Compassion Fatigue in Palliative Care Nursing PDF

Feature Article Compassion Fatigue in Palliative Care Nursing A Concept Analysis Lisa A. Cross, MSN, BA, CRRN, CHPN The purpose of this review was to define compassion patients and caregivers who are suffering. The prolonged fatigue in the context of pal...

Feature Article Compassion Fatigue in Palliative Care Nursing A Concept Analysis Lisa A. Cross, MSN, BA, CRRN, CHPN The purpose of this review was to define compassion patients and caregivers who are suffering. The prolonged fatigue in the context of palliative care nursing. contact with these individuals during times that they are at Compassion fatigue was first introduced as a description end stages of serious illnesses predisposes palliative care for nursing burnout; however, it was not fully described. nurses to physical, emotional, spiritual, and psychological An initial concept analysis within nursing placed it in terms distress, possibly limiting their ability to provide compas- of a psychological model for secondary traumatic stress sionate care.1 Compassion fatigue has been used to describe disorder, with continual revisions of this application. the distress that results from work-related stressors and has Palliative care nurses are routinely exposed to pain, trauma, been defined as ‘‘a state of exhaustion and dysfunctionV and the suffering they witness by nature of ongoing symptom management and end-of-life care delivery; biologically, physically, and sociallyVas a result of prolonged however, the focus of care is on healthy end-of-life exposure to compassion stress and all that it evokes.’’2 management rather than preservation of life. The Compassion fatigue in nurses can impact job satisfaction literature was reviewed to provide clarification of and patient outcomes and can lead to nurses leaving a profes- compassion fatigue for palliative care nurses to assist in sion already plagued by staffing shortages.3-5 Of significance, future identification and direction in the profession. compassion fatigue has been seen in diverse nursing settings CINAHL, EBSCO, Journals@Ovid, MEDLINE, PsycINFO, and has been associated with stemming from caring, a foun- PubMed, and ScienceDirect databases were queried for dational component to nursing.6 Identification of symptoms peer-reviewed literature, and dictionaries were examined is important for reducing occurrences of compassion fa- for subject-specific definitions. The method that was used tigue, improving patient care, and retaining nurses.3 Pallia- was a concept analysis in the tradition of Walker and tive care nurses are predisposed to distress, because they are Avant. A concept definition was proposed for the discipline of palliative care nursing. Identification of surrounded by seriously ill or dying patients on a regular ba- compassion fatigue for this profession helps facilitate the sis.1,7 The focus of this concept analysis is to define compas- recognition of symptoms for a group that deals with sion fatigue for palliative care nursing to assist in recognition patient suffering on a regular basis. of occurrences and future implications for this discipline. KEY WORDS BACKGROUND compassion fatigue, compassion satisfaction, concept Compassion fatigue emerged as a concept in health care analysis, hospice, palliative care nursing by Joinson8 in 1992, when it was introduced as a syno- nym for burnout. Figley,9 a psychologist, originally intro- urses are challenged with maintaining the balance N between everyday stressors and work stressors. Palliative care nursing is a demanding nursing subspecialty, requiring time and continual contact with duced the new concept of secondary catastrophic stress reactions as synonymous with the phenomena of sec- ondary traumatic stress disorder (STSD) and later clari- fied STSD as compassion fatigue in 1995.2 After years when compassion fatigue, STSD, and burnout became inter- Lisa A. Cross, MSN, BA, CRRN, CHPN, is doctoral nursing student, changeable terms, Coetzee and Klopper10 defined compas- University of Massachusetts, Lowell; and is clinical nursing instructor, North Shore Community College, Danvers, MA. sion fatigue in terms of nursing practice in 2010. Address correspondence to Lisa A. Cross, MSN, BA, CRRN, CHPN, 10 Compassion fatigue is complex, because its conse- Silas Meriam Way, Middleton, MA 01949 ([email protected]). quences affect nurses, organizations, and patients. The The author has no conflicts of interest to disclose. multiple levels of stress that are experienced place nurses This is an open-access article distributed under the terms of the Creative who have symptoms in a state of vulnerability.11 These Commons Attribution-Non Commercial-No Derivatives License 4.0 nurses may find the duties of their jobs in direct competi- (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or tion with their distress and find difficulties in providing used commercially without permission from the journal. compassionate care.11,12 This places patients at risk for Copyright B 2018 The Author. Published by Wolters Kluwer Health, Inc. circumstances that include low staffing, errors, abuse, DOI: 10.1097/NJH.0000000000000477 and neglect, as well as poor caring relationships.11 Health Journal of Hospice & Palliative Nursing www.jhpn.com 21  Feature Article care organizations face the challenges of retaining nurses Data Sources and maintaining safety outcomes by preventing, identify- English-language dictionaries and nursing and medical ing, and relieving the symptoms of compassion fatigue.11 dictionaries were reviewed for the terms ‘‘compassion fatigue,’’ Palliative nurses care for sick and suffering patients on ‘‘compassion,’’ ‘‘fatigue,’’ ‘‘palliative,’’ and ‘‘hospice.’’ Com- a continuum. Palliative care is a type of care that encompasses passion fatigue was a newer term; however, it appeared in the patients and the caregivers through a holistic approach nursing and medical dictionaries as well as in the online to manage the symptoms of serious illnesses, while address- dictionaries reviewed. The databases that were searched ing pain, symptoms, psychosocial issues, spirituality, and were CINAHL, EBSCO, Journals@Ovid, MEDLINE, PsycINFO, quality of life.13 The World Health Organization identifies PubMed, and ScienceDirect for the time frame of 2010 to 2018 palliative care as ‘‘an approach that improves quality of life and were limited to those items that were in the English of patients and their families facing the problem associated language. ‘‘Compassion fatigue,’’ ‘‘palliative care,’’ and ‘‘hos- with life-threatening illness.’’14 Because the focus of care is pice’’ were used as search terms or keywords and then comprehensive, palliative nurses bear witness to patient and were narrowed down to subject-specific terms to eliminate caregiver suffering on multiple levels that include physical, nonrelevant data. A second search was conducted with the psychological, social, emotional, and spiritual. search terms ‘‘concept analysis’’ and ‘‘compassion fatigue’’ Hospice and palliative nursing are frequently used as in- in the same manner. Abstracts, reviews, and commentaries terchangeable terms, programs, or types of nursing care. were excluded from this search. Studies that involved com- However, hospice care is a type of palliative care where the passion fatigue outside nursing or helping professions care delivery is intensified, because the disease is identified as were excluded. Duplicate results were eliminated. terminal or end-stage, with a prognosis of 6 months or less.13 Seventy-one articles within the identified time frame The movement for end-of-life care and bereavement services were found. Six concept analyses related to compassion began with Dame Cicely Saunders, a registered nurse from the fatigue were found. There were two analyses for other United Kingdom.15 She saw the need for extended support nursing subspecialties other than palliative care; however, during the dying process and opened the first hospice in En- the search did not yield one for palliative care nursing. gland in 1967.15 As recognition for services spread, the hospice Twenty-eight studies were identified, with four specifically philosophy eventually came to the United States, with hospice related to palliative care or hospice nurses and compassion also becoming a Medicare benefit during the 1980s.15 In the fatigue. The other disciplines that were studied were oncology United States, the terminology may be confusing, because nurses, student nurses, intensive care nurses, critical care the hospice Medicare benefit provides coverage that includes nurses, general nurses, pediatric nurses, military nurses, mental nursing care, medications, equipment, and psychosocial sup- health nurses, social workers, and genetic counselors. port for patients who are determined eligible by physicians.15 Two dissertations in palliative care nursing were found. Hospice and palliative care nurses are focused on deliv- Three recent literature reviews within the search years were ering quality health care to their patients and caregivers as found, reviewing compassion fatigue across all nursing care. they approach the end of life, and it is imperative that they Articles that were used outside the search parameters were maintain quality and health in their own lives.16 Palliative those by the original developers,2,8,9 as several other articles care nurses may experience three stressors unique to this referenced preliminary work in the area of compassion discipline.17 The first stressor arises from personal factors fatigue concept development. Two books were found to from the palliative nurse and includes the nurse’s discom- be relevant to the time frame and to the search terms.13,15,16 fort with the patient’s illness or treatment plan, inadequate preparation or training to manage the illness, or external distractions from outside life. The second stressor is derived RESULTS from the patient or caregiver and includes patient health de- cline or noncompliance with the treatment plan. The third Concept Selection stressor is related to the work environment and includes prac- This concept analysis was guided by the method of Walker tice issues such as poor staffing and resources. These stressors and Avant.19 The method included eight stages: choose the are distinct to the palliative care discipline and are associated concept, outline the purpose, determine uses of the con- with the struggles in finding a balance between intimacy and cept, describe its attributes, examine a model case, illus- empathy in the working relationship.7,18 The identification trate any additional situations, identify antecedents and of predisposing stressors has become critical to providing consequences, and establish empirical indicators.19 The future support for palliative care nurses. As palliative care stages are described hereinafter. nurses experience an intense relationship with their patients and their caregivers, there is a greater risk for compassion Aim of the Analysis fatigue, placing emphasis on the need to define compas- This analysis will separate compassion fatigue from the sion fatigue for the discipline of palliative care nursing. similar terms ‘‘burnout,’’ ‘‘secondary traumatic stress,’’ 22 www.jhpn.com Volume 21 & Number 1 & February 2019  Feature Article and ‘‘vicarious traumatization’’ and define the concept on as nursing, ministry, and counseling. Nurses were iden- its own. The purpose of this concept analysis was to further tified as prone to the phenomena because of the nature define compassion fatigue within the discipline of pallia- of their work. Later work by Figley2 portrayed compassion tive care nursing to make it relevant for those nursing care- fatigue as a state of exhaustion and biological, psycholog- givers who have routine exposure to the suffering of their ical, and social dysfunction that resulted from prolonged patients and their caregivers while providing quality end- exposure to compassion stress. Burnout was identified of-life care. Past research has defined the concept as STSD, as a process that existed simultaneously with compas- burnout, or vicarious traumatization. However, palliative sion fatigue or its synonymous concept, STSD, that de- care is delivered over a continuum, focusing on compas- veloped gradually as physical, emotional, behavioral, sionate care delivery rather than preservation of life as in professional, and interpersonal symptoms progressively other nursing disciplines.13 This analysis will provide a worsened.2 Although Figley2 applied compassion fatigue separate identity for compassion fatigue and place it within and STSD to nurses, he used the same concepts and defi- the context of palliative care nursing. nitions for psychotherapists and other disciplines. He continues to develop his work with STSD in formulating Use of the Concept a theory with resilience, stress, and trauma victims.26 The terms for the concept were identified in and out of the Coetzee and Klopper’s10 development of a compassion nursing literature to explore other uses of concept lan- fatigue concept analysis in 2010 was heavily influenced by guage.19 Palliative is identified as relieving care without Figley’s work with STSD. This was the first concept analysis curing or an individual who relieves an uncomfortable con- in relation to nursing care, and despite numerous nursing dition.20 The word hospice has origins in Latin that means articles and nursing studies examining compassion fatigue, ‘‘guests’’ or ‘‘hosts,’’ and its current use is as a care model or several years had passed before this analysis clarified what a location for care.15 Taber’s Cyclopedic Medical Dictionary was a relatively new concept during that time.10 Their con- defined it slightly differently than other sources; here, it was cept analysis indicated that compassion fatigue resulted described as a program derived from palliative and support- from a cumulative process where compassion discomfort ive services, interdisciplinary in nature, that focused on the led to compassion stress and, if not managed, led to com- ‘‘physical, spiritual, social, and economic needs’’ of termi- passion fatigue through prolonged and intense contact nally ill patients and their caregivers.20 with patients, exposure to stress, and self-involvement in Compassion is defined as having pity or the urgent care.10 The authors differentiated the concept of compas- desire to help or aid someone.21 It is also identified as sion fatigue as separate from STSD, with compassion fa- a synonym for sympathy.20 Fatigue is defined in different tigue resulting specifically from exposure to direct care of contexts that include manual work; an exhaustion from patients and STSD resulting from exposure to traumatic labor, stress, or exertion; or a ‘‘loss of power induced by events or stories of traumatic events of others.10 However, a sensory receptor.’’22 It can also be defined in military the definition that was used was slightly different from that terms as a unit or a uniform worn.22 The medical defini- proposed in a previous work by Figley2 in that it did not tion of fatigue placed it in the context of a diminished identify distress in the psychological domain. Psychologi- capacity for work in the mental and physical domains cal responses could be a causative or resulting factor asso- and also identified acute, alert, chronic, muscle, and voli- ciated with stress and are important elements for compassion tional fatigue in addition to compassion fatigue.20 fatigue concept definition.6,17 Compassion fatigue is medically defined as ‘‘cynicism, Sorenson et al27 provided an updated concept analysis emotional exhaustion, or self-centeredness occurring in of compassion fatigue using Rodgers’ evolutionary model a health care professional previously dedicated to his to guide the analysis in relation to nursing care. The defini- or her work and clients.’’20 Compassion fatigue is described tion was identified as interchangeable with STSD and indi- as a form of exhaustion resulting from prolonged exposure cated that compassion fatigue was the emotional cost of to caring for sick or traumatized patients.23 Compassion caring related to caring for those suffering individuals fatigue is also defined as ‘‘fatigue, emotional distress, or and, as a result, emotional, physical, and spiritual exhaus- apathy resulting from the constant demands of caring for tion occurred.27 Effects in the social and professional domains others or from constant appeals from charities.’’24 This def- were not addressed in this definition. This analysis also iden- inition of disinterest is fairly consistent with a 1983 public tified a similar concept, vicarious traumatization, or results policy application by The New York Times25 that described from caring for those with STSD.27 the United States’ detachment in helping refugees after the Soviet occupation of Afghanistan. Defining Attributes Almost a decade later, Joinson8 was the first to refer to Walker and Avant19 indicated that attributes were those compassion fatigue in nursing literature as a type of characteristics that were frequently associated with the con- burnout, specifically linking it to caring professions such cept. Compassion fatigue develops over time. There are five Journal of Hospice & Palliative Nursing www.jhpn.com 23  Feature Article domains identified as elements of compassion fatigue Increased Complaints upon pertinent literature review: emotional and psycho- Palliative care nurses often neglect their own physical needs logical, intellectual and professional, physical, social, and as they attend to the needs of their chronically suffering pa- spiritual. These are listed in the Table and will be reviewed tients.28 This poor self-care manifests as exhaustion, lack of in this section. sleep, increased physical complaints, and poor endurance. Nurses have described physical exhaustion as being Empathy Imbalance ‘‘sucked in’’ or ‘‘wrung out.’’11 Physical symptoms vary from Palliative care nurses are involved in the end-of-life process each person but may include headaches, gastrointestinal for all of their patients. Some have indicated that they ‘‘com- symptoms, chest pain, and malaise.27 partmentalize’’ their feelings from their everyday life to avoid feeling the stress of multiple deaths.28 However, as they sep- Inability to Share in Suffering arate their feelings, these feelings can become inappropri- The palliative care nurse with compassion fatigue experi- ate, leading to excessive empathy. Empathy is present ences greater difficulty enjoying outside life as exposure when nurses are actively aware of feeling or experiencing to stress and suffering at work combined with the energy the concerns of patients without having the thoughts or feel- expenditure to maintain productivity makes it difficult to ings described or communicated to them.29 Excessive empa- maintain personal relationships. Family members or thy can create role confusion or blurred boundaries, just as loved ones may have unrealistic expectations, finding it not enough empathy can create a poor connection between difficult to identify with the nurse’s feelings of suffering the nurse and the patient. When nurses dwell on their feel- or inability to share or acknowledge pain or feelings.11 ings and roles, other emotions such as self-doubt set in and This contributes to the nurse’s difficulties in working they become overwhelmed. Anxiety, depression, and irri- through his/her feelings and further exacerbates feelings tation with patients can result from this process. of anxiety and self-doubt. Diminished Performance Poor Judgment The nurse experiencing compassion fatigue has difficulty A normal function of the palliative care nurse is to provide concentrating on his/her job. There is diminished perfor- spiritual assistance to his/her patient and caregiver.15 How- mance as compared with the previous level of ability. As ever, the nurse feeling the pressures of compassion fatigue this becomes out of control, it may be evidenced by behav- has a spiritual disconnect and lacks the ability to provide ior that is out of character for the nurse such as disorderly judgment on a spiritual level.10 This also makes it difficult appearance, making mistakes, or calling out. to perform normal duties. TABLE Compassion Fatigue in Palliative Care Nursing Antecedentsa Consequencesb Attributesc Empirical Referentsd Ability to experience Loss of ability to feel Emotional/psychological: Emotional/psychological: compassion and empathy compassion and empathy empathy imbalance irritation, depression, anxiety, and self-doubt Exposure to suffering Burnout Intellectual/professional: Intellectual/professional: poor diminished performance performance, calling out, mistakes, and inability to concentrate Repeated exposure to stressors Breakdown Physical: increased complaints Physical: headache, nausea, chest pain, exhaustion, sleep loss, malaise, and poor endurance Disinterest Social: inability to share in Social: difficulty in maintaining suffering interpersonal relationships Moral distress Spiritual: poor judgment Spiritual: inability to provide judgment, lacks awareness a The events that exist before the compassion fatigue.19 b The outcomes of the compassion fatigue.19 c Those characteristics that were frequently associated with the compassion fatigue.19 d The real-world instances that help determine the existence of the compassion fatigue.19 24 www.jhpn.com Volume 21 & Number 1 & February 2019  Feature Article Cases about what will happen to them when they are ready to discharge. She has found herself unable to stop thinking Model Case about the shock on their young faces when they were A model case is a use of the concept as a pure example.19 brought in and has been crying at night. She is starting to The following is a model case with the defining attributes have difficulty sleeping and does not want to go to work identified. but is worried if she does not go in, ‘‘Who will take care M.D. is a 27-year-old man who has been a home pallia- of the boys?’’ tive and hospice nurse for 3 years. He loved his job and the connection he had with his patients, being able to identify Related Case with them on a personal level. Having lost his sister during A related case is a scenario that is close to the concept but his teens to a congenital heart defect, he always wanted to does not have all of the defining attributes.19 The following be a hospice nurse. He has recently experienced an in- related case is that of vicarious traumatization. Vicarious crease in his caseload due to covering another nurse’s ma- traumatization is similar to compassion fatigue, but it is ternity leave. Not long ago, his wife had their second child. the stress that results from caring for traumatized patients He has found himself becoming anxious about the number who are experiencing STSD.27 It can occur from hearing of death pronouncements he has had recently, having ex- about the trauma that patients have experienced and perienced incredible loss in a short amount of time, and has empathizing with those experiences and usually occurs been afraid to get close to his new patients. He has not in settings different than palliative care. been sleeping and has been arguing with his wife about R.T. is a 58-year-old woman working on an inpatient child care. The other day, he drew up the wrong amount rehabilitation floor treating military veterans with com- of morphine for a patient, and the week before, he went to plex injuries. She has been at her nursing job for 6 years the wrong house on the wrong day. It was okay, as neither and initially enjoyed coming to work because of the longer- patient really noticed, so he did not mention it to his super- term relationships she established with her patients. She re- visor, J.S. He stopped going to the bereavement groups af- cently has been caring for a young man of similar age to her ter interdisciplinary team meetings to save time to schedule son, and she has developed a special bond with him. She his nursing visits. He is frustrated and is starting to resent began to spend longer time on the unit to stay and talk to the drive to work and to the homes of the patients who live him about his injuries, and gave him her number so that he in the area that he is covering. ‘‘Why do I have to go to could call her when he had bad thoughts. She has become those towns, anyway?’’, he wonders. ‘‘They aren’t even so preoccupied with caring for him and thinking about his my patients.’’ war experiences that she has been having nightmares and making mistakes at work. She cannot reach out to her Borderline Case husband and son, who do not understand her work, and A borderline case is one that has most of the defining she has been thinking about talking to another colleague characteristics of the concept, but not all of them.19 The fol- to discuss these frustrations. lowing case is of STSD. Secondary traumatic stress disorder is a situation that develops when the caregiver experiences Contrary Case stress from providing support to a traumatized individual A contrary case demonstrates the opposite of the model and usually occurs when the caregiver imagines himself/ case.19 The opposite of compassion fatigue is compas- herself as integral to the individual’s support system.27 It sion satisfaction. Compassion satisfaction was presented is similar to compassion fatigue, but it occurs from caring in a concept analysis by Sacco and Copel,29 where it was for patients who have experienced trauma and is usually defined as occurring when empathy drives altruism and observed in different settings. results in alleviation of suffering, which further results in T.F. is a 38-year-old critical care nurse who has been a positive work experience for the nurse. The following practicing for 13 years. For the past week, she has been car- is based on this concept. ing for two young boys who were brought in as shooting J.D. is a 34-year-old nurse with 8 years of experience victims of a homicide-suicide committed by their father in an inpatient hospice unit. She has always wanted to be with their mother as the homicide victim. Before their a hospice nurse, finding joy in her connection with pa- mother was killed, they were held hostage in their apart- tients and families. Although she is sad at losing patients, ment with her for 3 hours before being rescued. Their fa- she finds support through colleagues and through formal ther killed himself before law enforcement came in. Social and informal meetings with the interdisciplinary team. service members have been in to see the boys on the unit. She leads the unit bereavement group and is a mentor to T.F. has become very protective of them and has trouble new nurses at the unit, helping them cope with their stress leaving her shift in the evening. She has been calling on management skills. During her recreation time from work, her off-hours to check on their progress and is concerned she enjoys being part of a book club, cooking, volunteering Journal of Hospice & Palliative Nursing www.jhpn.com 25  Feature Article at her children’s school, hiking, and vacationing with her nurse is having doubt of ability, or anxiety regarding work. family. When her friends and acquaintances ask, ‘‘Why hos- Callouts due to illness, visualization or verbalization of ex- pice nursing?’’, she tells them that she likes what she does haustion by the nurse, poor endurance, poor hygiene or and finds it satisfying, still looking forward to her work. professional appearance, and frequent mistakes in paper- work, medication administration, or skills are examples for Antecedents and Consequences the professional or intellectual domain. Antecedents are events that exist before the concept de- Physical complaints of nausea, chest pain, headache, poor velopment.19 Antecedents for compassion fatigue are the sleeping habits, and overall exhaustion may be signs of ability to experience compassion and empathy, exposure compassion fatigue. The nurse who closes himself/herself to suffering, and repeated exposure to stressors. To lose off from coworkers and family, refuses to assist others, or is something, one must first have it. The ability to feel empa- having relationship issues may be demonstrating signs of thy and compassion is a requisite to compassion fatigue. If compassion fatigue. The palliative care nurse who previ- the nurse does not have the ability to feel these two emo- ously was willing to participate spiritually and now is tions, there will not be a loss. The nurse who is continually unable to focus or demonstrate judgment or clarity in this exposed to stress will react with a change in ability to em- realm may be at risk for compassion fatigue. pathize.27 With exposure to suffering combined with the stress and empathy for the patient, the nurse does not have Proposed Definition of Compassion Fatigue the ability to focus on himself/herself, creating a risk for The proposed definition of compassion fatigue in the con- compassion fatigue. text of palliative care nursing is the result of compassion Consequences are the outcomes of the concept.19 The and empathy in the palliative care provider with chronic consequences of compassion fatigue are the loss of ability professional exposure to suffering and repeated exposure to feel compassion and empathy, burnout, breakdown, dis- to stressors. It is the state where compassion and empathy interest, and moral distress. The loss of the ability to feel are lost, demonstrated by emotional and psychological, compassion and empathy results from prolonged expo- intellectual and professional, physical, social, and spiritual sure to the stressors and suffering. One of the most impor- characteristics that, if left unattended, result in disinterest, tant roles of the palliative care nurse is that of care facilitator moral distress, burnout, and breakdown. as well as case manager of the interdisciplinary team.13 When the nurse is disinterested and no longer able to be concerned, he/she is no longer able to care, which is the DISCUSSION basic function of nursing.6 Moral distress occurs when the palliative care nurse conducts himself/herself in ways Strengths that contradict his/her personal values and beliefs.30 This is This analysis separates compassion fatigue from its similar a result of not performing professional nursing duties as to concepts of vicarious traumatization, STSD, and burnout, normal capabilities, including disinterest or poor perfor- providing a definition for palliative care nursing. Compas- mance. The nurse no longer has control over the situation, sion fatigue has not been defined in the context of palliative and burnout can occur. This has been described as similar care nursing in previous literature. Palliative care nurses are to compassion fatigue; however, burnout has been identi- routinely exposed to suffering and death of the patient fied as occurring over a longer period.12 It can occur from population they care for, and the caring leads to compas- similar stressors as compassion fatigue, and it can emerge sion fatigue.1 before compassion fatigue symptoms and may also be a contributing stressor. Emotional and physical breakdown Limitations is a consequence of compassion fatigue occurring when One limitation of the data search was its restriction to the other consequences exist unattended by the palliative care English language. Compassion fatigue is a concept that has nurse’s loved ones, peers, or managers.10 not been limited to English-speaking countries, so there may have been relevant data excluded.11,31,32 Another lim- Empirical Referents itation is that, by not exploring dictionaries outside the tra- Empirical referents are the real-world instances that help ditional, medical, or nursing dictionaries, ideas may have determine the existence of the concept.19 It is important been excluded through definitions that could have impacted that managers and coworkers recognize these situations this concept. Sources were obtained primarily from helping for the safety of the palliative care nurse and the patients profession databases, including nursing, medicine, social under care. work, and psychology, and the literature search was refined Examples for the emotional and psychological realm based on the search terms. However, using these data- include outward irritation, verbalizations that indicate lack bases and not expanding the initial search may have been of empathy or excessive empathy, indications that the a limitation. 26 www.jhpn.com Volume 21 & Number 1 & February 2019  Feature Article Implications for Nursing 6. Ledoux K. Understanding compassion fatigue: understanding Future implications include recognition of compassion compassion. J Adv Nurs. 2015;71(9):2041-2050. 7. Whitebird RR, Asche SE, Thompson GL, Rossom R, Heinrich R. fatigue with the goal of promoting strategies for compas- Stress, burnout, compassion fatigue, and mental health in hospice sion satisfaction. The concept analysis of compassion satis- workers in Minnesota. J Palliat Med. 2013;16(12):1534-1539. faction by Sacco and Copel29 identified three antecedents 8. Joinson C. Coping with compassion fatigue. Nursing. 1992;22(4): similar to this model: empathy connection, negative impact 116-121. 9. Figley CR. Catastrophes: an overview of family reactions. In: of exposure to suffering, and influence of stressors in the Figley CR, McCubbin HL, eds. Stress and the Family: Coping With environment. The authors expanded their model to in- Catastrophe. Vol. 2. New York, NY: Brunner/Mazel; 1983:3-21. clude three more antecedents for the development of com- 10. Coetzee SK, Klopper HC. Compassion fatigue within nursing passion satisfaction that are not present in compassion practice: a concept analysis. Nurs Health Sci. 2010;12:235-243. 11. Nolte AGW, Downing C, Temane A, Hastings-Tolsma M. Compassion fatigue: the nurse’s desire for a beneficial, caring relation- fatigue in nurses: a metasynthesis. J Clin Nurs. 2017;26:4364-4378. ship; meeting patients’ needs resulting in positive behav- 12. Sorenson C, Bolick B, Wright K, Hamilton R. Understanding iors; and the existence of positive aspects among negative compassion fatigue in healthcare providers: a review of current aspects of caring.29 Recognition and incorporation of those literature. J Nurs Scholarsh. 2016;48(5):456-465. 13. Coyle N. Introduction to palliative nursing care. In: Ferrell BR, additional factors in the palliative care setting could help pre- Coyle N, Paice JA, eds. Oxford Textbook of Palliative Nursing. vent the detrimental effects of compassion fatigue. Research 4th ed. New York, NY: Oxford University Press; 2015:3-10. in the area of identification of compassion fatigue empirical 14. World Health Organization. WHO definition of palliative care. indicators could help prevent manifestation of its attributes. http://www.who.int/cancer/palliative/definition/en/. Accessed April 9, 2018. Educational awareness of beneficial behaviors and practices 15. Battista V, LaRagione G. Pediatric hospice and palliative care. for palliative care nurses could reduce compassion fatigue In: Ferrell BR, Coyle N, Paice JA, eds. Oxford Textbook of risk factors and symptoms and help with coping strategies Palliative Nursing. 4th ed. New York, NY: Oxford University in the wake of stressors. Press; 2015:851-872. 16. Todaro-Franceschi V. Compassion Fatigue and Burnout in Nursing: Enhancing Professional Quality of Life. New York, NY: Springer; 2013:3-12. CONCLUSION 17. Kirkpatrick AJ, Cantrell MA, Smeltzer SC. A concept analysis of palliative care nursing: advancing nursing theory. ANS Adv Nurs Nurses who are satisfied and engaged are likely to provide Sci. 2017;40(4):356-369. better care for themselves and their patients.33,34 Ongoing 18. Slocum-Gori S, Hemsworth D, Chan WWY, Carson A, Kazanjian A. assessment of staff and development of programs that en- Understanding compassion satisfaction, compassion fatigue and courage appropriate engagement activities are some ways burnout: a survey of the hospice palliative care workforce. Palliat Med. 2013;27(2):172-178. to support palliative care nurses.7 Offering specialized 19. Walker LO, Avant KO. Strategies for Theory Construction in education, self-care resources, and individualized staff be- Nursing. 5th ed. Upper Saddle River, NJ: Pearson Education, reavement programs may decrease professional stressors.35 Inc; 2011:157-179. Compassion fatigue is a concept that is inversely related to 20. Venes D, ed. Taber’s Cyclopedic Medical Dictionary. 23rd ed. compassion satisfaction. Currently, there is a gap in the liter- Philadelphia, PA: F.A. Davis; 2013:526,902,1147-1148,1740. 21. Compassion. Merriam-Webster’s Online Dictionary. https:// ature regarding the theoretical connection that future research www.merriam-webster.com/dictionary/compassion. Updated might explore and bridge in the discipline of palliative nurs- April 20, 2018. Accessed April 21, 2018. ing. Developing a better understanding of the relationship 22. Fatigue. Merriam-Webster’s Online Dictionary. https://www. between these two concepts could provide more insight merriam-webster.com/dictionary/fatigue. Updated April 12, 2018. Accessed April 21, 2018. for palliative nursing care. 23. Compassion fatigue. Merriam-Webster’s Online Dictionary. https:// www.merriam-webster.com/medical/compassion%20fatigue. References Updated February 28, 2018. Accessed April 21, 2018. 1. Melvin CS. Historical review in understanding burnout, professional 24. Compassion fatigue. Dictionary.com’s Online Dictionary. http:// compassion fatigue, and secondary traumatic stress disorder from a www.dictionary.com/browse/compassion-fatigue. Accessed hospice and palliative nursing perspective. J Hosp Palliat Nurs. 2015; April 21, 2018. 17(1):66-72. 25. Compassion fatigue. The New York Times. November 18, 1983:A34. 2. Figley CR. Compassion fatigue as secondary traumatic stress https://search-proquest-com.libproxy.uml.edu/docview/12222 disorder: an overview. In: Figley CR, ed. Compassion Fatigue. 3791/fulltextPDF/1BF105032A59436BPQ/1?accountid=14575. New York, NY: Brunner/Mazel; 1995:1-20. Accessed October 9, 2017. 3. Harris C, Griffin MTQ. Nursing on empty: compassion fatigue signs, 26. Ludick M, Figley CR. Toward a mechanism for secondary trauma symptoms, and system interventions. J Christ Nurs. 2015;32(2):80-87. induction and reduction: reimagining a theory of secondary 4. Hegney DG, Craigie M, Hemsworth D, et al. Compassion satisfaction, traumatic stress. Traumatology. 2017;23(1):112-123. compassion fatigue, anxiety, depression and stress in registered nurses 27. Sorenson C, Bolick B, Wright K, Hamilton R. An evolutionary in Australia: study 1 results. J Nurs Manage. 2014;22(4):506-518. concept analysis of compassion fatigue. J Nurs Scholarsh. 2017; 5. Drury V, Craigie M, Francis K, Aoun S, Hegney DG. Compassion 49(5):557-663. satisfaction, compassion fatigue, anxiety, depression and stress in 28. Carter PA, Dyer KA, Mikan SQ. Sleep disturbance, chronic stress, registered nurses in Australia: phase 2 results. J Nurs Manage. and depression in hospice nurses: testing the feasibility of an 2014;22(4):519-531. intervention. Oncol Nurs Forum. 2013;40(5):E368-E373. Journal of Hospice & Palliative Nursing www.jhpn.com 27  Feature Article 29. Sacco TL, Copel LC. Compassion satisfaction: a concept analysis 32. Sinclair S, Raffin-Bouchal S, Venturato L, Mijovic-Kondejewski J, in nursing. Nurs Forum. 2018;53:76-83. Smith-MacDonald L. Compassion fatigue: a meta-narrative review 30. Prince-Paul M, Daly BJ. Ethical considerations in palliative care. of the healthcare literature. Int J Nurs Stud. 2017;69:9-24. In: Ferrell BR, Coyle N, Paice JA, eds. Oxford Textbook of Palliative 33. Sheppard K. Compassion fatigue among registered nurses: Nursing. 4th ed. New York, NY: Oxford University Press; 2015: connecting theory and research. Appl Nurs Res. 2015;28(1):57-59. 987-1000. 34. Smart D, English A, James J, et al. Compassion fatigue and 31. Sanso N, Galiana L, Oliver A, Pascual A, Sinclair S, Benito E. satisfaction: a cross-sectional survey among US healthcare Palliative care professionals’ inner life: exploring the relationship workers. Nurs Health Sci. 2014;16(1):3-10. among awareness, self-care, and compassion satisfaction and 35. Houck D. Helping nurses cope with grief and compassion fatigue, burnout, and coping with death. J Pain Symptom Manage. fatigue: an educational intervention. Clin J Oncol Nurs. 2014; 2015;50(2):200-207. 18(4):454-458. 28 www.jhpn.com Volume 21 & Number 1 & February 2019