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Feature: Self-Care for Nurses

An education intervention to reduce compassion fatigue in a community medical center

Kestler, Susan A. MSN, RN, NEA-BC; Barnett, Diana MSN, RN, CNOR, RN-BC; Kelly, Miranda DNP, APRN, CCRN, CNS, ACNP-BC; Delgado, LaDawn MSN, RN, RN-BC; DePaul, Debbie BSN, RN, IBCLC, RLC; Pontius, Amy MSN, RN; Vidales, Cinthya MSN, RN

Author Information
Nursing Management (Springhouse): June 2020 - Volume 51 - Issue 6 - p 30-37
doi: 10.1097/01.NUMA.0000662660.75547.a3
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In healthcare and among the general public, nurses are known for their compassion and caring attributes. Nurses have an innate talent to nurture and empathize with another's suffering, thereby connecting with their patients and personalizing care. This may lead to positive outcomes and increased patient satisfaction; however, with continued caring in intense situations comes the risk of developing compassion fatigue over time.

The purpose of this study was to evaluate the effectiveness of a resiliency education program in mitigating risk factors for and reducing some of the consequences of compassion fatigue. The primary objective was to decrease the physiologic and emotional responses of compassion fatigue among professional nurses providing direct care at a Magnet®-recognized Level II trauma community medical center. To achieve this, a multifaceted compassion fatigue educational intervention was implemented, with pre/post data collected using the Secondary Traumatic Stress Scale (STSS) instrument. Pre-and postintervention data were analyzed with the goal of achieving a reduction in “severe, high, moderate, or mild” scoring by at least one level. A secondary objective was to establish the prevalence of compassion fatigue at our medical center by evaluating the preintervention STSS data.

Background and significance

Compassion fatigue involves the loss of one's desire and capacity to love and nurture or empathize with another's suffering due to continued exposure to difficult situations.1,2 This results from healthcare professionals wanting to help alleviate the suffering of a traumatized patient and identifying with his or her emotional pain, which leads to a recurring fear for the traumatized individual.3,4 Compassion fatigue has been likened to posttraumatic stress disorder; however, whereas firsthand exposure to trauma such as military personnel experience during a war is a primary exposure, exposure to a patient's trauma is a secondary exposure.

Repeated exposure to patient suffering and the consequences of critical illness and injury place nurses at high risk for compassion fatigue. Burnout that's manifested by feelings of frustration, hopelessness, and futility stemming from environmental factors, such as perceptions of lacking administrative support, poor staffing, and heavy workloads, has been identified as a contributing factor to compassion fatigue in caregivers.4 A distinguishing factor between compassion fatigue and burnout is that burnout is due to factors outside of nursing practice that impact practice, whereas compassion fatigue impacts the emotional, physical, personal, and professional lives of nurses while providing care. The nursing profession and healthcare system may also be impacted because compassion fatigue has been associated with intent to leave the profession, and nurses have reported declining job satisfaction.5,6

Long-term physical and emotional effects of compassion fatigue have a negative impact on a nurse's overall health, sense of well-being, and workplace performance.7 High absentee rates, decreased productivity, and employee turnover have been reported.8 Emergency nurses and critical care nurses have been the focus of several studies on compassion fatigue, but Hooper and colleagues found that the prevalence of compassion fatigue and its effects in the workplace were no different across multiple nursing specialties.9-13 Since this study in 2010, the literature has been rife with subsequent research that has focused on compassion fatigue in nursing specialties.

It's prudent to employ effective strategies to minimize compassion fatigue because of its pervasiveness and deleterious effects on the health of individual nurses, the profession, and the healthcare system. Failure to recognize compassion fatigue or minimize it may increase the risk of jeopardizing patient care, and it may have financial implications for the hospital when addressing absenteeism and nurse turnover. Several researchers have explored ways to mitigate the impact of compassion fatigue, including the implementation of a resiliency education program to decrease compassion fatigue symptoms.14-16

Defined simply, resilience is the ability to become strong, healthy, or successful again after something bad happens.17 Potter and colleagues evaluated the impact of a resiliency education program on reducing compassion fatigue in oncology nurses and found a positive relationship.13 Flarity and colleagues demonstrated the effectiveness of an education program designed to enhance resilience in a sample of 59 emergency nurses.18 When evaluating 32 healthcare providers, Pfaff and colleagues found a positive result from a 6-week resiliency program (t = 3.5, P = .005).19

Methods

Study design. A cross-sectional, pre/post intervention design was used. The study was approved by the Institutional Review Board affiliated with the university and the hospital system.

Instrument. The 65-item STSS tool was initially developed to measure secondary trauma symptoms in social workers.20 Bride and colleagues conducted research on internal consistency of the STSS, validated its ability to correlate with measures of related and unrelated variables, and revealed to what extent individual items represent the subscales of intrusion, avoidance, and arousal (construct validity).20 In a recent systematic review of five health research databases from 1980 to 2014 evaluating instruments for measuring compassion fatigue, Watts and Robertson concluded that the Bride STSS has undergone the most rigorous psychometric testing.21

Each question was analyzed for reliability and items were qualitatively examined in terms of relevance, readability, and clarity. Items that performed poorly were deleted and the remaining items were further tested for content validity and congruence with the instrument's purpose. The resulting 50-item instrument achieved a coefficient alpha of 0.97. Ultimately, the tool was edited to a 17-item version.

The STSS uses a Likert scale, with responses ranging from never (1) to very often (5). Scores for the entire scale are summed for a total score, and subscale scores can also be reported. Scores range from 17 to 85. Scores greater than 48 should be interpreted as severe compassion fatigue; 44 to 48, high compassion fatigue; 38 to 43, moderate compassion fatigue; 28 to 37, mild compassion fatigue; and less than 28, little or no compassion fatigue.

Sample. RNs in a direct care role were invited to participate. Participants served as their own controls. Enrollees' participation in the study involved 30 to 40 minutes of pretesting before the education program, including a brief demographic questionnaire and the STSS administered via an online survey; three 1-hour classes (one class each week over a period of 3 weeks); and posttesting 3 months after the intervention.22 (See Table 1.) On the demographic questionnaire, participants were asked to supply a unique identifier to ensure anonymity. Those teaching the classes had no notion of how the participants scored on the preintervention STSS. At the first class session, participants brought a paper copy of the certificate from the online tool indicating that they completed the STSS and demographic questionnaire.

Table 1:
Table 1::
Education sessions 1 to 3

To be eligible, participants had been an RN for more than 1 year providing direct patient care as the primary focus of their job, were continuously employed in their current area of specialization for a minimum of 3 months, and weren't currently enrolled in the nurse residency program. The intent was to exclude nurses who may have had residual negative effects from a previous place of employment or specialty that could contaminate study results. Novice nurses who recently graduated and were enrolled in the nurse residency program, which takes 12 months to complete, were excluded because they had other opportunities for emotional support, which may have confounded results of the intervention's effectiveness. Also, nurse residents may experience negative emotions other than compassion fatigue by virtue of newly entering practice, which could falsely inflate STSS scores.

Data analysis

The original design called for 66 nurses to achieve 80% power with a 95% confidence interval (CI). Flyers were distributed throughout the hospital and nurse managers discussed the study during unit meetings. Fifty-seven RNs who met the inclusion criteria volunteered and completed the STSS and demographic questionnaire. Seventeen nurses didn't complete all three classes, and 15 didn't complete the postintervention STSS. Ultimately, 25 nurses across 11 different units completed the full study protocol. (See Table 2.)

Table 2:
Table 2::
Demographics

Differences between those who completed the protocol and those who didn't were examined using one-way analysis of variance (for age, years as an RN, and years in their specialty) and two-sample t-tests for categorical variables (shift usually worked and self-care in the last 7 days). No demographic differences were found between the group who didn't complete the protocol and the study sample. Therefore, the sample of 25 RNs seems to be representative of the larger sample of nurses with which we started out.

Pre- and postintervention STSS were matched by unique identifiers. Data were scored using statistical software and a spreadsheet for demographic analysis. Compassion fatigue results pre- and postintervention were plotted and it was found by initial visualization that almost all of the participants experienced a reduction in compassion fatigue. Figure 1 shows each individual's pre- and postscores; note that most postscores (boxes) are below the paired prescores (dots), which illustrates that most nurses reduced their level of compassion fatigue following the education program and incorporating learned strategies into practice. Univariate statistics were used, and data were examined for normalcy. We found a normal distribution of data and used paired t-tests for differences between pre- and postintervention; results were noted to be significant (P < .001, 95% CI 9.64-31.59). Figure 2 and Figure 3 show average pre- and postscores by question. The changes in the level of compassion fatigue occurred in 69.3% of participants. A large percentage moved from moderate to mild and mild to no compassion fatigue. (See Figure 4.)

Figure 1:
Figure 1::
Changes in mean total pre- and postscores
Figure 2:
Figure 2::
Average pre- and postscores (questions 1 to 9)
Figure 3:
Figure 3::
Average pre- and postscores (questions 10 to 17)
Figure 4:
Figure 4::
Changes to compassion fatigue levels

Participants' ages were bracketed according to birth generation; those 55 to 75 years old were classified as baby boomers, those ages 40 to 54 were classified as generation X, millennials were ages 25 to 39, and generation Z were ages 4 to 24. Using binary logistic regression, we investigated if factors such as generation (P = .096), years employed as an RN (P = .868), time worked in the current specialty (P = .398), or self-care activities within the last 7 days (P = .045) were related to changes in compassion fatigue scores. The self-care probability was barely significant, but the CIs (-43.82, -32.58) were large, which calls into question the significance. This study indicated that, irrespective of age, specialty, experience, or recent self-care, the education program helped nurses decrease their levels of compassion fatigue.

Discussion

Strengths. Positive outcomes indicate that this education program helped nurses develop strategies to reduce compassion fatigue and prevent future occurrences. This has implications for nurse managers to help retain staff members who are well-adjusted and satisfied with their work-life balance. Nurse managers who have compassion fatigue knowledge can support staff members who may be at risk for developing it. A prevention program open to hospital staff makes it possible to support compassion satisfaction and prevent compassion fatigue.

A literature review didn't find many studies in which nurses from all hospital units in a single organization were invited to participate. One of the strengths of this study was the wide variety of nursing specialties, including medical-surgical acute care, emergency center staff, observation unit, neonatal ICU and maternal nursing staff, postanesthesia recovery, surgical ICU, and intermediate care.

Limitations. The small sample size, which represented only one-third of the targeted sample size, was a key limitation of this study. Although results were positive, they weren't as strong as they may have been with a larger sample size, as the CI was wide though significant. A second limitation was the team's deduction that many nurses seemed to not understand the research process or the importance of attending all classes. Study requirements to attend all three education classes may have been a barrier to study participation and completion of the post-intervention STSS. Although the classes were offered 3 days each week, with a different start time for each class throughout the week for flexibility, it still may have been difficult for staff members to arrange class attendance with their work schedules. Also, the study was completed in one community medical center and, therefore, can't be generalized.

There were no more than four participants from any nursing unit engaged in the study; it's inadvisable to utilize these data to consider whether units have different levels of compassion fatigue. Several nursing specialties that historically had high levels of compassion fatigue identified in the literature didn't have sufficient staff participation in this study. This bears further investigation.

Future suggestions. A review of the demographic data noted that 57% of the participants were between ages 20 and 35. Results also indicated that young nurses appear to be experiencing compassion fatigue, as more than half of the participants had worked as a nurse for 11 years or less and had been in their current specialty for less than 4 years. This supports the importance of teaching positive coping strategies and allowing staff members time to process stressful outcomes and resolve issues.

One recommendation for future studies is that education should be offered in one longer session to include all topics, with multiple sessions available to enable more staff members to complete the protocol. It was our experience that many staff members attended the first class but dropped out after the second or third class. Further research is needed to validate that changing the education program to a single session will be as effective as three 1-hour sessions.

Administration of the STSS 3 months after the education program was intended to provide staff members time to practice and incorporate what they learned but may have contributed to the small sample size. The time delay may have created a perception that the study was completed, so nurses may have thought it wasn't important to participate in the postintervention data collection.

Lastly, this study demonstrated that there's a level of compassion fatigue that varies from mild to moderate in a substantial number of nurses who participated. It behooves nurse managers to learn about compassion fatigue and support staff members who are manifesting symptoms. This will help nurses strike a positive work-life balance and remain satisfied in their roles.

An important reduction

Data from 25 participants indicated that those who completed the study protocol had a significant reduction in compassion fatigue. Data analysis showed that more than half the participants decreased their compassion fatigue by at least one level on the Likert scale, most moving from moderate to mild or from mild to no compassion fatigue. For this reason, our research team recommends resiliency education be made available to reduce levels of compassion fatigue in professional nurses.

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