 24, 26, 28 emotional exhaustion,10-14, 23, 24, 29, 31 diminished endurance/energy,4, 10-12 and helplessness/hopelessness.11, 12, 23, 29, 32

3.7 Consequences

Five consequences take place after the concept of CF (refer to Appendix A for a conceptual model depiction and Appendix B for additional literature support). The consequences of CF include increased work errors,4, 10, 11, 13, 14 poor quality care,11, 18, 22, 33, 24, 26, 29, 31 values questioning,14, 23, 26, 29 a desire to quit the profession,10-14, 19, 30 and increased nursing shortage.11, 12

4.1 Model case

Jack has been a telemetry unit nurse for 2 years. The standard ratio is one nurse to seven patients. Jack's unit has been accepting high acuity postcardiothoracic surgery patients in the past 6 months. Owing to staffing issues on the psychiatric unit, Jack's unit has been designated the psychiatric overflow unit within the past 3 months. Jack has always worked hard to provide compassionate care and attend to multiple patient care needs in a prompt manner. In the past month, the exposure to diverse patient suffering and increased acuity has negatively impacted Jack. He has noticed that he is losing the ability to empathize with patients despite knowing it is his nursing duty to provide compassionate care. He is concerned something is physically wrong with him due to a loss of endurance and lack of energy. He is emotionally exhausted at work and at home. He has become less interested in tending to the emotional needs of his wife due to his own exhaustion, which has impacted their marriage. He feels a sense of helplessness and loss of hope that he will be able to recover from these effects. Jack is experiencing CF. This is a model case because Jack is experiencing all essential attributes of CF including declining empathetic ability, diminished endurance/energy, emotional exhaustion, and helplessness/hopelessness.

4.2 Contrary case

Charlie has been a trauma nurse for 5 years. The job is high stress and involves constant exposure to patient suffering. Charlie sets professional boundaries to prevent emotional overinvolvement and subsequently has high job satisfaction because he knows he is making a difference in patients’ lives by helping them heal. He works to empathize with his patients, knowing this action will make him a better nurse. Working with trauma patients is energizing and endurance enhancing due to the intense nature of patient needs. Sometimes the job can be overwhelming. After each shift, Charlie takes care of his emotional needs by reflecting on events that caused him to become overwhelmed. He always recalls the positive differences he has made. He uses self-awareness to address those triggering events and preserve moral values. Charlie loves his job, enjoys interacting with patients, and knows he is in the right profession. Charlie is experiencing compassion satisfaction. This is a contrary case because Charlie is displaying no essential attributes of CF. Although his job is high stress, Charlie's use of boundary setting, reflection, and self-awareness has protected him from CF.

4.3 Related case

Greta has been a psychiatric nurse for 12 years. She has become progressively dissatisfied with the way her unit is organized. There has been an increase in cell phone use in patient care areas, which is against hospital policy. Coworkers are taking 1 h lunch breaks instead of the designated 30 min lunch breaks, and management has done nothing to improve the situation. She constantly picks up the slack of her coworkers resulting in diminished energy and endurance. She is emotionally exhausted from constantly tending to the needs and concerns of new employees due to a high staff turnover rate in the department. Having already talked about these issues with her supervisor, she has decided if this continues for much longer, she is going to her manager's supervisor to address the issues as a helpful agent for change to benefit the department. Greta dislikes her job atmosphere but enjoys caring for psychiatric patients. She knows she could provide better care if the department was better organized. Greta can empathize with patients and knows this trait allows her to be an excellent psychiatric nurse. Greta is experiencing burnout. This is a related case because it contains the essential attributes of emotional exhaustion, diminished endurance/energy, but excludes declining empathetic ability and helplessness/hopelessness. Greta's initiative to make changes in the department contradicts helplessness/hopelessness, and she can express empathy because her frustrations stem from unit organization and coworker issues rather than repeated exposure to patient suffering.

4.4 Empirical referents

There are several measures of CF. The Professional Quality of Life Scale (ProQOL), incorporates three subscales of compassion satisfaction, burnout, and STS, with burnout and STS considered components of CF.31 The ProQOL consists of 30 Likert responses including the ranges 0 (never) to 5 (very often). The ProQOL has high Cronbach alpha reliability (compassion satisfaction = 0.87; CF = 0.80).15 The Compassion Satisfaction and Fatigue Test (CSFT), an older version of the ProQOL has also been used to measure CF.16 The CSFT also demonstrates good internal consistency (compassion satisfaction = 0.87; CF = 0.87).16 As noted by Sinclair et al.,20 none of these scales measure compassion.

4.5 Operational definition

An operational definition was formulated to establish construct validity and further clarify the concept of CF. CF is a preventable state of holistic exhaustion that manifests as a physical decline in energy and endurance, an emotional decline in empathetic ability and emotional exhaustion, and a spiritual decline as one feels hopeless or helpless to recover that results from chronic exposure to others’ suffering, compassion, high stress exposure, and high occupational use of self in the absence of boundary setting and self-care measures.