Compassion fatigue, compassionate care, nurses, resilience, secondary traumatic stress



  1. Salmond, Erin


Review question/objectives: : The objective of this qualitative systematic review is to examine available evidence on the experiences of direct care nurses of compassion fatigue (CF) within any nursing specialty or care setting. Specifically, this review will identify evidence on the following:


* 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' experiences of strategies that have assisted them to cope with CF.



Article Content


Nursing is an extremely demanding yet rewarding profession that requires physical, emotional and spiritual strength. Nurses enter into the lives of their patients during periods of physiological, emotional or spiritual vulnerability and are witness to the stress, pain and suffering accompanying these events. They are present at immediate and concrete levels to care for the physical and emotional/spiritual wellbeing of both the patient and the family. Having an impact on a person's life during this vulnerable period, whether it is assisting in delivering a healthy baby, alleviating one's pain after major surgery, comforting and counseling a person having received a catastrophic diagnosis, or enhancing one's sense of esteem in coaching them to manage the demands of a chronic illness can be extremely rewarding and bring about a sense of compassion satisfaction.


Compassion satisfaction is "the positive feelings derived from helping others through traumatic events".1(p.33) Compassion satisfaction creates a sense of worth that has been described as the most rewarding part of what nurses do.2 Those experiencing compassion satisfaction derive gratification from their work and feel positive about the patient/family, the 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 challenged 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 absorbing the patients' trauma or pain or when nurses care for traumatized patients and re-experience traumatic events.6 Sabo equates CF with secondary traumatic stress wherein caregiver's experiencing CF do not physically experience the traumatic events but do experience the event emotionally while caring for the patient.7 Coetzee and Klopper's8 definition goes beyond the experience of secondary traumatic stress and "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".8(p.237) The authors note that the absence of a definition within nursing has led to "the inability to identify and combat its effect on nursing practice".8(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. Compassion fatigue may encompass, but go beyond, burnout where nurses may be less empathetic 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 others9 or what has been labeled a state of exhaustion - physically, spiritually and emotionally.2,4


The nurse may succumb to the overall stress from human suffering if they do not have an adequate outlet to decompress or maintain a professional and emotional work/life balance.2 In CF, nurses absorb the emotions of traumatic stress from patients, colleagues and families and have little time to mourn and disconnect.9 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 resistance against CF.7 Additionally, age (being older), 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 buffer against CF.10


Compassion fatigue has negative effects on the emotional and physical health of nurses and their sense of job satisfaction. Moreover, CF impacts the healthcare organization as the nurse is more pessimistic about the ability for positive change. Consequently, productivity and quality go down, decrease absenteeism increases, intention to leave one's job rises and turnover increases.11-13 Compassion fatigue can take away a major attribute of effective nursing - empathy and caring - that is 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


Although many studies do not report the prevalence of CF, Van Mol et al.15 summarized the available literature indicating that the prevalence among intensive care nurses was reported as 7.3% and 40%. Reporting on professional care providers, Rao and Taliaferro16 suggested that an average of more than 30% of professional care providers, including nurses, exhibited CF symptomatology. Compassion fatigue has been found to be greater in specialties that deal with greater degrees of trauma and death. Thus nurses working in critical care, oncology and emergency care may be at greater risk.16


Compassion fatigue has been found to be more prevalent among nurses in the millennial generation (ages 21-33).17 Considering that an estimated 30-50% of all new registered nurses elect either to change positions or leave nursing completely within the first three years of clinical practice, one must question whether CF contributes to this.12 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.18 used a qualitative exploratory approach examining critical incidents among intensive care unit nurses to describe CF and the need for support. They identified four main themes contributing to CF: high emotional involvement in patient-related incidents, avoidable incidents, sub-standard patient care and intimidation. Nurses in the study described that after these events they experienced emotional, cognitive/behavioral and physical reactions. They coped by talking with peers or family/friend support networks but felt their need for support was inadequately met and stated they could have used additional support.


A search of the JBI Database of Systematic Reviews and Implementation Reports, Cochrane Library, MEDLINE, CINAHL and Google Scholar found only three systematic reviews and one systematic review protocol targeting components of CF in nursing related to the experience of CF and interventions to cope with CF. One review looked at the prevalence of CF and burnout among healthcare professionals in intensive care units and preventive strategies that had been successfully applied to reduce distress. The reviewers reported that prevalence studies for CF were much fewer for burnout, citing only two studies with prevalence of 7.3% and 40%.15 Interventions examined included communication skills support, intensivist work schedules, educational programs, relaxation exercise such as yoga and mindfulness, work environment support, teambuilding and individual coping strategies; however, almost all examined the influence of the intervention on burnout.15 Educational seminars aimed at increasing awareness of CF and possible resources to prevent or minimize CF were found to be promising and the reviewers concluded that the true prevalence remained open for discussion, and that the data to date suggested interventions that might be helpful but had not been validated to have an effect.15


A second quantitative review examined CF among healthcare, emergency and community service workers and interventions and workplace strategies to reduce CF.19 Thirteen studies examined interventions of music therapy, grief expression, rituals and resolution, connecting with colleagues who had experienced similar events, transcranial direct current stimulation and mindfulness education showed mixed or no effects.19 Structured meditation, interactive groups, seminars, guided imagery and resilience education were also examined and shown to reduce burnout and secondary traumatic stress and improve compassion satisfaction, but not directly impact the CF measure. The reviewers called for more research to determine best approaches for protecting vulnerable workers from CF but also concluded that promotion of resiliency and self-efficacy are promising.19


In the third review, spanning literature from 2009 to 2013, coping and resilience in palliative and oncology nurses caring for adult patients with malignancy was examined.20 Although encompassing a broader context, CF was listed as one of several phenomena of interest/outcomes measures in this review that captured both quantitative and qualitative studies. Relevant to CF, one metasynthesis was particularly relevant as specific findings addressed CF.20 The metasynthesis, "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",20(p.150) spoke to strategies that might be effective in preventing and coping with CF.


The systematic review protocol by Hodge and Lockwood21 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 focuses on the experience of planned interventions at decreasing CF that is more limited than what is proposed in this protocol.21


Clearly, while 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 and the strategies that may be used to minimize or cope with the condition.11 By gaining a greater understanding of CF in its entirety, including an understanding of the experience itself, contributory and mediating factors, and interventions can be undertaken by individuals and organizations to prevent or lessen the impact of CF. This can be used to provide a comprehensive definition for CF in nurses and to suggest interventions that can be tried and tested11 to combat CF.


Inclusion criteria

Types of participants

The current review will consider qualitative studies on direct care nurses.


Types of intervention(s)/phenomena of interest

The phenomena of interest will be the experiences of direct care nurses with CF. It will not include studies of nurses with burnout as burnout is conceptualized as a different phenomenon.



The current review will consider studies drawn from any nursing specialty or any nursing work setting.


Types of studies

The current qualitative review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research, narrative case studies and feminist research.


Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be used in this review. An initial limited search of PubMed and CINAHL will be undertaken using the terms CF and compassion satisfaction AND nursing. This will be 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 will then be undertaken across all included databases. Third, the reference lists of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review. Studies published from 1992, when the concept of CF was first described,18 till present will be considered for inclusion in this review.


The databases to be searched include the following:


* PubMed




* Academic Search Premiere


* Science Direct


* Scopus


* Psych Info


* Web of Science




* MedNar/Google Scholar.


Critical Care Nurse (CCN) and Journal of Nursing Administration (JONA) will be hand searched for the last five years (2011-2016).


The search for unpublished or gray literature will include the following:


* Virginia Henderson Nursing Library


* Robert Wood Johnson Foundation Research and Publications


* ProQuest Dissertations and Theses Global.


* Conference proceedings of the past five years from Magnet, American Organization of Nurse Executives, Sigma Theta Tau International and Press Ganey Associates.


Initial keywords to be used will be: compassion fatigue, compassion satisfaction, secondary traumatic stress, vicarious trauma, empathy, compassionate care, resiliency, nurses, strategies and or interventions, self care.


Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the Joanna Briggs Institute Qualitative Appraisal and Review Instrument (JBI-QARI) (Appendix I). All studies will be appraised using the full criteria; however, papers not meeting criteria 2, 4 and 8 will be excluded without further consideration. Any disagreements that arise between the two reviewers will be resolved by discussion or with a third reviewer.


Data extraction

Qualitative data will be extracted from included papers using the standardized data extraction tools from the JBI-QARI (Joanna Briggs Qualitative Assessment and Review Instrument), (Appendix II). Initial extraction will include data relevant to the phenomena of interest, populations, study methods and outcomes specific to the review question and specific objectives. Each reviewer will then extract findings separately for each study. The extracted data will include findings and, if present, a relevant illustration for each finding. The reviewers will then assign a level of validity or credibility such as unequivocal, credible or unsupported evidence to each finding. Authors of primary studies will be contacted for missing information.


Data synthesis

Qualitative research findings will be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (level 1 findings) rated according to their quality and categorizing these findings on the basis of similarity in meaning (level 2 findings). These categories will then be subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings (level 3) that can be used as a basis for evidence-based practice.


Appendix 1: Appraisal Instrument

JBI critical appraisal checklist for qualitative research

Appendix II: Data extraction instrument



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