Journal Logo


Compassion fatigue and the ART model

Fleming, Kathryn PhD, RN, CPHQ, NEA-BC, FACHE; Mazzatta, Grace Reilly MSN, APN, ACHPN; Matarese, Kathryn MSW, LSW; Eberle, Jennifer MSPT

Author Information
doi: 10.1097/01.NURSE.0000654168.38494.dd
  • Free

QUALITY NURSING CARE has a direct impact on patient satisfaction. As healthcare organizations strive to improve the patient experience, these facilities must address compassion fatigue (CF) on nursing units. CF is characterized by extreme tension, overwhelming exhaustion, and constant depression and feelings of hopelessness. It affects the entire individual, mind, body, and soul. Physiologic consequences such as increased weight and BP can also be seen.1

CF is an ongoing, insidious feeling stemming from prolonged patient interactions. It is the culmination of caring that grows over the course of treating many patients.2 Nurses with CF lose the ability to care for themselves and, subsequently, their patients. At the authors' healthcare facility in New Jersey, CF was recognized as contributing to absenteeism, high turnover rates, and decreased nurse and patient satisfaction.

Improving the patient experience requires healthcare facilities to develop practices to reduce CF. While nurses are interested in self-care, they also struggle to allocate enough time to these practices. This article describes perceptions of CF, including compassion satisfaction, burnout, and work-related secondary traumatic stress, in a random sampling of nurses from the authors' healthcare facility.3


CF and burnout are often thought of as interchangeable, but the two terms have different implications. Burnout stems from work environments and conditions.4CF draws from the relationships and feelings between patients and healthcare professionals, driving both personal implications such as depression and professional implications such as errors in judgment.4,5 Similarly, secondary traumatic stress refers to the emotional impact of dealing with another individual's trauma.6

Compassion satisfaction describes the feelings of joy and pleasure associated with careers that give the professional a sense of passion or purpose.7 The connections formed during nurse-patient relationships lead to a sense of compassion satisfaction in nursing.3 CF is the umbrella result of compassion satisfaction, trauma, and burnout.3

Based on recommendations in the literature and following a baseline survey among facility nurses, the authors implemented a multifaceted CF program beginning with education on self-care practices and self-regulation. Participating nurses were taught to use the ART model (acknowledge, recognize, and turn outward, as described below) and educated on mindfulness, compassionate caring, and self-actualization. The study was designed to provide participants with daily self-care strategies that might encourage acts of compassion centered on the meaning and purpose of their work, yielding professional and personal satisfaction and improving patient care.3 In nursing, acts of compassion may include supporting the ED staff when they forget to call before sending a patient to the unit, answering the call bell for a coworker who is having a difficult day, and providing authentic presence and time to a patient with many requests.

Terms of ART

The ART model can be broken into three steps: acknowledge, recognize, and turn outward.3 Participants were taught to acknowledge their feelings (or wounds that need healing), recognize their choices and take purposeful action, and turn outward by looking objectively at their self-care. For example, nurses experiencing a difficult situation during a shift should acknowledge how they feel (angry, stressed, ethically or morally challenged), recognize their options, and turn outward by leaving the situation for a moment to take a breath, gather their thoughts, or speak to a coworker or manager.

These steps are important to remember and practice when nurses start to dread work and feel they are being dragged down.3 The ART model is accomplished through mindful awareness, or the practice of staying mindful in the moment, which involves thinking a situation through rather than just reacting to it.

The successful implementation of a multifaceted CF program at a healthcare facility includes administrative governance, an employee-assistance program, pastoral care debriefing sessions, bereavement support workgroups, nurse manager involvement, and staff education on the development of healthy coping skills.8

According to the Institute for Healthcare Improvement, the Triple Aim of healthcare revolves around improving population health, enhancing patient experience, and reducing the cost of healthcare.9 The concept of a new Quadruple Aim of healthcare expands on the Triple Aim to include “attaining joy in work” for improved employee well-being.9,10


After obtaining institutional review board approval, this pilot study utilized mixed methods, including a questionnaire and three focus groups. Researchers used flyers, posters, and email communication to recruit nurses working on adult inpatient units in an acute care hospital over a 2-month period. A principle investigator attended nursing leadership meetings; distributed flyers on the units; and was available to explain the study, answer any questions, and provide additional access information.

An online survey was initiated, and participants were invited to attend a focus group session following implementation of the ART model on certain evenings after the second survey. Three focus groups were held in a hospital conference room with 13 total participants. They each lasted 60 minutes. All sessions were audio recorded and utilized a scribe. Participants were provided instruction on the ART model at the beginning of each session, as well as an explanation of the study and focus group. Examples of practices that might fit within each element of the ART model were discussed. For example, turning outward may involve journaling or exercising, while participants may acknowledge feelings such as anxiety.

The group also discussed secondary traumatic stress. This included witnessing another's physical or emotional pain, feeling powerless due to challenges at work, lacking resources or time, and competing priorities. When discussing examples of mindful moments, participants noted practices such as reciting the serenity prayer or taking a deep breath. Additionally, the group discussed how they had implemented elements of the ART model into their daily lives, such as by exercising, journaling, and acknowledging anxiety.

The participants were divided into focus groups designed to walk them through the three steps of the ART model and guide their practices. Their levels of compassion fatigue were measured using the Professional Quality-of-Life (ProQOL) nurse survey version 5, a 30-item, empirically validated self-report measure with good construct validity (see The ProQOL nurse survey).11 Measurements were conducted with the three online surveys at baseline, 3 months, and 6 months. Three participants completed all three surveys and their focus group.

The baseline survey was available for 2 to 3 weeks in August 2016, and a link was established through the facility intranet to complete the survey online. A convenience sample of 49 participants completed the survey, which collected data on demographics and the ProQOL. Informed consent was explained in an informational cover letter on the first page and implied upon survey completion.12 Quantitative data were analyzed using descriptive statistics and statistical software and evaluated to identify and report themes. The investigators read the face-to-face interview transcripts and met to discuss their findings and reach a consensus.


Most participants (N=49) were female (96%), non-Hispanic White (80%), and married (63%). They were largely made up of staff-level nurses (84%), with either 1 to 4 years (22%) or more than 25 years (27%) of experience. They mainly worked 3 days a week (53%) in 12-hour shifts (73%) on the day shift (69%) and during weekends (73%). While most participants (53%) reported utilizing physical exercise or outdoor activities for self-care, approximately 30% did not practice any type of self-care routine.

Researchers reviewed the ProQOL results. At baseline, participants reported no significant levels of CF, burnout, or secondary traumatic stress. The level of compassion satisfaction was described as “average” by 76% of the participants, suggesting that they were likely to derive pleasure from their work. Conversely, burnout and secondary traumatic stress were each reported as average-to-low in more than 90% of the nurses. The participants' ProQOL scores reflected positive feelings about their ability to be effective in their work and indicated that they do not consider their work environment frightening.

A thematic analysis was completed at the conclusion of focus groups. The investigation team reviewed the transcripts, analyzed the data, and discussed themes (see Nursing takeaways).


The ART model allows nurses the opportunity to examine their professional life and build practices to restore their compassion. The nurse participants in this study were eager to explore self-care, but they struggled to find time to apply the necessary practices. For example, all study participants reported the need for support in applying these practices, but permission to leave the unit for self-care is less effective when the ability to do so is prohibited due to lack of staff coverage.

Hospital administration was aware of the prevalence of CF in nursing before the implementation of this study. To address this growing problem, the facility had already implemented several initiatives to help reduce CF among the staff, including a zen room and Code Lavender Day. These initiatives offer healthcare staff unit-based spaces, self-care tools, and educational opportunities to assist in decompressing after moments of high stress, trauma, or anxiety.

Zen rooms were converted from supply closets or break rooms and redesigned with tools for relaxation, including aromatherapy, journaling, meditation cards, coloring books, and music. Code Lavender Day was implemented as a full day for the healthcare staff that starts with morning lectures on CF, burnout, and secondary traumatic stress, as well as a brief presentation on self-care. In the afternoon, each participant joins a 20-minute breakout session for activities such as yoga, meditation, art therapy, healing touch, and Reiki.

The facility also contracted with a nationally recognized organization to teach evidence-based holistic nursing and self-care principles and practices using caring science theory.13

Unresolved stress can lead to negative effects on the body, including lack of sleep, insomnia, depression, and exhaustion.8,14 As healthcare moves toward the Quadruple Aim, self-care practices are crucial to maintaining the health and well-being of the staff. To illustrate how these elements may improve patient care, further research is needed about:

  • the impact of a Magnet® designation on staff empowerment. Is there a correlation between Magnet organizations and staff self-care practices?
  • new methods for study recruitment, retention, and increased participation. Provide participants an opportunity to experience a range of self-care practices that were previously overlooked or not considered; for example, a “compassion fatigue” day in which multiple methods are demonstrated.
  • alternatives to traditional face-to-face focus groups and learning sessions. Technology is an important tool in nursing education. For example, video tutorials with expert speakers may help to alleviate time constraints. Similarly, social media is effective for daily reminders and relevant quotes. These shorter forms of communication promote continued staff engagement and awareness.
  • expansion of CF research outside of hospice, oncology, and critical care. CF can occur in any healthcare setting. Research should include all specialties, disciplines, and roles; for example, studies geared toward physical therapists, respiratory therapists, dietitians, and other healthcare professionals.


The study was limited by a small sample size. As such, the authors recommend further research with a larger participant population to complete all components of the study, as well as increased multidisciplinary representation. This would offer broader analysis regarding other healthcare professionals who may also experience CF.

Communication was also a challenge. Work email was convenient for the researchers, but it was not checked frequently by participants. In future research, email preferences should be solicited directly from participants to provide a more effective method of communication and engagement.


CF can negatively affect nurses, resulting in high turnover, frequent absenteeism, decreased satisfaction, and poor patient outcomes. The potential consequences may impact colleagues, employers, and patients. As healthcare administration and organizations become more aware of the link between patient satisfaction, CF, burnout, and secondary traumatic stress, it is important to develop a culture of recognition and support.14 By providing the tools and education for self-care practices, healthcare organization can help improve compassion satisfaction in the nursing staff.

The ProQOL nurse survey11,13

Participant ProQOL scores measured the positive and negative aspects of caring and indicated CF, burnout, and secondary traumatic stress. The survey addressed concepts that may be tied into caring science theory, which was used as a theoretical framework for self-care practices in the healthcare staff.

Caring science theory embraces connectedness and promotes 10 Caritas processes, one of which speaks to personal and professional practices of kindness, compassion, and inner balance to self and others. It is an evolving area of study geared toward nursing specifically, but the authors felt it may also apply to a larger population of healthcare professionals.

Nursing takeaways

Below are excerpts demonstrating the results of thematic analysis in which the participating nurses described their experiences with time constraints, mindfulness, and ART practices.

Stress and anxiety related to time constraints:

  • “I'm stressed out constantly due to [the] time constraints of the on-call schedule.”
  • “[It was either] work less to get better grades or work more to pay off student loans. I opted to work more.”
  • “School, work, buying a house, and being a new nurse.”

Importance of mindful moments and inability to participate:

  • “Way too busy to stop.”
  • “Unable to get off the floor.”
  • “[I] only take bathroom breaks. I rarely sit [or] take a break to eat.”

ART practices implemented:

  • “I stopped bringing work home. I practice self-reflection, yoga, and meditation each morning.”
  • “People need to slow down a bit. I say the serenity prayer.”
  • “Now I journal and write things down. It helps.”


1. Wentzel D, Brysiewicz P. The consequence of caring too much: compassion fatigue and the trauma nurse. J Emerg Nurs. 2014;40(1):95–97.
2. Coetzee SK, Klopper HC. Compassion fatigue within nursing practice: a concept analysis. Nurs Health Sci. 2010;12(2):235–243.
3. Todaro-Franceschi V. Compassion Fatigue and Burnout in Nursing: Enhancing Professional Quality of Life. New York, NY: Springer; 2013.
4. Kearney MK, Weininger RB, Vachon ML, Harrison RL, Mount BM. Self-care of physicians caring for patients at the end of life: “Being connected... a key to my survival”. JAMA. 2009;301(11):1155–1164, E1.
5. Jackson C. Healing ourselves, healing others: third in a series. Holist Nurs Pract. 2004;18(4):199–210.
6. The National Child Traumatic Stress Network. Secondary traumatic stress.
7. Stamm BH. Secondary Traumatic Stress: Self-Care Issues for Clinicians, Researchers, and Educators. 2nd ed. Derwood, MD: Sidran Press; 1999.
8. Potter P, Deshields T, Rodriguez S. Developing a systemic program for compassion fatigue. Nurs Adm Q. 2013;37(4):326–332.
9. Feeley D. The Triple Aim or the Quadruple Aim? Four points to help set your strategy. Institute for Healthcare Improvement. 2017.
10. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573–576.
11. Professional Quality of Life Measure. Professional quality of life scale (ProQOL) Version 5. 2009.
12. Range L, Embry T, MacLeod T. Active and passive consent: a comparison of actual research with children. Ethical Hum Sci Serv. 2001;3(1):23–31.
13. Watson Caring Science Institute. Caring science theory. 2019.
14. Potter P, Deshields T, Berger JA, Clarke M, Olsen S, Chen L. Evaluation of a compassion fatigue resiliency program for oncology nurses. Oncol Nurs Forum. 2013;40(2):180–187.

burnout; CF; compassion fatigue; compassion satisfaction; secondary traumatic stress; self-care

Wolters Kluwer Health, Inc. All rights reserved