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An inverse relationship

Compassion satisfaction, compassion fatigue, and critical care nurses

Fahey, Donna M. MFA, BSN, RN, CCRN, HNB-BC; Glasofer, Amy DrNP, RN, NE-BC

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doi: 10.1097/01.CCN.0000490957.22107.50
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Nurses spend significant time consoling, comforting, and supporting patients and their families. The daily, intense contact with patients and families who are emotionally distressed can affect nurses' physical and emotional health. This exposure places nurses at risk for developing compassion fatigue and subsequent burnout.1,2

Compassion fatigue is a major reason that nurses leave the profession; for those nurses who remain working, burnout can increase feelings of apathy and absenteeism, and decrease the quality of patient care.1,3,4 Compassion fatigue negatively impacts the physical and emotional health of nurses, organizational finances, patient satisfaction, and patient mortality.2,3

Objective. The goal of this exploratory study was to assess the presence of compassion satisfaction and compassion fatigue in critical care nurses caring for adult patients in a community hospital in Southern New Jersey. The authors hypothesized that as compassion satisfaction increased, the presence of compassion fatigue would decrease. This is significant because organizations that implement interventions to lessen compassion fatigue and enhance compassion satisfaction may experience increases in nurse retention and patient satisfaction.2 When nurses experience more satisfaction from the care they provide they begin to thrive, making a positive impact on patient care and quality outcomes.3

Definition of terms. A concept analysis developed by Coetzee and Klopper describes compassion fatigue as the final result of a progressive and cumulative process caused by prolonged, continuous, and intense contact with patients, and exposure to stress.4 The result of this progression is physical, social, emotional, spiritual, and intellectual changes that intensify over time. Eventually, the compassionate energy expended by nurses surpasses their restorative processes.4 If compassion fatigue is not addressed in the early stages, the power of recovery is lost and full restoration of the previous level of compassionate functioning is unattainable.4 In other words, nurses' capacity to care burns out.

Compassion satisfaction relates to the affirming or positive experiences related to nurse caring. If compassion fatigue and burnout relate to the “cost of caring,” compassion satisfaction relates to the “positive payment” that comes from caring.5-7 Compassion satisfaction and compassion fatigue are theoretical opposites, suggesting that as compassion satisfaction increases, compassion fatigue decreases. This relationship, however, has not been established empirically. If established, this inverse relationship may have greater potential to mediate the dilemma of compassion fatigue and burnout than currently speculated.

Theorist Kathleen Ledoux argues that compassion is actually limitless and not vulnerable to depletion.8 In addition, she describes compassion fatigue as a result of an interruption of care, when that act of caring has been impeded or obstructed.8 Ledoux's theory suggests that by supporting the development of compassion and allowing it to occur within the nurse-patient relationship, compassion fatigue may be prevented.


Study design and setting. This exploratory study used a cross-sectional survey conducted between November 2015 and January 2016 with RNs from a 21-bed community ICU. A 30% response rate required a sample size of 27 nurses; 88 were available to complete the survey. Permission was obtained from nursing leadership and the hospital's institutional review board. The nurses completed a questionnaire measuring compassion satisfaction and compassion fatigue along with demographic information.9

Variables. An assessment using the Professional Quality of Life: Compassion Satisfaction and Fatigue (ProQOL) scale was used to measure the degree of compassion fatigue and compassion satisfaction.9 The ProQOL tool is well established. Over 1,000 studies in the past 15 years have used it to measure the negative and positive effects of helping others who experience suffering.9 There have been several revisions; ProQOL 5 is the current version. The interpretation of scale scores is based on the distribution of more than 2,000 participants.7 The tool is a self-report questionnaire that rates the frequency of certain experiences that have occurred as a result of caring for others.9 The 30 items are rated on a 5-point Likert scale from 1 (never) to 5 (very often).9

Compassion satisfaction and compassion fatigue are two aspects of professional quality of life. The subscales of compassion fatigue, which include burnout and secondary traumatic stress, are calculated separately within the tool. Psychometric testing has demonstrated the tool has adequate reliability and validity to measure these constructs among nurses.10

Procedures. Four nurse champions were recruited from the unit-based shared governance committee to distribute the questionnaires and answer questions. Information about the study, including the nature of the research and risks and benefits, was provided to each RN before they completed the ProQOL tool. Descriptive statistics such as primary shift worked, years employed in their specialty, highest related degree earned, and age were also collected. Completed questionnaires were placed in a manila envelope stored in the unit's break room, along with extra questionnaires and study information. After the first month, study administrators sent an e-mail to unit RNs encouraging participation. At the conclusion of the second month, the completed questionnaires were collected.


Collected data were coded and analyzed with Minitab®. Descriptive data were analyzed, testing for significant variance within these subgroups. Scale scores for compassion fatigue, burnout, and compassion satisfaction were tallied for each participant and mean scores collected for each of the three constructs. Scale scores were compared with the benchmark data available for the ProQOL tool.11 The relationships among three of the constructs (compassion satisfaction, compassion fatigue, and secondary traumatic stress) were also analyzed.

Twenty-nine nurses out of 88 completed the survey (a 32% response rate). The majority of the participants were female, BSN prepared, and worked the day shift. There was a range of both years of experience and age (see Demographic distribution of sample). Correlations analysis and t-tests revealed no significant differences in subscales for compassion satisfaction, compassion fatigue, and secondary traumatic stress associated with age, gender, shift, education level, and/or critical care experience.

The aggregate data for compassion satisfaction revealed high (42 or greater) to average (23 to 41) levels, with a mean score of 40. Fifty-nine percent of the RNs scored high, while 41% scored in the average range. The aggregate data for compassion fatigue revealed low (less than or equal to 22) to average (23 to 41) levels, with a mean score of 22.7. Fifty-two percent scored average and 48% scored low. The aggregate data for secondary traumatic stress revealed low (22 or less) to average (23 to 41) levels, with a mean of 19.6.

Importantly, compassion satisfaction and compassion fatigue demonstrated a negative correlation (correlation coefficient [r] = -0.71; p <0.001). Relationships between compassion satisfaction and secondary stress were not statistically significant (r = 0.02; p = 0.975) (see Correlation among studied constructs).


The goal of this exploratory study was to assess the presence of compassion satisfaction and compassion fatigue in critical care nurses working in an adult community ICU in southern New Jersey. The nurses who completed the survey showed average to high levels of compassion satisfaction and average to low levels of compassion fatigue. These findings are reflective of a positive work environment.12 Creating a healthy work environment involves interventions that value and support nurses as empowered members of the care team, such as encouraging authentic leadership, effective communication, collaboration, appropriate staffing, and meaningful recognition.13

While average to low levels of compassion fatigue may seem acceptable, there is room for further improvement. Moving nurses with average compassion fatigue into the lowest levels and similarly moving nurses with average levels of compassion satisfaction into the highest levels would be optimal. This might be achieved by focusing on interventions that promote compassion satisfaction. Creating a healthy work environment, promoting personal resilience, and the use of nurse-driven rituals are effective suggestions for increasing compassion satisfaction.14,15

The secondary aim of this study was to determine the relationship between compassion satisfaction and compassion fatigue. Researchers confirmed their hypothesis and found a negative relationship: As compassion satisfaction increased, compassion fatigue decreased. Although this does not establish a causal relationship, it does suggest that actions that affect one of the constructs may produce an opposite effect in the other. Interventions directed toward increasing compassion satisfaction in nurses, therefore, may also decrease compassion fatigue.

Correlation among studied constructs

Areas for future research. Successful interventions available to nurses to counter the frequent experience of compassion fatigue and burnout include on-site professional resources, educational programs, and specialized retreats.16 Self-care and holistic modalities used to decrease work-related stress and increase resilience include mindfulness-based stress reduction techniques, expressive writing, guided imagery, and music.2 Other research modalities that may help reduce the prevalence of moral distress and compassion fatigue are aromatherapy, art, spirituality, and prayer.17,18 Researching the effectiveness of any of these interventions separately or in combination would be beneficial.

Most of the research on mitigating compassion fatigue has focused on self-care, that is, things that nurses can do before a stressful event to create resilience or after a stressful event to reduce residual stress. Few studies looked at an intervention that can create resilience and reduce stress while an event unfolds.

Demographic distribution of sample

However, there is potential for a “real-time” intervention based on the theoretical work of Dr. Erika Summers-Effler on nursing rituals.19 Because rituals are implemented in real time, they provide a sense of organization and meaning that can transform intensely stressful situations into positive experiences.19 Nurses may cope more effectively with repeated exposure to stress when they find ways to understand and consolidate their experiences into meaningful structures.20 Rituals also offer a safe structure for nurses to experience intense emotions in a healing and often transcended way, potentially providing real-time support for compassion within the patient and caregiver relationship.19


The study sample size was small and was restricted to nurses working in the critical care environment of a community hospital. A larger study including other nursing specialties and other institutions may be helpful in generalizing results. Findings are also limited by the cross-sectional design because results may have been influenced by the nurse's experience immediately prior to questionnaire completion, such as the type of day the nurse was having. A longitudinal study would help determine the prevalence of compassion satisfaction and compassion fatigue with allowance for day–to-day variability. The utilization of the four “champions” to distribute the questionnaires and answer questions may have introduced potential bias. In addition, although the relationship between compassion satisfaction and compassion fatigue was statistically significant, a more precise estimation of the strength of this relationship would require a larger sample size.


There is a cost associated with caring. This cost often manifests in nurses as compassion fatigue or burnout. Interventions that help to reduce compassion fatigue include optimal self-care, education programs, and institutional resources and retreats. Additional support for nurses may exist in the form of rituals and other structure intended to create a more meaningful and satisfying experience. Compassion fatigue is not necessarily a result of compassion depletion, but a result of barriers that prevent compassion. By allowing compassion to develop within the therapeutic relationship, nurses may experience more satisfaction in their care delivery. Interventions that promote compassion satisfaction are ultimately worthwhile for organizations and individuals to pursue.


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    burnout; compassion fatigue; compassion satisfaction; critical care nurses

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