Compassion fatigue in critical care nurses

Prevalence of CF among critical care nurses

In terms of RQ1, the finding in this review that there is inconsistency in the prevalence rates of CF between nurses in diverse critical care settings reported in cross-sectional studies is reflected in the broader literature.

According to Van Mol et al20 appropriate measures of CF among critical care nurses “remains open for discussion” given the diverse ways it can manifest in nurses and the fact that its expressions are not always easy to identify. The prevalence of CF among the nurses investigated in the selected studies was generally measured according to the same 4 outcomes: the nurses’ indications of sadness and grief in relation to patient conditions, avoidance of care towards patients, detachment from colleagues and patients, and decreased social interactions with others in the workplace.4,24,26 It remains difficult to determine the true extent to which these outcomes manifest as CF4,26 given the diverse ways it can find expression. This is because exposure to the same risks of psychological distress when providing care to patients can impact critical care nurses in diverse and unique ways based on the temperament of the nurse and the work conditions when seeking to measure CF.30

Causes of CF among critical care nurses

The focus in RQ2 on the causes of CF among critical care nurses is intended to provide insights into the nature of the relationship between nurse demographic characteristics and workplace characteristics as contributor to CF. This review found that multiple and diverse factors may contribute to the onset of CF including the personal characteristics and attributes of the critical care nurse, previous exposure to trauma and complex patient care scenarios, years of experience working in critical care settings and the work environment more broadly.3,25,26 The association between the identified nurse demographic characteristics and CF onset is perhaps not surprising. The broader research literature commonly points the ways in which the age, years of nursing experience, and personal attributes including ‘resilience’ and ‘high self-expectations’ can influence diverse care-related outcomes for nurses in critical care settings.29 These outcomes include moral distress,31 burn out,32 perceived poor job satisfaction,33 and all factors associated with CF. Indeed, Craigie et al2 refer to the ‘costs of caring’ and to the occupational hazard of working in critical care settings. In turn, the review finding suggests that the demographic characteristics of the critical care nurse can influence their capacity to cover the ‘costs’ of continued exposure to patient mortality and suffering, and high-pressure working conditions.

This paper also found that the constant demands on nurses’ emotional reserves due to high patient mortality rates and feelings of being unable to provide adequate relief to suffering patients contributed to compassion exhaustion. This outcome may be explained by drawing on reports in the literature that difficult working conditions including work overload and complex patient demands can lead some nurses to lose their sense of purpose and understanding of the meaning of compassionate and dignified care.34

Furthermore, the finding reported above regarding the challenging work conditions (such as poor management support or inadequate training) can exacerbate distressing patient situations for critical care nurses leading to CF is supported in the wider research literature. For instance, a systematic review by Adriaenssens et al35 found that work environment factors including exposure to traumatic events, job characteristics (workload, colleague support) and organizational variables (staffing or communication and collaboration issues) contributed to deterioration in psychological wellbeing among nurses.

Factors and coping strategies to reduce the risk of compassion fatigue

The results for the relationships between nurse demographic characteristics, workplace characteristics, and the onset of CF for critical care nurses reported above provide context to the findings related to RQ3. This question focused on the factors that reduce the risk of CF or which assist nurses to manage their experiences of CF. The main finding in this regard was that both personal (years of work experience, education level, personality attributes) and workplace factors (management support and education and training programs) can impact nurses’ experiences of CF.

At the individual level, the broader literature identifies ongoing learning, the adoption of self-care strategies, and the enforcement of suitable emotional boundaries as 3 potential self-directed approaches for critical care nurses to reduce the risk of CF.30 The focus on these approaches appears to reinforce the importance of nurse self-awareness of the impact of workplace conditions on personal wellbeing combined with a proactive attitude towards achieving a satisfying work-life balance.30

At the organizational level, the findings reported by Hunsaker et al3 showing an association between access to manager support and experiences of CF among nurses also point to the importance of formal programs and initiatives for the prevention and management of CF. As discussed in the broader literature, there is importance placed on workplace education and training provisions to nurses on how to identify the early symptoms of CF such as emotional detachment and care avoidance.30,36 However, these suggestions of course only address the nurses’ personal response to the CF experience.36 Equal importance must arguably be placed on the workplace response to reduce the risk of CF among nursing staff. Some of the selected cross-sectional studies3,25 emphasized the need for positive and supportive practice environments and adequate manager support to limit the onset of CF among nurses. However, the depth of detail to which these institutionally driven strategies are discussed in the studies is limited. Indeed, none of the studies provided clear descriptions of what constitutes good supervision in critical care settings.

According to Etherington,37 for CF-related supervision to be effective it should attend to the inter relationships among the trauma, the patient, the nurse, the therapeutic relationship and the dynamics within the workplace. Any attempt to address all these aspects for the prevention and management of CF among nurses must arguably rely heavily on effective collegial and leadership support mechanisms. A recent study by Berg et al38 provides a useful 8-step process for managers in this regard: 1) ensure CF is acknowledged and accepted as a reality; 2) provide education to staff on how to recognize CF signs and symptoms; 3) facilitate team-based stress-coping skills (mindfulness, self-soothing) development; 4) ensure managers openly demonstrate social support; 5) normalize the workplace discourse around coping in response to challenges; 6) ensure managers are proactive in high-crisis interventions; 7) place emphasis on the positive aspects of patient care; and 8) seek regular feedback from staff on their CF experiences and coping strategies.

Practice implications CF among critical care nurses

The finding in this review of 10 cross-sectional research studies of CF among critical care nurses of an inconsistency in reported prevalence has implications for the nature of the culture of the workplace in relation to collaborative and supportive care. The reasons for this inconsistency were nurse reluctance to openly acknowledge CF experiences in combination with our general lack of understanding of how CF may manifest. As alluded to above, the extent to the organizational culture values open debriefing by nurses regarding taxing care experiences or endorse and supports education and training on coping strategies is critical to establishing the types of support systems needed to encourage nurses to share CF experiences and to identify signs of CF in colleagues.27 Moreover, a workplace culture that reflects the 8 elements for effective organizational responses to CF by Berg et al37 is recommended.

The second practice implication associated with the findings reported in this review relate to self-assessment practices of critical care nurses to identify and respond to the signs and symptoms of CF. The broader literature alludes to the greater need for nurses to be educated in appropriate self-assessment processes to identify CF indicators and to develop effective recovery plans. As stated by Poncet et al,39 failure to acknowledge and respond to the pressures of caring can result in the depersonalization of patients by nurses and a lost sense of empowerment in the practices of care. In turn, the extent to which nurses are supported in the processes of self-assessment for CF can significantly influence their capacity to build the physical and emotional fortitude required to avert CF.39

Notably, effective self-assessment strategies by critical care nurse to the impact of CF on their personal lives and professional practices generally include a focus on interpersonal and communication skills.40 Part of the self-assessment process is gauging one’s emotional state and responses relative to others in the care setting.40 The implication for nurses in critical care settings is that they engage in opportunities to share experiences of the care demands of the setting and to explore coping strategies with colleagues in the workplace.10

Implications for further research

The findings reported in the selected cross-sectional studies of CF imply the importance of gaining a better understanding of the optimal training and support provisions to nurses to avoid and/or manage CF. In turn, there are several opportunities for further empirical research of the effectiveness of self-management and institutional-based strategies to assist critical care nurses to reduce CF. Our clinical practice and academic understanding of CF and its management would also benefit from further research of the types of strategic workplace initiatives required to best support critical care nurses to achieve a work-life balance. The findings from such research may enable health organizations to better support nurses assert their personal needs and values while providing compassionate and empathetic care aimed at optimizing outcomes for patients.

This review also asserts the importance of further studies of effective CF coping strategies for nurses. Acknowledging the potential for critical care nurses to experience CF due to working conditions in combination with education and training on coping techniques is integral to reducing the likelihood of CF onset and to improving patient care.4 As such, research investigating how the care environment can best be designed to assist nurses to understand and respond to their emotional experience to the provision of care may help to reduce the development of CF among these nurses.

Lastly, the cross-sectional studies included in this review all sought to collect quantitative data related to nurses’ CF experiences using the Professional Quality of Life Scale (ProQOL41) instrument except for Kenny and Hull21 and Dominguez-Gomez and Rutledge.22 Given CF is a highly subjective experience for critical care nurses, valuable research insights could be gleaned from studies employing qualitative research paradigms. Indeed, qualitative studies of this phenomenon can assist researchers and clinical care nurses to better understand the manifestation and impacts of CF by accessing nurses’ interpretations of their CF experiences. Qualitative data of this type can be combined with quantitative data sets to provide a more comprehensive understanding of the CF phenomenon through consideration of both the statistical and interpretive representations of CF in critical care settings.

In conclusion, the results from the literature review demonstrate that research studies have been conducted on various aspects of CF and the coping strategies employed by nurses who experience this phenomenon. The key findings reported and discussed above included the way in which the nature of the therapeutic relationship and the specialised type of care allows for the development of close relationships between nurses and their patients. As such, the risk of CF is higher among critical care nurses than nurses working in non-critical care settings due to the critical nature of patients’ conditions and the closeness with which the nurses work with patients and family members. Given the onset of CF may include indicators including clinical and medication errors, higher rates of sick leave, and nosocomial infections, it is of some concern that the international literature is replete with studies examining CF coping strategies. This integrative review therefore asserts the importance of further studies of CF and the coping strategies employed by nurses to reflect on their experiences to inform future strategies and policy initiatives to improve compassion satisfaction.