Mason, Virginia M. PhD, RN, ACNS-BC, CCRN; Leslie, Gail MSN, RN, PMHCNS-BC; Clark, Kathleen BSN, RN, MMHC; Lyons, Pat MS, RN, CNS-BC, CCRN, CPAN; Walke, Erica MSN, ACCNS-AG, RN; Butler, Christina BSN, RN; Griffin, Martha PhD, RN, FAAN
Critical care nurses working with trauma patients and their families are at risk for moral distress and compassion fatigue due to the impact of sudden, potentially tragic outcomes they must face while caring empathetically for both patients and families in a time of uncertain crisis. Compassion fatigue may cause nurses to leave the unit or the profession prematurely. Currently, we are preparing the next generation of nurses to replace the largest nursing workforce in recent memory. Retention of the critical care nurse has never been more important. Preparation for replacing the large proportion of staff nurses reaching retirement age in the next few decades is essential to delivering high-quality nursing care and improving patient outcomes.1-4 The average age of staff nurses is 46 years.1,3 This is especially crucial as the population grows older and the lifespan lengthens. Retaining experienced critical care nurses is imperative to successfully planning and implementing the orientation of new inexperienced intensive care unit (ICU) nurses. Given the burgeoning number of baby boomers adding to the aging patient population in the United States; and the addition of millions of new patients becoming insured with the final enactment of the Accountable Care Act, these efforts need to start immediately and must include the retention of experienced preceptors. Sustaining our workforce and educating new nurses are an urgent matter as half of the nursing workforce in America is approaching retirement age.1-3 The expense of orienting new critical care nurses also includes not only the cost of hiring and orienting new nurses, but also the cost of replacement staff to work during this time frame. The estimated cost of orienting a specialty nurse is $64 000.5 The additional expense to hire replacement personnel to cover the shortage created by nursing staff turnover is $145 000.5 Recent research studies have found that compassion fatigue, moral distress, and staffing ratios impact nurse turnover rates, sick time usage, and productivity. These factors may also affect patient satisfaction, patient outcomes, and mortality rates.6-9
Critical care nurses working with trauma patients and their families are at risk for moral distress and compassion fatigue due to the impact of sudden, potentially tragic outcomes they must face while caring empathetically for both patients and families in a time of uncertain crisis. These work-related stresses are inherent in the type of critical care nursing involving trauma. Many studies have demonstrated the potential for damage to the psychological, physical, and emotional aspects of nurses working in an ICU setting.9 Prior work on compassion fatigue has dealt with “first responders” in other fields of employment; however, nurses care for patients around the clock and thus experience longer exposure to the suffering and grief of patients and families. Compassion fatigue encompasses 2 components: the frustration from the inability to act in accordance with one’s beliefs and the fear of reliving the stressful trauma episode.9 The opposite of compassion fatigue is compassion satisfaction, in which nurses are enriched from offering help to people in need at a time of life-threatening crisis. Compassion fatigue and moral distress are described as overwhelming feelings of being powerless to do what is believed to be right. This can lead to feelings of wanting to resign or transfer to avoid further emotional and physical stress. Years of work experience may influence the level of compassion fatigue. Burnout tends to progress gradually over time, whereas compassion fatigue tends to occur suddenly in response to an identifiable event.
Findings of a Florida hospice nurses’ study revealed that nurses who were employed 5 or more years experienced a higher degree of secondary traumatic stress symptoms than did those working less than 5 years.11 Results from Slocum-Gori and colleagues’11 study of 630 palliative care nurses with respondents from hospital, community-based, and care homes indicated a significant negative correlation between compassion satisfaction and burnout (r = 0.531, P < .001) and between compassion satisfaction and compassion fatigue (r = 0.208, P < .001), and a significant positive correlation between burnout and compassion fatigue (r = 0.532, P < .001).11 Elkin’s study of 30 ICU nurses in 2 private African hospitals resulted in the majority of nurses (73.34%, n = 22) reporting a moderate to high compassion satisfaction score, whereas a majority (89.90%, n = 27) reported a moderate to high burnout subscale.12
Compassion fatigue is a progressive and cumulative process that is influenced by interaction with patients, the nurse’s own resources, and exposure to stress.8-12 It can be caused by a prolonged or continuous exposure to stressful events or by a single very intense event.13 Compassion fatigue is often compounded by moral distress.8 Nursing specialties such as trauma, oncology, and pediatrics involve nurses on a continuous basis interacting with patients and families facing the consequences of life-threatening experiences.9,10 Manifestations of emotional compassion fatigue may include anger, apathy, cynicism, sarcasm, dreams, flashbacks, feelings of being overwhelmed, hopelessness, and irritability. Intellectual manifestations may reflect boredom, impaired concentration, inability to pay attention to detail, conflicting loyalties, and disorderliness.9-15 Figley14 has reported vicarious or secondary trauma effects in emergency personnel from reliving someone else’s life-threatening experiences. Yoder15 found that compassion fatigue or secondary trauma was significantly higher in nurses who worked 8-hour shifts compared with nurses who worked 12-hour shifts, which may reflect that longer shifts allow more days away from the source of distress to replenish oneself. Previous research shows that compassion satisfaction was significantly higher in ICU nurses than in emergency department nurses, which may reflect the value of a relationship over time to see patients and families through such a traumatic experience.10-15 Nurses with the longest work experience reported significantly lower rates of compassion satisfaction than did the least experienced nurses.10-15 This raises the question of the effect of persistent trauma exposure on how compassion responses develop over time in experienced nursing staff.
Much of the research on moral distress in critical care nursing has involved medical ICUs, not surgical ICUs (SICUs).16,17 Moral distress is an important contributing factor in nurses’ relationships with management, patients, families, visitors, safety from violence in the hospital setting, and therefore retention of staff.18 Since 2004, the American Association of Critical-Care Nurses has recognized moral distress as a national problem in critical care units in their position statement “The 4 A’s to Rise Above Moral Distress.”18 Most of the interventions provided by other disciplines such as chaplaincy, social work, or debriefing sessions are held during the day shift. This raises the question of any variability in results by shifts. Also, timeliness of interventions is difficult, that is, getting the nurses who cared for the patient to the debriefing held on a later date. In a trauma ICU, the nurse who cared for the patient in jeopardy is now on to the next critical patient on her assignment.
The balance of compassion satisfaction or fatigue and level of moral distress may have profound effects on work engagement. Work engagement measures well-being and is defined as vigor or level of energy, the extent of absorption (when time passes quickly), and the amount of dedication applied to the work setting.20 Work engagement reflects particularly job resources that act as motivators. Engaged employees exhibit positive attitudes and good mental health and seem to perform better than do those who are less engaged.20 Christian et al21 in their meta-analysis of over 90 engagement research studies found that engagement is distinct from job satisfaction, organizational commitment, and job involvement. Work engagement includes 2 sources: (1) job resources such as social support, feedback, and opportunities for autonomy and variety, and (2) growth of employees’ own personal resources such as self-esteem and optimism.19 Contrary to popular belief, engagement and high-quality performance are greatest when the demands of the job are highest, according to Schaufeli and Bakker.20
LEVEL OF EDUCATION
A 10% increase in the proportion of nurses holding a bachelor’s degree has been associated with a 5% decrease in the likelihood of patients dying within 30 days of admission and also the odds of failure to rescue (odds ratio, 0.95; 95% confidence interval, 0.91-0.99) in both cases.22 Improved outcomes might be expected to impact levels of moral distress and compassion fatigue.23 The study adjusted for both patient characteristics and hospital structural characteristics (size, teaching status, level of technology), as well as for nurse staffing and nurse experience.22
Watson’s24 human caring theory provides the theoretical framework encompassing carative factors; transpersonal caring relationships, which affect both patient and nurse; and the genuine caring moments in which the nurse is empathetic, nonjudgmental, and warm, while sharing intrapersonal learning and hope in a safe environment. Providing an authentic caring interaction means both the patient and the nurse benefit from allowing the patient and/or family to choose the perceived best action for themselves at that time with hope in the future for potential growth.24
The purpose of this study of surgical trauma intensive care nurses is to examine the effects of compassion satisfaction as well as compassion fatigue, moral distress, and educational level on work engagement. This pilot study is a partial replication of Lawrence’s25 study. Research questions include the following: (1) What are the correlations between 4 key variables: compassion fatigue, moral distress, level of nursing education, and work engagement? (2) How does nurse educational level and hospital shift worked relate to compassion satisfaction or fatigue, moral distress, and work engagement? (3) Does compassion satisfaction or fatigue or moral distress have a direct relationship to work engagement? (4) Do nurses identify themes in their work-related experience?
The survey consisted of 55 question in 4 parts: (1) educational level measured as the highest nursing degree earned to practice nursing; (2) a 30-item Professional Quality of Life Scale (ProQOL-5) instrument with 3 components measuring compassion satisfaction and compassion fatigue, which is made up of both Burnout and vicarious stress subscales; (3) the 9-item Utrecht Work Engagement Scale (UWES) from the Netherlands measuring work and well-being; and (4) a 7-item moral situations subscale called “not in the patient’s best interest” from Mary C. Corley’s Moral Distress Scale.25-27 Only the frequency from the moral situations subscale score was used in this pilot study, to reduce the potential for a participant “fatigue effect” from respondents becoming bored with the questions and performing less well.20,24,26 All instruments demonstrated adequate reliability and validity as presented in Table 1.20,26-30 Shortened versions, where available, of instruments were chosen to prevent undue burden on the subjects. The Moral Distress Scale tool demonstrates good reliability, Cronbach α = .98.26-28 All study instruments (including shortened versions) demonstrated adequate reliability with Cronbach α of .83 or greater.20,25-30
A purposive sample of 34 trauma surgical intensive care nurses met eligibility requirements for this survey. The inclusion criteria for study participation were as follows: (1) registered nurse status, (2) greater than or equal to 50% of on-duty work time spent in the provision of direct nursing care to patients in an ICU setting, and (3) computer literacy.
All nurses were experienced in surgical trauma care and were currently working in a 496-bed safety net hospital that is also an academic medical center in a northeastern urban city. Participants were informed prior to engagement in the survey that the typed aggregate data would be maintained in a confidential manner, that there were no inherent risks associated with study participation, and that they would be free to choose not to participate or could withdraw at any time without recourse to their employment status. Questionnaires were e-mailed to the nurses at their work e-mail address.
Twenty-six of 34 nurses responded to this survey. Recruitment strategies included the following: (1) the SICU nurse manager, who was familiar to the respondents, sent the recruitment messages via e-mail; (2) all surgical intensive care nurses were eligible for a raffle of a random drawing for three $50.00 gift certificates, regardless of study participation to further protect anonymity; (3) recruitment of subjects was discussed at staff meetings; and (4) a 2-month e-mail reminder, poststudy initiation, was forwarded to prospective participants by the SICU nurse manager.
Opened-ended questions were placed at the end of each instrument: (1) “What factors in your work setting, if any, may be worthwhile to examine?” (2) “Please add any comments you may have about your experiences with moral issues in your practices.” (3) “What was your worst experience with caring for a patient in which you developed overwhelming feelings of dissatisfaction?” (4) “How do you replenish yourself to be able to feel empathy and sympathy for patients in tragic circumstances? (5) What do you like about nursing?” (6) “Anything else you would like to add?”
Data security was maintained throughout the study. Aggregate data were kept from numbered questionnaires to protect identities. All data were deidentified and kept secured by the researchers. Nurses’ responses were typed into a computer and printed out to avoid the possibility of handwriting recognition. These measures were undertaken to ensure strict participant confidentiality. Neither the hospital leadership nor the nurse manager had access to the personal identification of participants, and participant names did not appear on any reports that resulted from this study. Respondents’ questionnaires were collected over 2 months to allow time to fill out the questionnaire on work time.
Twenty-six of the 34 eligible nurses completed the study, indicating a 77% response rate. All nurses work 12-hour shifts, either days, nights, or rotating shifts. Table presents nurses demographics, by shift. Overall, 77% of respondents have been in nursing for 21 to 30 years, and 62% have been in the trauma SICU for 21 to 30 years. The majority have a bachelor of science degree in nursing (BSN) (89% overall), 1 nurse has an associate’s degree (4%), and 2 have a master of science degree in nursing (MSN) (8%). Gender or age was not required information for this study to minimize possible identification of the nurse in the workplace situation. There are very few male nurses in this study. Certain ages could indicate which nurses had responded to the survey and therefore not protect anonymity. Other than the difference in years worked in SICU, there were no major differences between the different shifts on demographics. This sample represented a very experienced, expert group of critical care nurses with 11 to more than 31 years of working in the field of nursing. No one in this sample had worked less than 10 years in nursing. This sample reflected maintaining a coveted nursing position in a trauma SICU as well as a reduction in force that had affected those nurses with fewer years in the union.
(1) What are the correlations between 4 key variables: compassion fatigue, moral distress, level of nursing education, and work engagement?
Overall, 73% of SICU nurses scored average on compassion satisfaction and 27% scored high. None of the nurses scored low on compassion satisfaction. There were no major differences between the shifts on this scale. Compassion fatigue was also measured by both the burnout and the secondary traumatic stress subscales as seen in Table 3. Of the trauma SICU nurses 58% scored average on burnout and 42% scored low. None of the nurses scored high on the burnout subscale. The number of SICU nurses scoring average was slightly higher among the day shift (73%) compared to the night shift (50%) but this difference was not statistically significant. On the second part of the compassion fatigue subscale 62% scored low on secondary traumatic stress, and 38% scored average. None of the nurses scored high on experiencing secondary traumatic stress. There were no major differences between the shifts on this secondary traumatic stress scale. Table 4 presents ProQOL-5 by nursing shifts for compassion satisfaction and fatigue scales.
The mean work engagement UWES total score was 3.8, which is considered low.26 The UWES mean vigor subscale score was 3.6; the mean dedication subscale score was 4.2; the mean absorption subscale score was 3.6 on the UWES work engagement scale. There were no significant differences across the shifts on these scores. Lower scores reflect lower levels of work engagement. Table 5 presents work engagement by nursing shift.
The overall mean moral distress situations subscale score was 3.4, which is considered elevated. There were no major differences between shifts. In the moral situations subscale, higher scores reflect higher levels of moral distress.27 Table 6 presents moral distress subscale by nursing shifts.
(2) How does nurse educational level and hospital shift worked relate to compassion satisfaction or fatigue, moral distress, and work engagement?
Of the SICU nurses, all but 1 (n = 25) had BS preparation in nursing. Previous research has shown that the higher the level of preparation, the higher the level of moral distress measured especially in the intensive care units.21,23,26 However, Corley and colleagues’27 research showed that education level did not predict moral distress. This study cannot speak to this effect of educational level because of the high proportion of BSN and MSN nurses in the trauma SICU.
(3) Does compassion satisfaction or fatigue or moral distress have a direct relationship to work engagement?
Significant positive correlations between work engagement (total and dedication) and ProQOL-5 compassion satisfaction subscale (r = 0.49, P < .05) were demonstrated in this sample. As work engagement increases, compassion satisfaction subscale increases. Significant negative correlations between work engagement (total, vigor, and dedication) and ProQOL-5 burnout subscale were demonstrated in this sample (r = −0.49, P < .05); as work engagement scores increase, burnout, the compassion fatigue subscale, decreases. Table 7 presents bivariate correlations in this study.
(4) Do nurses identify themes in their work-related experience?
Krippendorff’s31 content analysis determines the presence of certain themes within communicative language; it quantifies the presence of themes and was applied to this study with an audit trail.32 Summary of open-ended question on worst experiences of distress revealed the following themes: (1) role conflict with management/rules 39% (10/26), (2) death and suffering end-of-life decision making 23% (6/26), (3) dealing with violence in the ICU 19% (5/26), (4) dealing with family 15% (4/26), (5) powerlessness–moral distress 15% (4 /26), (6) physical distress 12% (3/26), and (7) medical versus nursing values–moral distress 8% (2/26). Table 8 presents the summary of the worst experiences of distress exemplar.
Summary of open-ended question on “what you like about nursing” in Table 9 revealed caring, helping families, long-time interdependent supportive relationships of colleagues, and satisfaction in trauma nursing from caring for patients 27% (7/26). Summary of open-ended question “How do you replenish yourself?” in Table 10 revealed (1) self-care 54% (14/26), (2) relationships of professionals 23% (6/26), and (3) compassion/empathy 23% (6/26).
To the question, “Please add any comments you may have about your experiences with moral issues in your practices,” there was 1 comment on moral distress issues of keeping separate compartments of feelings, which rolled into the how you replenish yourself theme of self-care. Findings demonstrate 3 comments on additional work-related factors to be examined in your work setting: (1) bed control issues, (2) staffing components and ratios, and (3) supplies, which were included in identified themes of role conflict with management/rules. Three comments elicited from “Anything else you would like to add” were rolled into the role conflict with management/rules on (1) dislike of double documentation and (2) pressure to work within time limits adding to burnout and (3) a thank you for this project.
There was no significant difference across shifts in this study on the ProQOL-5 measuring compassion satisfaction and fatigue. In this trauma SICU, there are proportionately more females than males working at this time, but no conclusions can be drawn because of small sample size. There was virtually no difference between compassion fatigue risk scores of nurses who worked rotating shifts versus those who did not rotate in this small sample. Compassion satisfaction was reported as high to moderate in this study, which may have a positive effect on patient outcomes. In addition, the preponderance of nursing education preparation in this study was at the bachelor’s degree level or higher, which may also contribute to more favorable patient outcomes based on current research. Research findings are conflicted on the impact of the educational level of nurses’ preparation on the moral distress. Burnout and traumatic secondary stress scores, the subscales of compassion fatigue, were moderate to low in this study. A high burnout and stress score on the ProQOL-5 would mean that the nurse suffered from posttraumatic stress disorder symptoms, inability to focus or pay attention to detail, which would impact being able to function at work.33,34 This was not found to be the case in this study.
The mean moral distress subscores in this study for ICU nurses by shift for days, for nights, and rotating shifts were 3.0, 3.4, and 3.9, respectively, with an overall mean of 3.4, which is higher than some other studies of critical care nurses.10,25,34
There was no significant correlation found in this study between moral distress and work engagement. This study reports a UWES score of 3.8 of a possible 6.0, which is lower than similar nursing studies.25,31,35 Higher scores reflect higher levels of work engagement; lower scores reflect lower levels of work engagement.
The norm in the trauma ICU often includes a steady level of stress or potential violence that nurses encounter every day. This would be their norm in coping and thus would not necessarily be reflected in a high secondary stress or burnout score. This exposure may explain why no ICU nurses reported high burnout or traumatic secondary stress. Perhaps this continuous exposure to stress encourages resilience, consistent successful coping, and self-care needed for survival.
Findings of a Florida hospice nurses’ study revealed that nurses who were employed 5 or more years experienced a higher degree of secondary traumatic stress symptoms than did those working less than 5 years.10 In this study, there were no nurses with less than 5 years of experience for comparison. In looking at these variables across selected nursing subspecialties, in Hooper and colleagues’34 study, the scores of emergency nurses evidenced a risk for less compassion satisfaction, whereas intensive care nurses in Hooper and colleagues’34 study demonstrated a higher risk for burnout, and oncology nurses reflected a higher risk for compassion fatigue.10,25,34,36
Moral Distress Situations
In this study, more than 65% of ICU nurses reported experiencing moral distress, which is similar to percentages reported in 2 other comparable research studies.25,37 There was no significant correlation found in this study between moral distress and work engagement, unlike Lawrence’s25 study, which demonstrated an inverse relationship between moral distress and level of work engagement.
Intensive care unit nurses in this study reported a mean work engagement level of 3.8, which is lower than other comparable studies.38 Mauno and colleagues’38 Finnish, 2-year longitudinal, all-sector health care provider study, which included 261 hospitals, demonstrated mean nurse work engagement levels of 4.45 and 4.31 two years later. Increase in work engagement scores should also benefit compassion satisfaction scores.
Helping nurses to deal with death, suffering, physical exhaustion, burnout, and emotional distress is crucial to retaining and recruiting nurses in critical care and improving the work situation.
Allowing nurses to recognize the duality of the nurse-patient relationship, in giving and taking from one another, is an important element of healing and growth. Critical care nurses felt that introspection and sharing personal experiences with supportive colleagues, family members, and friends helped to process unresolved issues. Optimal performance in a critical care work environment requires learning and implementation of new self-care strategies that includes maintaining current professional knowledge of evidence-based practice to provide exceptional patient care. Serious issues that continue in the realms of patient ratios, staffing, supplies, and equipment are relevant to nurses to improve patient care. Replenishing one’s self is important to retention of experienced nurses as well as newly dedicated critical care nurses facing these traumatic issues. Intensive care unit nurses are arguably a critically ill patient’s best resource in besting acute, life-threatening illness. This study identifies some critical factors that can protect and strengthen this resource. Further exploration of these factors: compassion fatigue and satisfaction, levels of moral distress, and work engagement in this population of nurses, is indicated.
Two identified sampling limitations within this study were identified. First, the sample was purposive and nonrandomized, which made generalization of findings more difficult. Second, because the study’s sample size was small (n = 26), the power analysis of 59 nurses was not achieved in this pilot study. The higher level of nursing education preparation in this sample made comparisons of educational level moot. Typical response rates to survey may be as low as 30%; therefore, a larger sample pool is required to offset this fact.26 Again, this limited any generalization of findings that potentially could have resulted from this study. Because this study’s convenience sample was limited in size, future replications should recruit a larger sample pool of critical care nurses from more than 1 type of ICU in more than 1 hospital or academic medical center to ensure adequate sample size as indicated by power analysis of 4 variables for statistical analysis of the relationship between these and future variables to refine a theoretical model.
Results of this study did support the theoretical idea that compassion satisfaction or fatigue, moral distress, and work engagement are clinically important issues for ICU nurses and are relational in effect.
Future recommendations for research include examining the interaction of these variables utilizing this design in larger sample sizes and in more than 1 ICU. One additional strategy could be added with the intention of examining approaches for motivation and behavior change to benefit ICU nurses. Strengthening team building and unit-based councils may be examples of addressing the qualitative findings. The effect on new graduate nurses in the trauma SICU has not been studied to identify ways to focus their orientation and easement into dealing with the trauma and violence in critical care. Examining development of resiliency may prove beneficial. Qualitative findings in this study may reflect an ongoing need for greater support for experienced ICU nurses, from both education and management.
These finding are consistent with a body of evidence that recommends nurses in clinical practice implement strategies to reduce moral distress. These include storytelling and group gatherings to share and discuss ethical and clinical situations. Suggestions include educators, social workers, managers, and chaplains lead debriefing sessions after difficult days or events, develop a patient/family task force or invite families to come to talk to staff after discharge, encourage social events within the unit and hospital, and address the systems issues that were brought up in this study such as staffing, role conflicts and management rules, double documentation, supplies, and nurse-patient ratios. Additional formal or informal forums may be designed to allow nurses to talk about feelings and encourage them to listen to patient’s and families’ views, however divergent, to hear the stakeholders and understand their meaning in supporting the choices they make.6,17,26,35,38-40
Trauma research indicates that people involved in traumatic events need to be able to “tell their story” 8 or 9 times before defusing the physiological and psychological impact of stress/distress.15 This is applicable to ICU nurses who report collegial support and relationships in trauma nursing as crucial.15 Timeliness of psychological first aid rather than intensity and detail of initial debriefing has been especially significant in avoiding development of acute stress reaction and acute posttraumatic stress disorder. Thus, caring for the patient is authenticated, and caring for the caregiver is crucial to nursing practice.17,40 Browning40 challenges all leaders in ethics, education, and clinical areas to develop creative approaches to learning that will cultivate moral solutions for patients that are fair to all stakeholders.6,17
2. Needleman J, Buerhaus P, Pankratz S, Leibson CL, Stevens SR, Marcelline H. Nurse staffing and inpatient hospital mortality. N Engl J Med. 2011; 364: 1037–1045.
6. Wiegand DL, Funk M. Consequences of clinical situations that cause critical care nurses to experience moral distress. Nurs Ethics. 2012; 4: 479–487.
7. Ulrich CM, Taylor C, Soeken K, et al. Everyday ethics: ethical issues and stress in nursing practice. J Adv Nurs. 2010; 66 (11): 2510–2519.
9. Ulruh JA. Moral distress: a living nightmare. J Emerg Nurs. 2010; 36 (2): 253–255.
11. Slocum-Gori S, Hemsworth D, Chan WWY, Carson A, Kazanjian A. Understanding compassion satisfaction, compassion fatigue and burnout: a survey of the hospice palliative care workforce. Palliat Med. 2013; 2: 172–178.
13. Coetzee SK, Klopper HC. Compassion fatigue within nursing practice: a concept analysis. Nurs Health Sci. 2001; 12 (2): 235–243.
14. Figley CR. Compassion Fatigue: Coping With Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. New York: Brunner-Mazel; 1995.
15. Yoder EA. Compassion fatigue in nurses. Appl Nurs Res. 2010; 23 (4): 191–197.
16. Boyle D. Countering compassion fatigue: a requisite nursing agenda. Online J Issues Nurs. 2011; 16 (1). Manuscript 2.
17. Elpern EH, Covert B, Kleinpell R. Moral distress of staff nurses in a medical intensive care unit. Am J Crit Care. 2005; 14: 523–530.
18. Houghtaling DLH. Moral distress: an invisible challenge for trauma nurses. J Nurs Trauma
21. Christian MS, Garza AS, Slaughter JE. Work engagement: a quantitative review and test of its relations with task and contextual performance. Personnel Psychol. 2011; 64: 89–136.
22. Aiken L, Clarke S, Cheung R, Sloane D, Silber J. Educational levels of hospital nurses and surgical patient mortality. JAMA. 2003; 290: 1617–1623.
23. Nathaniel AK. Moral reckoning in nursing. West J Nurs Res. 2006; 28: 419–438.
24. Watson J. Jean Watson: theory of human caring. In: Parker ME, ed. Nursing Theories and Nursing Practice. Philadelphia, PA: Davis; 2001: 343–354.
27. Corley MC, Minick P, Elswick R, Jacobs M. Nurse moral distress and ethical work environment. Nurs Ethics. 2005; 12 (4): 381–390.
28. Corely MC, Elswick RK, Gorman M, Clor T. Development and evaluation of a moral distress scale. J Adv Nurs. 2001; 33: 250–256.
29. Meltzer LS, Huckabay LM. Critical care nurses’ perceptions of futile care and its effect on burnout. Am J Crit Care. 2004; 1: 202–208.
31. Krippendorff K. Content Analysis: An Introduction to Its Methodology. Beverly Hills, CA: Sage Publications; 2004.
33. Mobley MJ, Rady MY, Verheijde JL, Patel B, Larson JS. The relationship between moral distress and perception of futile care in the critical care unit. Intensive Crit Care Nurs. 2007; 23: 256–263.
34. Hooper C, Craig J, Janvrin DR, Wetsel MA, Reimels E. Compassion satisfaction, burnout, and compassion fatigue among emergency nurses compared with nurses in other selected inpatient specialties. J Emerg Nurs. 2010; 36: 420–427.
35. Roberts SF, Flannelly KJ, Weaver AJ, Figley CR. Compassion fatigue among chaplains, clergy, and other respondents after September 11th. J Nerv Ment Dis. 2003; 191: 756–758.
36. Lauvrud C, Nonstad K, Palmstierna T. Occurrence of post traumatic stress symptoms and their relationship to Professional Quality of Life (ProQoL) in nursing staff at a forensic psychiatric security unit: a cross-sectional study quality of life outcomes. 2009; 7: 31.
37. Mobley MJ, Rady MY, Verheijde JL, Patel B, Larson JS. The relationship between moral distress and perception of futile care in the critical care unit. Intensive Crit Care Nurs. 2007; 23: 256–263.
38. Mauno S, Kinnunen U, Ruokolainen M. Job demands and resources as antecedents to work engagement: a longitudinal study. J Vocation Behav. 2007; 70: 149–171.
39. Helft PR, Bledsoe PD, Hancock M, Wocial LD. facilitated ethics conversations: a novel program for managing moral distress in bedside nursing staff. JONAS Healthc Law Ethics Regul. 2009; 11: 27–33.
40. Browning DM. Sturdy for common things: cultivating moral sensemaking on the front lines of practice. J Med Ethic. 2011; 38 (4): 233–235.
Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.