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SYSTEMATIC REVIEWS

Experiences of compassion fatigue in direct care nurses: a qualitative systematic review

Salmond, Erin1,2; Salmond, Susan1,3; Ames, Margaret1,2; Kamienski, Mary1,3; Holly, Cheryl1,3

Author Information
JBI Database of Systematic Reviews and Implementation Reports: May 2019 - Volume 17 - Issue 5 - p 682-753
doi: 10.11124/JBISRIR-2017-003818
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Abstract

Summary of Findings

Introduction

Compassion satisfaction creates a sense of worth that has been described as the most rewarding part of what nurses do.1 It is “the positive feelings derived from helping others through traumatic events”.2(p.33) Those experiencing compassion satisfaction derive gratification from their work and feel positive about the patient, patient's family, care team and their ability to contribute to better care and, therefore, better patient outcomes.3

Compassion satisfaction is not a static phenomenon, rather, it is influenced by the cumulative demands of experiencing and helping others through suffering.4 These demands, sometimes referred to as the “cost of caring”,5 can have negative consequences. The emotional demands of constant exposure to human suffering, no matter how satisfying the outcome, can lead to compassion fatigue (CF). Compassion fatigue may emerge as nurses continually connect with patients who are suffering and absorb the patient's trauma or pain, or when nurses caring for traumatized patients re-experience their patient's traumatic events.6 Figley5 equates CF with secondary traumatic stress, wherein caregivers experiencing CF do not physically experience the traumatic events, but do experience the event emotionally while caring for the patient. Coetzee and Klopper's7 definition of CF goes beyond the experience of secondary traumatic stress stating that CF “is the final result of a progressive and cumulative process that is caused by the prolonged continuous and intense contact with patients, the use of self, and the exposure to stress.”(p.237) The authors find it important to note that the absence of a consensus on the definition of CF within nursing has led to “the inability to identify and combat its effect on nursing practice.”(p.235)

The ongoing empathic connection of caring for others, especially those with significant trauma or stress, has consequences that can manifest as psychological distress and an inability to empathically connect. Experiences of CF may encompass and even go beyond burnout, when nurses may be less empathic with patients and more irritable with coworkers.6 Rather, CF is a state of destructive emotional distress in which one feels isolated, confused and helpless in caring for others8 and has also been labeled a state of exhaustion – physically, spiritually and emotionally.1,4

Nurses may succumb to the overall stress of human suffering if they do not have an adequate outlet to decompress or maintain a professional and emotional work-life balance.1 In CF, nurses absorb the emotions of traumatic stress from patients, colleagues and families and have little time to mourn and disconnect.8 Personal mediators of CF have been proposed to include level of empathy, resilience and hope – all of which may lead to a positive sense of accomplishment from caring and act as a barrier against CF.9 Additionally, older age, years of education and experience may provide some protection against CF. Management support in the work environment, reasonable work hours and caseloads, and specialized trauma training are management strategies that may build resilience and mitigate CF.10

Compassion fatigue negatively affects the emotional and physical health of nurses and their sense of job satisfaction. Moreover, CF impacts the healthcare organization as nurses become more pessimistic about the ability for positive change. Consequently, productivity and quality go down, absenteeism increases, intention to leave one's job rises and turnover increases.11-13 Compassion fatigue can take away major attributes of effective nursing – empathy and caring – which are essential to building trust in the nurse/patient relationship. Compassion fatigue leads nurses to withdraw or distance themselves from the patient and family and focus on the technical aspects of the job, avoid the essential development of the nurse/patient relationship and generally become more pessimistic about the ability for positive change.14

Van Mol et al.15 summarized the available literature indicating that the prevalence of CF among intensive care nurses ranged from 7.3% to 40%. Reporting on professional care providers, Rao and Taliaferro16 suggested that an average of more than 30% of professional care providers, including nurses, exhibit CF symptomatology. Compassion fatigue has been found to be more prevalent in specialties that deal to greater degrees with trauma and death.16

MacKusick and Minick12 examined why nurses left the bedside and they identified recurring themes of emotional distress related to patient care, fatigue and exhaustion. The nurses in the study reported that their feelings of hopelessness and emotional distress led to calling in sick, looking for other positions or leaving the profession. De Boer et al.17 used a qualitative exploratory approach examining critical incidents among intensive care unit (ICU) nurses to describe CF and the need for support. They identified four main themes contributing to CF: i) high emotional involvement in patient-related incidents; ii) avoidable incidents; iii) sub-standard patient care; and iv) intimidation. Nurses in the study stated that after these events they experienced emotional, cognitive/behavioral and physical reactions. They coped by talking with peers or family/friends, but felt their need for support was inadequately met and could have used additional support.

A search of JBI Database of Systematic Reviews and Implementation Reports, Cochrane Library, MEDLINE, CINAHL and Google Scholar found three systematic reviews and one systematic review protocol related to the experience of CF in nursing and interventions to cope with CF. One review15 looked at prevalence of CF and burnout among healthcare professionals in ICUs and preventive strategies that have been successfully applied to reduce distress. A second quantitative review18 examined CF among healthcare, emergency and community service workers and interventions and workplace strategies to reduce CF. In the third review19 spanning literature from 2009 to 2013, coping and resilience in palliative and oncology nurses caring for adult patients with malignancy were examined. Although this is a broader question than CF, CF was listed as one of several phenomena of interest in this review, which captured both quantitative and qualitative studies. One synthesis reported in the study was that “personal coping and resilience is facilitated by a conscious effort to maintain a work life balance, engage in self-care, process emotions that arise from work encounters, acknowledge death, and apply insights gained with maturity”.19(p.157) This finding was particularly relevant to the current study as it spoke to strategies that may be protective in preventing and coping with CF. The systematic review protocol by Hodge and Lockwood,20 published in the JBI Database of Systematic Reviews and Implementation Reports in December 2013, seeks to explore interventions that can be implemented by nursing leaders to decrease CF in acute care oncology nurses. The qualitative aspect of the review focused on the experience of planned interventions at decreasing CF, which is more limited than what was proposed in this review.

Although systematic reviews have addressed the concept of CF, it remains poorly understood. It is important that we gain a more comprehensive understanding of CF in its entirety, including an understanding of the experience itself from those who actually gone through it. With a more in-depth understanding it is expected that factors contributing to or mediating CF, symptoms of CF, and strategies used to minimize or cope with the feelings encountered will be elucidated.11 The objective of this qualitative systematic review was to examine the phenomenon of CF in direct care nurses and nurse midwives working in any specialty within any care setting.

Review question

The overarching review question was: what are the experiences of compassion fatigue (CF) in direct care nurses in any nursing specialty or care setting? The review examined evidence on:

  • Direct care nurses’ perceptions of factors that contribute to or mediate CF.
  • Direct care nurses’ ability to recognize CF and care for themselves when experiencing the phenomenon.
  • Direct care nurses’ experience of strategies to cope with CF.

Inclusion criteria

Types of participants

This review included qualitative studies of licensed nurses working in direct care nursing roles. Direct care nurses are defined as nurses who provide direct hands-on care to patients and includes nurses working at the bedside as well as nurses in expanded roles such as nurse midwife and nurse practitioner. Papers describing CF in the student nurse population were excluded.

Phenomena of interest

The current review explored the experiences of direct care nurses with CF as a result of their work. It did not include studies of nurses with burnout as burnout is conceptualized as a different phenomenon. For the purposes of this review, CF is defined as the final result of a progressive and cumulative process that evolves from compassion stress after a period of unrelieved compassion discomfort caused by prolonged, continuous and intense contact with patients, the use of self, and exposure to stress.7

Context

This review considered studies drawn from any nursing specialty or any nursing work setting in which nurses were working directly with patients.

Types of studies

This review considered studies that focused on qualitative studies including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research, narrative case studies and feminist research. Studies included in this review include those published in full text, English and between 1992, when the concept of CF was first described,21 and May 2017 when the search was performed. This broad search strategy was used to increase the sensitivity of the results.

Methods

This review followed the JBI approach for qualitative systematic review.22 An a priori protocol was published July 2017.23

Search strategy

The search strategy aimed to find published and unpublished studies by searching academic databases for published studies, searching sources of gray literature for unpublished literature, and hand searching reference lists for studies not identified through the search of databases and gray literature.

Academic database searching was initially undertaken with a limited search of PubMed and CINAHL using the terms “compassion fatigue and compassion satisfaction AND nursing”. This was followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second expanded search using all identified keywords and index terms tailored to specific databases was then undertaken. The databases searched during this phase included: PubMed, CINAHL, Academic Search Premiere, Science Direct, Scopus, PsycINFO, Web of Science and JSTOR. The full search strategy is presented in Appendix I. The search was completed in May 2017.

The following were searched for unpublished studies: MedNar, Google Scholar, Virginia Henderson Library of Sigma Theta Tau International, Robert Wood Johnson Foundation Research and Publications, and ProQuest Dissertations and Theses. These sources were searched using various keywords and combinations of keywords suitable to the source. Keywords included nurses, compassion fatigue, compassion stress, fatigue, secondary traumatic stress, vicarious trauma, strategies and or interventions, self-care.

Hand searching of all publications and identified reports was done to identify additional studies.

Study selection

Following the search, all citations were collated and uploaded into EndNote X8 (Clarivate Analytics, PA, USA) for Windows and duplicates were removed. The titles and abstracts of articles identified from the search were reviewed independently by two reviewers for appropriateness. The independent assessments were compared and any differences were handled by joint review and discussion of the relevant title and abstract. Those deemed appropriate for inclusion were retrieved in full text, re-reviewed against the inclusion criteria, and eligible study details were entered into the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI) (Joanna Briggs Institute, Adelaide, Australia).

Assessment of methodological quality

Papers meeting inclusion criteria were assessed independently by two reviewers for methodological validity prior to inclusion in the review using the JBI Critical Appraisal Checklist for Qualitative Research.22 All studies were appraised using the full criteria; however, papers not meeting criterion 2 (congruity between the research methodology and the research question or objectives), criterion 4 (congruity between the research methodology and the representation of the analysis of data) and criterion 8 (participants and their voices are adequately represented) were excluded without further review. This ensured that the methodological approaches were appropriate and that the voices and meanings of study participants were captured. Any disagreement that arose between the two reviewers was to be resolved by a third reviewer; however, the two reviewers were able to resolve all disagreements.

Data extraction

Qualitative data were extracted from included papers independently by two reviewers using the standardized JBI Qualitative Data Extraction Tool.22 Results were cross-checked, and any differences discussed and clarified prior to entering data into JBI SUMARI. Initial extraction included data relevant to the phenomena of interest, populations, study methods, outcomes specific to the review question and objectives. Findings were verbatim extractions of the authors’ analytic interpretations (themes), along with relevant illustrations (participant quotes or fieldwork observations), if available, and page numbers of the findings. The reviewers then assigned a level of validity or credibility; these were unequivocal (evidence beyond reasonable doubt), credible (an interpretation, plausible in light of the data and theoretical framework), or unsupported (findings are not supported by the data or lacking data). Authors of primary studies were to be contacted for missing information; however, this proved unnecessary.

Data synthesis

Qualitative research findings were pooled using methods outlined in the JBI approach for qualitative systematic review.22 This involved the aggregation or synthesis of findings to generate a set of statements that represent that aggregation by: assembling the findings (level 1 findings), rating findings according to their quality, and categorizing these findings on the basis of similarity in meaning (level 2 findings). These categories were then subjected to a meta-synthesis to produce a comprehensive set of synthesized findings (level 3 findings) that could be used as a basis for evidence-based practice.22

Two members of the review team (ES and SS) undertook repeated readings of the papers and extracted findings and accompanying illustrations. The extracted findings were examined for shared meaning, coded and grouped into draft categories collaboratively. The draft categories and accompanying findings/illustrations were reexamined one week later. The categories were refined and defined and all findings were re-reviewed for fit. The categories, consisting of at least two findings per category, were cross-checked by an additional coauthor (CH) and final definitions and findings were achieved by consensus. Two reviewers then grouped common categories into final meta-syntheses statements that addressed the three research questions pertaining to direct care nurses’ perceptions of: factors that contribute to or mediate CF, ability to recognize CF and care for themselves when experiencing the phenomenon, and strategies that assisted them to cope with CF. The final meta-synthesis statements were reviewed and refined by the entire team.

Assessing certainty in the findings

The synthesized findings were subjected to an assessment, using the JBI ConQual approach, to determine the level of confidence (trust) knowledge users may have in the value of the synthesized findings for informing healthcare practice and policy.24 Within the approach, the level of confidence for each synthesized finding is scored as high, moderate, low or very low on the basis of the dependability of the primary studies from which the synthesized finding was composed and the credibility of the research findings from those studies. Dependability for each study is established through the responses to five criteria on the JBI Critical Appraisal Checklist for Qualitative Research. The dependability score (i.e. high, moderate, low) of the specific study is then applied to the research findings from that study. The dependability for the synthesized finding is thereafter determined on the basis of the aggregated level of dependability from across the included research findings. The credibility of each research finding is established through determining the congruency between the study author's interpretation and the accompanying data (e.g. participant quotations), that is, whether the finding is unequivocal, credible or unsupported. The credibility for the synthesized finding is determined as high if research findings comprising the synthesized finding are unequivocal, as moderate if the research findings are a combination of unequivocal and credible, and as low if the research findings are credible only. The ConQual score is downgraded in consecutive order, from a starting point of high, on the basis of summing the scores applied to dependability and credibility.

Results

Study inclusion

Figure 1 presents a diagrammatic representation of the results of the search approach and study selection process using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method.25 There were 3146 studies identified from the search strategy and a total of 2297 were eligible for inclusion after duplicates were removed. No additional studies were located through hand searching. All were screened for inclusion based on title and abstract and 2229 were excluded. A total of 68 publications (including 55 articles, 12 dissertations and one book reporting a nationwide study) were assessed for inclusion through full text review using inclusion and exclusion criteria. Thirty-eight articles and six dissertations were then excluded after full text review, leaving 24 total studies that were appraised for methodological quality.22 One study was excluded for not meeting inclusion criterion 2 as it lacked congruity between the research methodology and the research questions or objectives – a mandatory criterion in this review. Appendix II provides information on excluded studies and the reasons for exclusion.

Figure 1
Figure 1:
Search results and study selection and inclusion process25

Methodological quality

A total of 24 articles were reviewed for methodological quality. One study26 was excluded because it lacked congruity between the research methodology and the research questions or objectives, a mandatory criterion; the remaining 23 studies were of moderate to high quality: 11 studies met all 10 of the critical appraisal criteria,27-37 nine studies38-46 met nine of the criteria and three studies47-49 met eight of the criteria. All studies rated positively for questions related to congruity between research methodology and research question, research methodology and methods, methodology and representation of the analysis of data, research methodology and interpretation of results, ethical approval, conclusion drawn and voices represented. Six studies39,40,43,47-49 did not describe data related to congruity between philosophical perspective and research methodology. Five studies did not have a statement locating the researcher culturally or theoretically.38,44,47-49 Four studies did not identify the influence of the researcher on the research.41,42,45,46 Critical appraisal of the excluded studies is presented in Table 1.

Table 1
Table 1:
Assessment of methodological quality of included studies

Characteristics of included studies

The 23 included studies were papers published over a 12-year period from 2004 to 2016. All used a qualitative methodology, specifically: nine used phenomenology28,30,33,36,37,40,41,45,46 11 were interpretive qualitative descriptive27,29,31,32,34,35,39,42-44,48 and three were mixed methods38,47,49 inclusive of a qualitative component, which allowed extraction of data relevant to this review. Studies used semi-structured in-person or telephone interviews,27,28,30-37,39,40,42-46,48 open-ended interview questions answered by pen and paper,38,41,43,47,49 or focus groups29 to collect data. Sample sizes ranged from five to 27 for studies using verbal interviews or focus groups.29-37,39,40,42,44-46,48 For studies that used a written narrative approach asking participants to describe situations where they experienced CF or a traumatic event and how they got through it, sample sizes ranged from 25 to 322.38,41,43,47,49 The total aggregate sample size for this review was 821 participants.

Seven countries were represented in the studies: US29-32,35-38,42,47-49 South Africa45,46 Canada27,28,33,34,43 Jordan41 Netherlands,39 Israel,40 and Australia.44 A variety of clinical contexts in terms of nursing specialties were represented including: emergency room, intensive care, maternal-child, oncology, hospice, home health, community health, ambulatory and psychiatry. Appendix III provides key characteristics of included studies.

Review findings

A total of 261 findings were extracted from the 23 studies (Appendix IV) and combined to form 18 categories based on similarity of meanings. The categories were collated to four synthesized findings (meta-synthesis). One synthesis related to factors perceived to contribute to CF (i.e. stressors related to nurses’ caring work and the work environment itself); one to how nurses responded to high stress and critical incidents; one to the symptoms of CF; and one to coping strategies used to deal with potential and actual CF. Table 2 depicts the number of findings that are included in the categories and the categories that connect to each synthesized finding to illustrate the overall synthesis process. Appendices V–VIII present each synthesis with accompanying categories and findings.

Table 2
Table 2:
Results of meta-synthesis of qualitative research findings

Synthesized finding 1

Central to the work of nursing and the professional environment in which nurses work are significant psychosocial stressors that contribute to compassion stress and, if left unchecked, can lead to CF.

This meta-synthesis was created from seven categories and 99 findings. Studies clearly described ongoing demands of connecting with patients and family who were suffering or experiencing traumatic events while working within a perceived war zone environment of rapid fire, high priority demands and high workload expectations creating constant stress. When the nurse knows the right thing to do to provide quality care but lacks the skills or support to provide this level care, the nurse feels powerless and overwhelmed. Lack of awareness and lack of action to address these issues puts the nurse at risk. Together the stage is set for CF.

Category 1: A movie constantly on rewind

Fourteen findings were combined to form this category, which captured the experience of intrusive, vivid, recollections occurring when nurses witness and care for patients with traumatic events, especially those associated with moral distress or not knowing the outcomes of patients in their care.

Category 2: Anguished, helpless and powerless: reacting to moral distress

Captured in 20 findings were the strong emotions of anguish, helplessness and powerlessness when nurses face situations where they know the right thing to do but constraints make it impossible to pursue the right course of action. The many forces causing nursing to be less humanistic–predominantly a focus on tasks and treatment–prevent care from being delivered in the way nurses want and leaves them feeling helpless.

Category 3: Blind to CF

Six findings portrayed that some nurses are unaware of CF even though it looms over most helping professions. Colleagues may see it, hear it and notice it, but the person experiencing CF may remain unaware. The system in which the individual nurse works generally avoids acknowledging CF and does not provide resources or supports to prevent CF.

Category 4: Strong connections… and I can’t make the outcome better

Six findings were grouped to illustrate the belief that nurses vulnerability to CF increases in situations where patient outcomes cannot be changed, despite strong connections and quality care.

Category 5: The double-edged sword of connection

Nineteen findings captured both the favorable and unfavorable aspects of connection in relation to compassion satisfaction and CF. Engaging in meaningful human-to-human encounters and developing connections with patients fuels nurse satisfaction even when it is accompanied by sadness. However, excessive connection and loss can eat away at one's reserves and lead to emotional overload.

Category 6: The war zone of nursing – juggling continuous demands

Twenty-one findings were combined to represent the psychosocial stressors associated with the work environment. The front line of nursing is marked by regular bombardment of high-priority demands leaving the nurse rushing and juggling multiple tasks. In an environment where you are helping a patient through their “worst day” while trying to balance three other people's worst days, the nurse barely has time to “tie one's shoes or go to the bathroom”35(p.155) as there is always something that needs to be done. Due to this ongoing pressure, nurses are fearful that they will make a mistake – that a ball will drop.

Category 7: The system is letting me down

Thirteen findings were related as they addressed inadequate support in the system to stave off CF. This included lack of system and managerial support for ongoing problems, providing needed respites and ongoing education. Inadequate staffing, high workload expectations and a sense that there is no time for patients due to other demands on a nurse's time (documentation, meetings and compliance requirements) frustrated nurses and impeded their ability to provide care.

Synthesized finding 2

Protection against the stress of the work and professional environment necessitates that the individual and team learn how to respond to “the heat of the moment”.

This meta-synthesis was created from five categories and 50 findings. Protection against the stress of the work and professional environment necessitates learning and practicing strategies that allow one to keep going and continue giving. This may involve distracting oneself to cool down and accepting the situation or outcome and moving on. Reviewing the events by reflecting on what could be done differently can facilitate learning or leave the nurse trapped in regret. It is clear that stress cannot generally be managed alone. Suffering in silence and moving on to the next patient depletes the nurse, whereas availability and support from the team can replenish energy.

Category 8: Accept and move on

Six findings were combined to capture the coping strategy of accepting and moving on. Some nurses cope with traumatic and critical events by learning to accept the situation so they can move on and care for others. It requires a level of detachment, in which you can still have empathy and still appropriately interact with the patient, but then walk away.

Category 9: Did I do things right?

Six related findings focused on the self-reflection and questioning of whether the nurse did the right thing during a traumatic episode, critical incident or unexpected event. This entails reflection and analysis of the situation as to what could have been done differently. Sometimes this leads to learning and sometimes to self-blame and guilt.

Category 10: I can’t handle this alone… you need a team

Twenty-two similar findings were brought together to emphasize that managing the psychosocial stressors that may precede CF cannot be done alone. Protection from CF within a workplace with a high demand environment and exposure to suffering and traumatic stress requires support from the team; assistance when physical and emotional demands are high and an opportunity to debrief and decompress. Getting through it together refuels the individual and provides the needed emotional and practical support to recover. In the absence of team refueling, the nurse feels abandoned, betrayed and isolated.

Category 11: Managing the traumatic event – distraction

Three findings were categorized as managing the traumatic event through distraction. Needing to take a break from the high stress of a traumatic event helps to “cool the person down” and distract from the situation. Organizations that require nurses to take breaks provide a forced period of rest and distraction.

Category 12: Suffering in silence… moving on to the next patient… putting on a new face of happiness

Thirteen findings collectively addressed how in the aftermath of trauma, loss or other painful experiences, the nurse must move on to the next patient. It is emotionally draining to be strong, or at least to appear strong, while suffering inside. Without supports to assist or debrief, the nurse may not handle the situation and keep events, emotions, and suffering a secret; a private burden. They continue to take care of patients while putting on a mask to hide their emotions.

Synthesized finding 3

Nurses and other administrative and colleague staff should be alert to the symptoms of CF that present as profound, progressive, physical and emotional fatigue: a feeling that the nurse just can’t go on and a sense of being disconnected and drained, like a gas tank on empty.

This meta-synthesis summarizes 49 findings divided into two categories. Unmanaged, the stress accumulates and overwhelms the nurse. They experience profound, progressive, physical and emotional fatigue and feel that they just can’t go on. They may be present at home or work but are only going through the motions; they are disconnected and drained, like a gas tank on empty.

Category 13: Drained, disconnected and running on empty

Thirty-seven findings blended into the category describing CF symptoms. Compassion fatigue is marked by profound, progressive physical and emotional tiredness which is accompanied by manifestations such as headache, heaviness in the chest, aches and pains, disrupted sleep, foggy memory, holding back tears and crying. A marked distinction is the inability to refuel, leaving the nurse with no spark left, feeling empty, defeated by the work and wondering how they can go on. The nurse is exhausted and disconnected with no emotion. They work on “auto-pilot” sensing they are not the nurse they know they should be. These symptoms extend beyond the walls of the workplace and begin to take over one's life, robbing family of what should be their appropriate attention.

Category 14: Physically present but emotionally running away

Twelve findings shared the experience of continuing patient care while emotionally detached due to CF. Nurses experiencing CF detach emotionally and act on “autopilot”. They go through the tasks of providing care but are emotionally detached from the human side of the patient experience. If possible, they try to avoid high risk patients as they don’t know how they can continue to give care in the presence of ongoing sadness and suffering.

Synthesized finding 4

Keeping CF at bay requires awareness of the threat of CF, symptoms of CF, and the need for work-life balance and active self-care strategies.

This meta-synthesis summarizes 63 findings that fell into four categories. The following behaviors help nurses assess whether they are slipping into CF and take measures to cope: being aware of the ever-present threat of CF, the symptoms of CF stress and fatigue, and the need for work-life balance. Reflecting on the purpose and value of nursing and the “good” accomplished is central to staying positive and continuing to care. To keep caring, nurses need to undertake periodic self-assessments of what and how much they are doing to cope and renew themselves. Sharing responsibility with leaders and staff in creating strong teams and supportive work environments helps to manage the stress. The absence of strategies to keep CF at bay can lead to a decision to move away from the stress and pain that is nursing.

Category 15: Can I stay or do I leave?

Six related findings were sorted into the category where nurses questioned whether they would stay in the profession. Feeling that they can no longer live up to their expectations of being good nurses and feeling emotionally overwhelmed, disengaged, and ineffectual, some nurses considered taking positions that were less emotionally demanding or leaving nursing all together.

Category 16: Creating a culture of compassion for the nurse

Thirteen findings shared a focus on creating a culture of compassion for the nurse. If nurses are to provide quality, compassionate care they must work within an environment that values nursing and is aware of and takes active measures to mitigate CF. There is no one approach for keeping CF at bay but providing support in the form of being positive, intolerant of incivility, acknowledging staff, and providing time for decompression, support groups, mentorship, and education are meaningful. One person cannot create the culture nor provide the needed support; it must come from the team, so proactive investment in team development is important.

Category 17: My balance is slipping

Nine findings stressed the importance of being aware when one's balance was slipping. Nurses need to be alert to the risks of a misaligned work-life balance. Taking the time to assess whether they are neglecting one part of their life allows for readjusting. If working long hours or feeling overpowered by work, then it may be helpful to take time for self, keep busy out of work and separate work and non-work. If home life is overpowering, then stepping back from work stress may be needed.

Category 18: Developing individual resiliency to manage the collar of compassion fatigue

Thirty-five findings were combined, as they provided strategies for developing resiliency and managing compassion distress before it developed into CF. Coping with the ever-looming collar of CF requires developing one's own resilience to stay energized. Nurses do this by focusing on the gift that is nursing and the value nurses brings in making things better for a person or family even when painful outcomes cannot be avoided. Investing in one's own learning to develop skills to strengthen the ability to manage the emotional stressors of work and reaching out to supportive networks to avoid “suffering” alone, can revive the spirit. Renewal and resilience also come from investing in self-care and finding what is renewing for each individual, whether it is reflection, exercise, spirituality, hobbies or socialization.

Discussion

This systematic review of qualitative evidence was undertaken to better understand the experiences of direct care nurses with CF, antecedents, responses to critical events, symptoms and coping mechanisms. Sixteen research papers,27,30,32,33,38-49 six dissertations29,31,34-36,48 and one book28 describing a nationwide study were included in the review after an exhaustive search and inclusion process. Direct care nurses from seven countries yielded qualitative descriptive data through various qualitative and mixed methods designs. The level of evidence, using ConQual, was interpreted to be high. The four synthesized findings had high dependability ratings. For credibility ratings, 258 findings were unequivocal and 6 were credible. Synthesized findings one and three included only unequivocal findings. Of the remaining two, the percent of unequivocal findings was greater than 90% (synthesized finding 2 had 48 unequivocal and two credible findings and synthesized finding 4 had 60 unequivocal and four credible). Although Munn et al.25 recommend that 100% of the findings be unequivocal, this approach is in its early stages and open to interpretation. One of the authors of this study (SS) discussed the large number of unequivocal findings and the small number of credible findings with the first author, Munn, of the seminal paper on the ConQual approach, and it was resolved that it was legitimate to conclude that the findings had high credibility (Munn, 2017). The use of a range for qualitative findings is consistent with quantitative methods where an I2 is used to examine the percentage variation and a confidence interval is provided for readers to assess the consistency of the results in the meta-analysis.50 This approach is plausible due to the lack of homogeneity between international studies, given differences in language, context and illness severity of patients as well as the differing ways in which individual nurses address and handle stressful situations and the lack of conceptual clarity for CF in the included studies.

The literature is replete with articles on CF, but the definition of CF varies greatly. Some see CF to be vicarious trauma or secondary traumatic stress,4,48 others see CF as the result of post-traumatic stress5,51,52 or from a combination of post-traumatic stress and burnout,49,53 and in some cases, burnout is equated with CF.54 This systematic review understands the continuous exposure to compassion stress, moral distress events, and secondary traumatic events to be contributors to compassion distress and compassion satisfaction to be a mediator of the distress. This distress can be further aggravated by the stress inherent in working within a healthcare environment marked by multiple stressors, what was termed by one nurse as a “war zone”48 because of the intense passion, emotion and fast pace that characterized the work place. These environmental stressors, frequently identified as antecedents to burnout, contribute to work stress and are part of the work environment in which nurses must develop compassionate connections with patients. When environmental stressors, such as resource shortages,55 marginalization of nurses, poor nurse staffing, high work-loads, and the increasing complexity of health care, prevent nurses from being able to provide compassionate care, they become an antecedent to not only decreased satisfaction but also compassion distress, which if not managed can lead to the development of CF.9,56,64 Separation of the concepts of CF and burnout is consistent with the CF in mental health professions narrative review,57 which differentiated the distinguishing features of burnout to encompass environmental and organizational stressors and CF as psychological and emotional processes arising from interactions with others. The findings in this review suggest support for Coetze's8 definition that CF is the final result of a progressive and cumulative process that evolves from compassion stress after a period of unrelieved compassion discomfort, which is caused by prolonged, continuous, and intense contact with patients, the use of self, and exposure to stress.8 Compassion fatigue is not inevitable. As proposed by Fernando and Consedine,58 there appears to be a dynamic interplay between the caregiver, clinical condition, patent and family and the work environment itself. Bringing CF out of the closet and actively providing support to nurses in moments of high compassion distress, building resiliency for compassion, and managing compassion distress are key priorities from this study.

Taken together, the synthesized findings answer the specific research objectives to understand direct care nurses’ perceptions of factors contributing to and mediating CF, ability to recognize CF, ability to care for themselves, and CF coping strategies.

Direct care nurses’ perceptions of factors that contribute to or mediate compassion fatigue

Findings from this systematic review reinforce results from multiple studies that found that nurses are exposed to numerous stressors arising from the work of nursing, the work environment, and the challenges of balancing home and work responsibilities.59-61 These stressors (captured in synthesized finding one) may result in distress, depending on how they are perceived and responded to by the nurse.

Inherent in nursing work, is what Figley4 terms the cost of caring. A compassionate, intimate connection occurs between nurses and patients and their families as the nurse cares for the patient during critical times in that person's life. Within this connection, the nurse is drawn into existential concerns of pain, altered life, death, sadness and loss. Oftentimes, this compassionate connection leads to compassion satisfaction, the inspiration and self-fulfillment that a nurse receives “from connecting with and sharing in a patient's suffering” to “relieve and alleviate the patient's pain” and distress.7(p.239) For these individuals, the meaningful human-to-human encounter is seen as a gift and enhances job satisfaction. As captured by one nurse: “what other professional has such a chance to confront daily the real essence of living—relating to another person. How could I not love my job?”33(p.89) With connection, nurses receive gratification and reward in their caregiving role62 and, although also exposed to stress, they are able to grow and flourish. These findings are consistent with studies on workplace compassion, which have demonstrated that compassionate interaction, whether with patients or colleagues, can strengthen emotional connections in the workplace and facilitate affective commitment and productivity.58,63,64

The paradox, however, is that there is a “double edged sword of connection”. Although it is affirming and associated with a job well done, using one's therapeutic self, being emotionally and physically present to alleviate suffering, can cause compassion distress and take a toll on the nurse's emotional wellbeing, resulting in escalating compassion stress, manifesting as physical and emotional fatigue that can progress to CF.9,11,62 The continuous, day-in and day-out exposure to patient suffering and need for connection in order to provide compassionate care is an occupational stressor that may increase the vulnerability of the nurse to compassion distress and ultimately CF.43,65

There are a number of circumstances that potentiate connection stress or that may be a deterrent to compassion thereby contributing to CF, including inability to alter suffering and negative outcomes, witness to vivid trauma, moral distress and reflective guilt and distress over events. The inability to relieve suffering or influence a negative outcome despite quality care (as may occur with downward trajectories, death and return of patients to traumatic environments) were key factors in intensifying distress. Sheppard66 identified similar antecedents and labeled the concerns as “life is unfair” and “endless suffering”.(p.58)

Recognizing and responding to critical incidents that cause compassion distress

Although nurses may be at risk for CF, many were not aware of CF as a phenomenon and the need to assess for its occurrence. In addition to being individually blind to the potential for CF, there was a sense that the system had generally avoided acknowledging CF and failed to provide resources and supports to prevent CF. Compassion fatigue was the “elephant in the room”; although some knew about it, it was swept under the rug. Awareness of the potential for CF and facilitating adaptive responses to compassion distress has become a priority in health care today67 as provider satisfaction with work life/workplace has become a priority.

Fernando and Consedine58 refer to the transactional model of physician compassion that recognizes the dynamic interplay between the caregiver, clinical condition, patient and family and the work environment itself. Findings from this review support this transactional interplay, highlighting that CF is not a foregone conclusion. Bringing CF out of the closet, actively planning to provide support to nurses in moments of high compassion distress, building resiliency for compassion and managing compassion distress are key priorities from this study.

Stressors are not inherently deleterious. Each individual nurse's personality traits and own cognitive appraisal gives meaning to events and determines whether events are viewed as threatening or positive.60 Coping refers to the ability to manage stressors that are interpreted as adverse so they can be minimized or tolerated.68 The initial coping reaction in response to the critical event and the support received, together, determine the stressfulness of the experience. The ability to accept the situation and move on is an adaptive skill that allows the nurse to continue to care for others, both within the workplace and at home. Figley4 refers to this as detachment: the extent to which the nurse can let go of thoughts, feelings and sensations associated with the patient; detachment is an important component of a balanced life. Figley's findings are consistent with those of Sheppard66 who similarly found that an inability to let go led to ongoing memories that triggered ongoing pain, sadness or anger.

Being able to detach following a traumatic event required distraction to help “cool the person down” and relieve the tension. This distraction could take the form of a break, but more frequently required supportive team members and/or supervisors to help the person to debrief, decompress, and provide supportive acknowledgement. Supportive debriefing facilitated reflection on the situation, confirmed team member support and compassion, and sometimes led to learning from the situation, all of which helped the nurse move on. Absence of supportive debriefing can lead to self-blame and guilt. Kapoulitsas and Corcoran69 identified a similar need for a supportive work environment and positive supervision in developing resilience among social workers in response to critical events.

Peer support refuels the individual and provides the needed emotional and practical support to detach and recover. Without this, stress increases and the nurse is left to manage alone. Alone, the nurse feels abandoned, isolated and must suffer in silence; the nurse must move onto the next patient, the next situation, with a mask, a façade of happiness.

Recognizing signs of compassion fatigue

The symptoms of CF summarized in this systematic review within synthesized finding three can be captured in the metaphor of “running on empty.” Nurses who are constantly caring for others and not replenishing their energy stores may exhibit compassion distress and ultimately CF. The job that once empowered them becomes an emotional burden that drains their energy. Compassion distress, which leads up to CF presents as mild CF.4,8 Symptoms summarized in this review are consistent with other literature across disciplines, which have classified symptoms as physical, emotional (behavioral and psychological), and spiritual although there is some overlap in their presentation.69-72 Physical symptoms identified in this review include what one nurse referred to as a “cycle of fatigue…heaviness in the chest, lumps in the throat, foggy memory, and holding back tears. I began not to feel as strong. The constant pain and suffering along with seeing people die was affecting me personally. I couldn’t remember ever feeling so exhausted”.43(p.95) The exhaustion, often accompanied by sadness, presented as “an overwhelming fatigue that I couldn’t get rid of no matter how much I slept.”43(p.94) Sleeplessness contributes to the fatigue and sleeplessness becomes a reality when work stress accelerates and nurses wake up thinking of work and critical events that have not been worked through. Stemming from the fatigue, the individual withdraws from normal social interactions and routine self-care. Hypervigilance was present: “the feeling of hypervigilance—where my pulse is a bit higher, blood pressure too probably, where I am ever ready? If there was a loud noise I may hit the floor running.”43(p.94)

The fatigue is both physical and emotional and becomes a barrier to accomplishing one's work and personal activities. As compassion stress advances, there is an inability to provide compassionate care. Nurses go through the motions of providing care but there is a disconnection – an absence of feeling. This disconnection was described as feeling like a robot. Continuing to provide care becomes taxing and emotionally overwhelming. In response to these feelings, some nurses tried to avoid patients that were high stress while others invested more and became “extra-attentive to the patients”,39(p.170) yet it did not result in the satisfaction that had previously come from nursing. Spiritual symptoms manifested as questioning the value of one's work and one's commitment to nursing and ability to stay in the profession of nursing. Dissatisfaction with the profession was evident.

Direct care nurses’ experience of strategies used to cope with compassion fatigue

There are different conceptions in the literature on whether it is possible to halt the progression of CF.58,70,73 This systematic review does not support the notion of the inevitability of CF, rather it suggests that there are both personal and organizational coping strategies and adaptive processes to counteract or alleviate the symptoms of CF. Responding to CF is an evolving process that occurs throughout compassion stress/distress and CF, which encompasses both personal and organizational strategies.74

Personal approaches

Coping is often multifaceted: there is no “one size fits all” approach. Individual nurses develop their own personal resilience plan and are on the alert for a misaligned work-life balance. Taking the time to assess misalignment and making needed adjustments is an ongoing process. It is important to be mindful of one's own personal plan of care for healthy work-life balance and manage compassion distress and stress. Healthy self-care strategies, sleep, nutrition, exercise, hobbies, socializing, reflection and spirituality (prayer, devotions, and meaningful, enjoyable creative pursuits), are important to balance and renew.

In addition to self-care and work-life balance strategies, approaches are needed that help nurses keep their spark going; the spark that reminds them of the positives in nursing, good that has been accomplished and differences that have been made. These approaches are restorative and reconnect nurses to the satisfaction of compassionate connection.7 This includes supporting nurses to recognize that they cannot change all outcomes, but they can still make a difference. Maintaining one's spark is facilitated by keeping a positive attitude through the stressful events; by remembering the moments when one made a positive difference, one is given the energy to deal with the stressors of the present. Nurses should be encouraged to reconnect to the essence of one's nursing practice with personal self-reflection, journaling, or facilitated discussions at staff meetings drawing out discussions of compassionate connection, satisfaction and management of difficult situations.

Personal strategies to develop resilience included professional development targeting high-stress components of nursing practice (end-of-life situations, loss, suffering) and the skills needed to handle these situations: therapeutic communication, setting boundaries, managing grief, interprofessional communication and patient advocacy. Skill development, whether through education or ongoing work experience, better positions the nurse to deal with suffering and trauma and be ready to “expect the unexpected”. Education advanced the nurse's professional skills and incorporation of these skills into daily care helped to alleviate some of the compassion stress; it helped the nurse move beyond merely surviving the day to be more effective carers.29 Strengthening one's skills in communication by learning to have hard conversations was also found to be of value.

Acknowledging the care provided is also regenerating. Seeing a patient smile or an individual survive and be responsive can mitigate the sadness experienced. Similarly, recognition and appreciation by peers and administrators about the care one has delivered is important in easing fatigue. One of the most consistent findings was the importance of peer support: talking with colleagues to help ease stress and regenerate the nurse. Colleagues understand the day-in and day-out stressors. They know about the difficult situation their colleagues went through that day, and they understand it because they went through a similar situation yesterday. They have an in-depth understanding of the work environment, the compassion needed to provide care and the suffering that is part of caregiving; this understanding is the foundation for heart-to-heart discussions about the stress that accompanies nursing.

Organizational approaches

No matter how effective personal interventions are, a supportive work environment that is nurturing, caring and compassionate for nurses as well as patients is important in resisting and managing CF. Managerial support was a significant component of this supportive work environment; however, it was clear that creating healthy work environments and an organizational culture of recognition and support was not a one-person job but required commitment on the part of the organization, manager and individual team members. Support to manage compassion stress and fatigue begins by acknowledging its existence, encouraging the team to be aware of it and being supportive when someone needs relief. The literature identifies a range of educational programs designed to increase this awareness and promote skill development in coping and self-care.75,76

Organizations that watch out for CF ensure that everyone is taking the necessary time for healing and renewal by supporting the need for schedule or assignment changes, relieving a stressed colleague, and mandating break times. Established quiet spaces such as a tranquility rooms provide a space where stressed nurses can feel “safe, secure, and secluded from the chaos”28(p.121) Other forms of support recommended were mindfulness training, counseling and support groups to help nurses deal with overwhelming emotions of anger, sadness, frustration, and grief. These proactive strategies facilitate reflection and discussion (versus keeping emotions bottled up and suffering in silence) and give the nurse strategies to deal with situations to help defuse stress and fatigue. Research into the effectiveness of these strategies has been predominantly with before and after designs that have no comparison groups.53,77

Limitations of the review

The following limitations should be taken into account when considering the findings of this review:

  • i) There were many publications that included multiple disciplines, inclusive of nursing; however, if there was not a discernable nurse voice, the study was excluded; consequently, it is possible that some findings were missed.
  • ii) There is an evident lack of conceptual clarity about CF. This study pooled findings concerning antecedents, critical incident stress coping mechanisms, symptoms of CF and personal and organizational measures to combat compassion distress and CF. Further research is needed to obtain conceptual clarity.
  • iii) Contributing to the difficulty in finding studies were the varying definitions of CF by different researchers. It is possible that some studies referred to CF as burnout. Burnout was purposefully not included as a search term as it represents a different phenomenon.
  • iv) Due to resource limitations, studies published in languages other than English could not be included in this review.
  • v) The majority of studies are drawn from Western countries and therefore may not be reflective of experiences from other contexts.
  • vi) Although many of the studies did not give personal demographics of participating nurses, this review did capture the voice of nurses from the specialties of emergency care, intensive care, maternal-child, oncology, hospice, home health, community health, ambulatory and psychiatry nursing. Certainly, CF exists in other nursing specialties but no qualitative studies were found from these areas.

Conclusion

This systematic review had a high level of evidence based on ConQual analysis. The review has corroborated, clarified and reinforced knowledge about CF: its antecedents, responses to stress, symptoms of compassion stress and CF, and both personal and organizational coping measures to support nurses to prevent or manage compassion distress and fatigue. The major implications of this review are that CF prevention and management must be brought to the forefront of nursing and that both personal and organizational coping strategies and adaptive responses are needed to keep the nurse balanced and renewed to continue compassionate connection and caring. The results and implications of the study add to approaches for avoiding CF.

Recommendations for practice

This review suggests recommendations for creating a supportive culture that keeps CF at bay. Strategies require both individual and organizational commitment. Recommendations are rated according the JBI Grades of Recommendation.78

  • i) Acknowledge the threat of CF and actively educate nurses about risks, mitigating factors and self-care strategies so that CF is understood and potentially averted (Grade A).
  • ii) Promulgate policy that supports the establishment of systems and managerial support for managing critical incidents, providing needed respites and ongoing education (Grade A).
  • iii) Ensure adequate support for nurses in dealing with compassion distress (Grade A).
    • ∘ Team building and team development (management and staff) to develop a culture of support that sets a positive tone and provides both physical and moral aid (Grade A).
      • Encourage team support during times of stress to give colleagues needed instrumental and emotional support.
      • Understand the need for schedule and/or assignment changes to protect a nurse's emotional wellbeing.
      • Have a heightened awareness for nurses who may be showing signs of CF.
      • Assist the team to develop informal debriefing strategies that can be used to support colleagues after critical incidents.
      • Identify mentors for new nurses. Mentors can empower nurses and help them achieve life balance as well as learn how to cope with workplace stressors such as lateral violence.
      • Encourage formal and informal breaks.
    • ∘ Provide grief counseling, formal debriefing, and compassion stress support (Grade B).
    • ∘ Encourage all staff to perform on-going self-assessment on work life balance and compassion stress symptoms (Grade A).
    • ∘ Encourage all staff to develop and commit to a personal plan for managing stress and grief and maintaining balance, whether this means eating well, exercising, taking a yoga class, maintaining a hobby or something else, depending on the individual nurse (Grade A).
    • ∘ Facilitate renewal by discussing examples of nurses making a difference, identifying and recognizing the moments that matter in the nurse-patient relationship, and reflecting on their purpose and passion in nursing and how they live these in practice (Grade B).
    • ∘ Promote reflective processes (journaling, discussion, self-analysis) to facilitate understanding and renewal (Grade B).

Recommendations for education

  • i) Provide in-service education that increases awareness of CF, promotes skill development in coping and self-care, discusses the symptoms of CF stress and fatigue, and covers the need for work-life balance. This education should begin at orientation and continue throughout the nurse's career. It can be provided through informal mechanisms such as staff meetings or more formal in-service classroom events (Grade A).

Recommendations for research

  • i) There continues to be lack of conceptual clarity around CF. Future research is needed to examine antecedents of CF: is it the antecedents distinct phenomena that may contribute to CF or are they overlapping with the concept of CF?
  • ii) More research is needed to link components of compassion with CF. This would bring understanding to the question of whether CF occurs due to a myriad of stressors which impede the nurse's ability to be compassionate or whether CF is an obstruction or loss of compassion.
  • iii) More research is needed to determine the relationship of compassion satisfaction and CF. Is compassion satisfaction a mediator for CF? Should interventions target building compassion satisfaction?
  • iv) Further research should examine whether a “culture of compassion” surrounding the nurse can be created thereby minimizing risks of CF. To this end, should interventions be universal or is it possible to identify “high risk” individuals?
  • v) What is the effectiveness of programs focused on enhancing compassion versus programs focused on CF in preventing CF?
  • vi) Results from this qualitative systematic review can be used to examine quantitative measures of CF to validate conceptual relevance of measures.

Appendix I: Search strategies (performed May 2017)

Appendix II: Studies excluded on full text

Appendix III: Characteristics of included studies

Appendix IV: Findings and illustrations

Appendix V: Synthesized finding 1 – categories and findings

Appendix VI: Synthesized finding 2 – categories and findings

Appendix VII: Synthesized finding 3 – categories and findings

Appendix VIII: Synthesized finding 4 – categories and findings

Acknowledgments

This work is in partial fulfillment of a doctoral degree at Rutgers University under the auspices of the Northeast Institute for Evidence Synthesis and Translation (NEST): a Joanna Briggs Institute Centre of Excellence. We would like to thank Ann Watkins, the librarian at the John Cotton Dana Library, Rutgers Newark Campus, for her contribution in the development of the search strategy.

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Keywords:

Compassion fatigue; compassion stress; nurses; secondary traumatic stress; vicarious trauma

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