Keywords

Caring ability, Critical care nursing, Professional quality of life

 

Authors

  1. Mohammadi, Marzieh MSc
  2. Peyrovi, Hamid PhD
  3. Mahmoodi, Mahmood PhD

Abstract

Background: Critical care nursing has some features that may affect the ability of critical care nurses to provide care. Professionals as critical care nurses who deal with peoples' health and life often experience some levels of stress that affects their quality of life.

 

Objective: This study examined the relationship between professional quality of life and caring ability of critical care nurses.

 

Method: In this descriptive correlational study, 253 critical care nurses working in the medical and surgical intensive care units of Tehran University of Medical Sciences were recruited by convenience sampling method. The data collection tools included demographic data form, Caring Ability Inventory, and questionnaire for professional quality of life version 5.

 

Results: There was a statistically significant positive relationship between the professional quality of life and the caring ability (P < .0001). A significant inverse relationship was found between burn-out subscale of compassion fatigue as one aspect of professional life quality with all 3 aspects of caring ability (knowledge, courage, and patience). Secondary traumatic stress, as another subscale of compassion fatigue (as one aspect of professional quality of life), had no statistically significant correlation with caring ability aspects of knowledge and patience. However, there was a significant inverse correlation between the secondary traumatic stress and courage aspect of caring ability (P < .0001). There was a statistically significant positive relationship between compassion satisfaction aspect of professional life quality with knowledge and patience aspects of caring ability, but there was not any relationship between the compassion satisfaction aspect of professional life quality and the courage aspect of caring ability.

 

Discussion: Improvement of critical care nurses' professional quality of life may increase their caring ability, thereby leading to better and more effective nursing care. Increased awareness by critical care nurse managers of the compassion fatigue phenomenon (secondary traumatic stress and burnout) and its effect on quality of critical care would be helpful in planning more specific strategies and preventing the onset and progression of these symptoms.

 

Article Content

Caring is considered as an essential value in nurses' personal and professional lives and as one of the inseparable components of professional nursing practice. According to Mayeroff, caring is helping others to develop and actualize themselves. The quality of patient care and its consequence is largely dependent on the caregiver.1

 

Patient care is a stressful experience. This is of great importance in the intensive care unit (ICU), where the patients are more dependent on the care provided by critical care nurses2 and the ability of critical care nurses in providing care is one of the prerequisites of quality care assurance.

 

Providing high-quality care depends on nurses' physical, mental, and spiritual health. Quality of work life is a quality that a person working as a helper experiences in the job. Quality of work life has both positive and negative aspects. The positive aspect of work life quality is called "compassion satisfaction," and the negative aspect is called "compassion fatigue." "Compassion satisfaction" is defined as the benefits that the members of a profession in which helping is an essential component experience when working with injured or suffering people and is a degree of feeling success at work.3 On the other hand, prolonged relationship with patients and their family members may cause problems for nurses that are called "compassion fatigue."4

 

One study showed that the caring ability of nurses improved after implementation of a humanistic nursing care model.5 Another study indicated that critical care nurses who perceived themselves more prepared and better able to care had higher scores in compassion satisfaction and lower scores in compassion fatigue and burnout as parts of the quality of professional life.6

 

Caring ability is defined as the individual's ability to provide care to others.7 One of the features expected from professional caregivers is sympathy. The fact that nurses should be compassionate is frequently emphasized; however, the ability to sympathize with others varies from person to person. Sympathy may expose nurses to the risk of experiencing symptoms of secondary traumatic stress. Nurses undertake the responsibilty of caring a patient 24 hours a day in their professional role and are frequently exposed to many stressors.

 

Critical care nurses are more exposed to occupational stress than nurses in other wards. Among the main factors that cause stress in the critical care unit are using high technology, addressing communication problems, encountering moral issues, witnessing patients' death, not having enough information, and managing workload. Based on a study conducted on oncology nurses in Brazil, the 5 major stressors reported were witnessing others suffering and inability to help them, high workload, lack of equipment, lack of executives' effort in difficult situations, and nurses' mistakes.8

 

Empathy is one of the essential values in nursing, but if not properly balanced, it may have negative consequences, such as compassion fatigue. Self-compassion, as a protective factor of some well-being indicators, is associated with compassion for others. Teaching self-compassion and self-care skills is considered as an important intervention to reduce burnout and compassion fatigue.9

 

One study showed that taking care of patients with Ebola increased the feelings of social isolation in health care professionals.10 Another study reported low levels of resilience and controlling organizational leadership as most predictive of poor professional quality of life.11

 

Compassion fatigue occurs in people who have been affected by others' injuries. Typical symptoms of compassion fatigue include re-experiencing the traumatic events, intrusive thoughts, avoiding to recall events, sleep disturbances, irritability, anxiety, and loss of hope.12 Nurses' burnout has long been considered, but the concepts of compassion fatigue and secondary traumatic stress and their effect on caregivers are unknown.13 This clinical phenomenon has been brought forward as a serious issue, because it may negatively affect the ability of caregivers in providing services and maintaining personal and professional relationships.14 Compassion satisfaction can improve harmful effects of compassion fatigue or burnout.3 Meadors and Lamson's study on 185 health care providers working on children critical care units revealed that providers with higher levels of personal stressors experienced higher levels of compassion fatigue.15 Maiden et al reported a statistically significant correlation of compassion fatigue with moral distress and perceptions about medication errors among certified critical care nurses.16 In a pilot study, it was reported that 73% of surgical ICU nurses experienced moderate levels of compassion satisfaction and the remaining experienced high levels of compassion satisfaction. Moreover, most of them reported average levels of burnout.17

 

According to a systematic review on 40 publications about compassion fatigue and burnout in health care professionals in ICUs, the prevalence of compassion fatigue ranges between 7.3% and 40%, and up to 70% of ICU health care personnel experience burnout.18

 

Professional quality of life among critical care nurses has been the subject of many studies. Although such information is of great importance, another question raised is how critical care nurses' professional quality of life may be related to caring ability. Considering that being with a patient can both positively and negatively affect a critical care nurse's work life, the question that arises concerns that the degree of compassion satisfaction and compassion fatigue may decrease or increase critical care nurse's caring ability. Although the effect of culture cannot be ignored, it seems that the existence of any relationship between such variables as professional quality of life and caring ability would be somewhat invariable in different health care contexts, and the findings of the study may be considered by nurse managers in other contexts. The aim of this study was to determine the relationship between professional quality of life and caring ability in critical care nurses.

 

MATERIALS AND METHODS

This descriptive correlational study was conducted at the teaching hospitals of Tehran University of Medical Sciences in Iran. The study population consisted of all critical care nurses working in the adult medical and surgical ICUs of university teaching hospitals. First, 30 ICUs were randomly selected. Then, 9 critical care nurses of each selected ICU were recruited through convenience sampling and based on inclusion criteria (bachelors degree, working in the medical and/or surgical ICU for at least 1 month). Of 290 questionnaires delivered to the critical care nurses to be completed, 253 questionnaires were returned (response rate, 87%).

 

After obtaining the approval of the ethical committees of Tehran University of Medical Sciences and the permission to enter the hospitals, the researcher referred to the medical and surgical ICUs, and after introducing herself to the participants, she explained the aims of the study, its importance, and the confidentiality and anonymity of the participants. Critical care nurses who were willing to participate in the study signed an informed consent and completed a demographics form (eg, sex, age, marital status, education, work experience, work experience in ICU, and work setting), a Professional Quality of Life Questionnaire (version 5), and the Caring Ability Inventory. The Professional Quality of Life Questionnaire (version 5) includes 3 subscales of burnout, secondary traumatic stress, and compassion satisfaction. The subscales of burnout and secondary traumatic stress are grouped as compassion fatigue. Each subscale consists of 10 items. The score given to each item ranges from 1 (never) to 5 (very often). Five items are reversely scored (items 1, 4, 15, 17, and 29). The responses to the 10 items of each subgroup are calculated to estimate the overall score of the subscale.16 Some examples of questions include "I get satisfied from being able to help people," "I feel invigorated after working with those I help," "I have beliefs that sustain me," and "I am a very caring person." The Caring Ability Inventory is a self-reporting instrument including 37 items with 5-point Likert scale that is designed "to measure the degree of a person's caring ability." The scores range from 37 to 259. The range of scores for the subscales of knowledge, courage, and patience are 14 to 98, 13 to 91, and 10 to 70, respectively. Some items are negatively phrased and reversely scored (items 4, 8, 11, 12, 13, 14, 15, 16, 23, 25, 28, 29, and 32).17 The scores of all 3 subscales were calculated based on 100. To confirm content validity, the translated questionnaires were given to 10 faculty members of the Nursing and Midwifery School of Tehran University of Medical Sciences, and their comments were used in the Persian questionnaire. The reliability of the questionnaires was examined using test-retest. Cronbach [alpha] value was estimated as 0.74 for the Caring Ability Inventory and 0.78 for the questionnaire of professional quality of life.

 

The researcher attended different work shifts of critical care nurses, and either waited until the questionnaire was completed or returned another time for collection when the questinnaires were completed. The SPSS version 19.0 for Windows (SPSS Inc, Chicago, Illinois) was used for descriptive and inferential statistical analysis.

 

RESULTS

Supplemental Digital Content 1 (see Supplemental Digital Content 1, http://links.lww.com/DCCN/A24) shows some demographic characteristics of the subjects. Most of the participants were female (85.4%), between 20 and 30 years old (47.5%), and married (55.7%). They held a bachelor of science (97.2%), had less than 6 to 15 years of work experience (47.6%) and less than 6 years of work experience in the ICU (55.7%), and were working in surgical ICUs (53.4%).

 

Supplemental Digital Content 2 (see Supplemental Digital Content 2, http://links.lww.com/DCCN/A25) depicts frequency distribution of critical care nurses in terms of professional quality of life and caring ability. As shown in the table, the highest percentage of critical care nurses experienced moderate levels of professional quality of life. Regarding subscales of professional quality of life, most of the critical care nurses experienced high levels of compassion satisfaction (55.3%) and moderate levels of burnout (54.5%) and secondary traumatic stress (58.5%). Most critical care nurses reported high levels of caring ability. Moreover, in the caring ability subscales, most of the critical care nurses had high levels of knowledge (67.6%) and patience (83.7%) and moderate levels of courage.

 

The results showed that a statistically significant positive relationship was found between the professional quality of life and the caring ability (r = 0.337, P < .0001). There was a statistically significant inverse relationship between the burn-out subscale of compassion fatigue, as one aspect of professional life quality, and all 3 aspects of caring ability (knowledge: r = -0.414, P < .0001; courage: r = -0.31, P < .0001; and patience: r = -0.349, P < .0001). Another subscale of compassion fatigue, secondary traumatic stress, had no statistically significant correlation with caring ability aspects of knowledge and patience; however, there was a significant inverse correlation between the secondary traumatic stress and courage aspect of caring ability (r = -0.353, P < .0001). There was also a statistically significant positive relationship between the compassion satisfaction aspect of professional life quality and the knowledge (r = 0.542, P < .0001) and patience aspects of caring ability (r = 0.503, P < .0001), but there was not any relationship between the compassion satisfaction aspect of professional life quality and the courage aspect of caring ability.

 

DISCUSSION

This study indicated that the professional quality of life and caring ability are directly correlated (r = 0.337, P < .0001), meaning that higher quality of work life was associated with an increased ability to care. The finding that a significant inverse relationship exists between the burn-out subscale of compassion fatigue and the knowledge domain of caring ability is consistent with the results of Burston and Estichler study in which a negative significant relationship was reported between compassion fatigue and knowledge.19 Moreover, an inverse relationship was found between burnout and secondary traumatic stress (as subscales of compassion fatigue) and courage aspect of caring ability. These findings convey that increasing one's knowledge about patient care and enhancing the individual's courage may reduce the negative effects of compassion fatigue (burnout and secondary traumatic stress). It is also conceivable that compassion fatigue has some undesired effects on the courage aspect of caring ability, and frequent exposure to traumatic events gradually decreases the individual's courage in facing challenges of care.

 

A direct correlation of compassion satisfaction with knowledge and patience aspects of caring ability shows that compassion satisfaction positively influences the professional quality of life. It can be explained in a way that satisfaction of caregiving may cause an individual to be more patient when taking care for others and may increase their tendency to enhance knowledge in order to provide better care.

 

A review of previous studies indicates that critical care nurses may not have an optimal professional quality of life because of providing services in a stressful environment and taking care of patients with critical conditions.8,14,20,21 This is important, because low levels of professional life quality may affect their caring ability. Conducting research in the field of professional quality of life and caring ability of critical care nurses sheds light on some aspects of the caring phenomenon in the ICU, providing a knowledge basis to improve quality of nursing care for patients with critical conditions.

 

According to the findings of Yoder,8 the situations that staff nurses addressed as stimulant for compassion fatigue and burnout include patient care, organizational problems, and personal issues. The nurses reported many caring situations in which they had experienced physical, emotional, or financial threats and witnessed imminent death. Organizational problems included large numbers of patients, high workload, and patient acuity. Individual issues included inexperience, lack of energy, and failure to identify serious symptoms of patients.10 It is suggested that nurse managers should be aware of the prevalence of compassion fatigue (secondary traumatic stress and burnout) among critical care nurses. Increasing awareness about these aspects of professional quality of life can be helpful in targeting specific strategies that may prevent the onset and progression of these symptoms. Moreover, caring ability of critical care nurses and their professional life quality should be measured periodically, and if necessary, proper action should be implemented.

 

CONCLUSION

Given that this study found a significant correlation between caring ability and professional quality of life, it can be concluded that promoting professional quality of life in critical care nurses may enhance caring ability, thereby leading to better quality of care.

 

One of the limitations of this study is that it was conducted as a cross-sectional study. Another limitation is the use of self-report instruments, which may affect the validity of the responses. Moreover, including nurses in the study with at least 1 month's experience may have led to the underestimation of compassion fatigue and burnout. The fact that critical care nurses were asked to recall their past feelings may have affected the study's results by underestimating or overstimating when giving scores to questionnaire's items because it is possible that their emotional impression had faded over time. Although participants were assured of anonymity, answering to questions related to past traumatic experiences can create unpleasant feelings to the participants.

 

Acknowledgment

The authors would like to thank all participants in the study.

 

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