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• To understand the detrimental effects that compassion fatigue can have on emergency nurses and the quality of patient care they provide
• To learn about the findings of a mixed-methods study that explored emergency nurses’ experiences and perceptions of compassion satisfaction and compassion fatigue
• To recognise the importance of providing strategic resilience training and well-being interventions for emergency nurses
Background Compassion fatigue can have detrimental effects on emergency nurses and the quality of patient care they deliver. Ongoing challenges such as operational pressures and the coronavirus disease 2019 (COVID-19) pandemic may have increased nurses’ risk of experiencing compassion fatigue.
Aim To explore and understand emergency nurses’ experiences and perceptions of compassion satisfaction and compassion fatigue.
Method This study used an explanatory sequential mixed-methods design comprising two phases. In phase one, the Professional Quality of Life (ProQOL-5) scale was used to obtain information on the prevalence and severity of compassion satisfaction and compassion fatigue among emergency nurses. In phase two, six participants’ experiences and perceptions were explored via semi-structured interviews.
Findings A total of 44 emergency nurses completed the ProQOL-5 questionnaires. Six respondents had a high compassion satisfaction score, 38 had a moderate score and none had a low score. In the interviews, participants revealed different explanations regarding their compassion satisfaction levels. Three main themes were identified: personal reflections; factors identified as maintaining stability; and external factors affecting compassion.
Conclusion Compassion fatigue needs to be prevented and addressed systemically to avoid detrimental effects on ED staff morale and well-being, staff retention, patients and care delivery.
Emergency Nurse. doi: 10.7748/en.2023.e2164
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Francis-Wenger H (2023) Exploring compassion satisfaction and compassion fatigue in emergency nurses: a mixed-methods study. Emergency Nurse. doi: 10.7748/en.2023.e2164
Published online: 06 June 2023
Emergency department (ED) work has always been challenging but fulfilling. However, operational pressures and the coronavirus disease 2019 (COVID-19) pandemic have intensified the challenges experienced by staff working in this setting. A UK workforce survey by the Royal College of Emergency Medicine (2021) found that three out of five emergency medicine staff said they had experienced high levels of burnout, stress and exhaustion from working during the second wave of the pandemic. Additionally, more than 70% of the respondents reported that patient safety had been affected by ED workforce pressures before the pandemic (Royal College of Emergency Medicine 2021).
Healthcare staff working in challenging situations have direct contact with patients and those in need, which can affect their compassion levels in positive ways (compassion satisfaction) and negative ways (compassion fatigue, including secondary traumatic stress and burnout) (Stamm 2010, Center for Victims of Torture 2021). These challenging situations place a significant demand on the compassion satisfaction levels of ED staff and exposure to them can cause inner conflict, manifesting as compassion fatigue (Stamm 2010).
Exposure to trauma, distress, frustration, violence, resuscitations and patient death can be negative aspects of the healthcare professional’s role (Crowe 2016). Furthermore, nurses are regularly exposed to elevated levels of human suffering, often with little or no opportunity for self-care and emotional decompression (Morrison and Korol 2014). This regular exposure can precipitate nurses’ increased indifference and reduced empathy, described by the term compassion fatigue (Austin et al 2009). Compassion fatigue can be conceptualised as emotional, moral and physical distress as a result of being witness to the suffering of others (Ledoux 2015), and it can be a precursor to burnout, a syndrome characterised by emotional exhaustion, depersonalisation and reduced personal accomplishment (Maslach and Jackson 1981). The inability to care for patients effectively and safely can be a major trigger for compassion fatigue (Dolan et al 2012, Morrison and Korol 2014).
Nurses working in high-intensity areas such as the ED and intensive care units (ICUs) are at risk of reduced compassion satisfaction and may be particularly vulnerable to the effects of burnout due to patients’ intense needs, uncertain outcomes and the highly charged environment (Rushton et al 2015). It is important to be aware of compassion satisfaction and compassion fatigue levels among emergency nurses because of their significant effects on mental and physical health and turnover intention (Yu and Gui 2022).
The use of strategies to improve resilience is often recommended to address compassion fatigue. However, it is important that resilience is explored across operational systems, processes and organisations, rather than being considered solely an individual responsibility. A visionary approach is required to develop a positive working culture where compassion fatigue is recognised, mitigated and appropriately managed. Ensuring that nurses remain focused and energised can optimise care delivery and minimise staff turnover.
This article presents the findings of a study undertaken in 2018 to explore emergency nurses’ perceptions of compassion satisfaction and compassion fatigue. Although the study was completed before the COVID-19 pandemic, it remains relevant to the ED workforce as its findings are discussed in relation to the latest literature on the subject.
• All ED staff should be regularly screened for compassion satisfaction and compassion fatigue, for example during the annual appraisal process
• Structured hot and/or cold debrief sessions should be conducted after traumatic events
• A member of staff in the ED should be employed or trained as a counsellor or trauma risk management facilitator
• A strategic resilience training programme and/or well-being sessions for staff should be implemented to enable them to remain caring and patient focused
To explore and understand emergency nurses’ perceptions of compassion satisfaction and compassion fatigue. The objectives were to:
• Assess the prevalence and severity of compassion satisfaction and compassion fatigue in nurses working in an ED.
• Gain an understanding of emergency nurses’ perceptions of compassion satisfaction and compassion fatigue using validated tools.
• Explore the aspects measured by the Professional Quality of Life (ProQOL-5) scale (Stamm 2010) in greater depth.
• Identify further areas of research to implement strategies that could improve compassion satisfaction levels and reduce compassion fatigue.
The study was conducted in the ED of an acute NHS trust in south west England between September 2017 and February 2018. An explanatory sequential mixed-methods design (Creswell 2014) was adopted and the study comprised two phases. In phase one, a quantitative approach was used to obtain information on the prevalence and severity of compassion satisfaction and compassion fatigue. This information influenced phase two, in which a qualitative approach was used to explore participants’ perceptions and experience of compassion satisfaction and compassion fatigue in depth.
All registered nurses working at band 5 or above in the ED were invited to participate in phase one of the study. The inclusion criteria for phase two were:
• Registered nurse working at band 5 or above.
• Held a Nursing and Midwifery Council registration for one year or longer.
• Employed in the ED for six months or longer.
• Low, moderate or high score for compassionate satisfaction on the ProQOL-5.
The ProQOL-5 scale (Stamm 2010) was used to determine the prevalence and severity of compassion satisfaction and compassion fatigue among emergency nurses. Compassion fatigue comprises two elements: burnout and secondary traumatic stress (Stamm 2010). Respondents with a high (≥42), moderate (between 23 and 41) and low (≤22) compassion satisfaction score were identified. Simple demographic information was also collated, including respondents’ age, sex, role in the ED and length of service in the ED.
In phase two of the study, two respondents scoring highest, two scoring moderate and two scoring lowest on the compassion satisfaction subscale were invited to be interviewed individually by the researcher to explore their perceptions of compassion satisfaction and compassion fatigue. The semi-structured, focused interviews used a topic guide comprising nine statements – three from each of the compassion satisfaction and compassion fatigue (burnout and secondary traumatic stress) questions on the ProQOL-5. The participants were also given the opportunity to explore relevant areas that the ProQOL-5 had not identified.
The interviews were conducted away from the workplace and while the participants were not on shift as this may have affected the interview. The time allotted was one hour. Interviews were recorded and transcribed verbatim to ensure all information was captured.
An inductive framework was adopted to identify themes and meanings across the data (Braun and Clarke 2006) relating to compassion satisfaction and compassion fatigue. An initial coding framework was established, which yielded information pertinent to the study aim and objectives. Each time a participant referred to a particular subject, personal reflection, belief, emotions or experiences, a code was placed next to the relevant text in the transcript. The codes were then grouped together, creating a working analytical framework.
Ethical approval was obtained from the Health Research Authority via the Integrated Research Application System, the university faculty ethics committee and the NHS trust’s research and development team. Participants completed consent forms and received project information sheets from the researcher before taking part. The data were anonymised to protect participants’ confidentiality.
Of 58 questionnaires distributed, 44 were completed, yielding a response rate of 76%. Of the respondents, 14% (n=6) had a high ProQOL-5 score for compassion satisfaction, 86% (n=38) had a moderate score and none had a low score. Since no respondents had a low score, the inclusion criteria for phase two were adapted, with new low (≤29) and moderate (between 30 and 41) groups used.
Table 1 shows the respondents’ ProQOL-5 compassion fatigue results. No respondents identified high levels of burnout or secondary traumatic stress.
Three themes emerged from the data analysis: personal reflections; factors identified as maintaining stability; and external factors affecting compassion. The themes and subthemes are outlined in Table 2.
Participants had differing views regarding their role and position in the ED; some had a positive outlook, while others saw their role as being constrained and negative. These differences appeared to be due to their individual experiences and there was also a tentative link between positivity and age. Those aged between 41 years and 50 years appeared to be generally more positive and resilient than those who were younger and had spent less time working in the ED.
The overall tone of the interviews with Participants 2, 3 and 5 – who all scored highly in compassion satisfaction on the ProQOL-5 – was more positive compared with the other interviews. These participants also alluded to a greater level of emotional intelligence, alongside coping mechanisms that they had developed over time to protect themselves, patients, the department, colleagues, family members and friends.
Responses from all the participants demonstrated a desire to help patients and staff alike. There appeared to be general acceptance that if staff could ‘do their best’ then they had some form of positive emotion. The idea of beneficence and enjoyment from delivering care is fundamental in nursing, but was being jeopardised by conflicts, which led one participant to reconsider their career choice:
‘And then it makes you question whether you want to be here or not.’ (Participant 6)
Many of the participants perceived ED work to be chaotic and disorganised. They stated that emergency nursing attracted a certain ‘type’ of personality and that not all nurses would thrive in the emergency care setting, and this was potentially seen as a motivational factor. All the participants described teamwork as a positive factor, and team cohesion was seen as important in providing protection from the relentless and non-stop nature of work in the ED:
‘You deal with one thing and the next minute there’s someone new… move on, next one. That’s the job to be honest.’ (Participant 3)
‘Your colleague support is incredible… you’ve all been in the same boat; you’ve all survived it – it can make such a difference.’ (Participant 2)
All participants discussed the quality of care delivered, indicating that this was important to them as emergency nurses. Conflicts often arose when care quality was affected by external factors outside the individual’s control, such as time, the quantity of patients in the ED, patient acuity and departmental politics. For example, Participant 1 said:
‘Playing politics to the expense of patient care is absolutely ridiculous and I find that very frustrating.’
In contrast, when participants delivered the quality of care that met their personal standards they felt a sense of satisfaction:
‘When it all goes smoothly, and I feel like I have done a good job for that patient, I feel very satisfied… that I have done the best job that I can possibly give, but that doesn’t always happen.’ (Participant 4)
Participant 5 demonstrated how personal stress affected the quality of care being delivered:
‘Sometimes the stress might take over and my caring side might lapse occasionally perhaps or get hidden.’
This indicates a level of self-awareness of the frustration that ED staff are not always able to deliver the care that they wish they could.
All six participants mentioned their home life and personal circumstances. Half referred to their family and personal networks as part of their support and coping mechanisms, while the other half stated that these areas of their lives were affected by their role as an emergency nurse. While most participants stated they were able to separate home and work, they were emotionally affected by the events occurring within and outside of the ED. It should be considered whether this may have long-term effects on staff.
A variety of coping mechanisms were described by the participants. Communication was a significant coping mechanism mentioned in several interviews, with Participant 2 describing it a tool to alleviate anxiety and stress for patients. Participant 3 described their ability to detach themselves from work to limit the risk of trauma, despite being emotionally engaged with patients. Similarly, Participant 5 adopted the coping mechanism of limiting their thoughts about certain situations:
‘I don’t dwell on what’s happened.’
All the participants had a strong motivation to provide appropriate and high-quality care, with some demonstrating emotional intelligence and self-awareness. For example, Participant 2 said:
‘I’ve developed coping mechanisms right throughout… if I hadn’t or if I weren’t aware of how I feel at times or how I behave, I would have probably left.’
Participant 2 also stated:
‘It’s taken me years not to take stuff home with me… so I have built up to that over my career.’
This suggests there are benefits of working in an environment for several years. Experienced staff could role model their learned resilient behaviours for junior staff to assist them in developing these as coping mechanisms.
Guidance and feedback were mentioned throughout the interviews, with Participant 4 stating:
‘There’s no positive feedback and no negative feedback, so you’re kind of stuck, you don’t really know what you’re doing.’
This is a concerning statement because staff require input from others to guide them in improving their practice and support them to process experiences that may affect their compassion levels. Formal and informal debriefing was underused in the ED and could be another approach to address the negative aspects of nurses’ caring role.
Rewards were another motivational factor for the participants. These rewards took many forms, including compliments from patients, public thanks from the team and individuals, and even no response, which typically meant that everything went well. All the participants mentioned that making a difference to a patient’s experience was a reward that led to a greater sense of compassion satisfaction. While participant 5 agreed with this, they elaborated:
‘I hate the forces that are against me, but actually I love my job.’
Participants 1, 4 and 5 described how, in emergency nursing, they had to go straight from coping with a bereavement on to the next patient, with no time for reflection or debriefing.
All the participants mentioned a disconnect between the approaches and views of management and what they were experiencing ‘on the shop floor’. For example, Participant 1 described an inequality in shift patterns among the team and felt the unsocial shifts were not fairly distributed, while Participant 3 stated:
‘I feel the frustration is [managers] telling you how to do things… so being told to treat patients in the corridor with dignity, I’m like, “well, what else do you want us to do?” We do our best.’
It was evident that compassion satisfaction in the ED was challenging to maintain at times:
‘I will try, from the depths of my soul to find some compassion for [patients] but sometimes it is just really hard.’ (Participant 1)
Working in a strong and dedicated team was identified as a positive factor by all participants, but some felt disconnected from the department as a whole. For example, Participant 1 said:
‘I feel that it is very difficult to call on the rest of the department if I need help.’
The way in which participants coped with traumatic events also appeared to vary. Five of the six participants suggested that they merely had to ‘move on’ following a traumatic event and rarely got a chance to fully ‘deal’ with the event:
‘You just kind of move on from it as opposed to dealing with it.’ (Participant 1)
‘I don’t let it bother me… I’ve been able to think “right, I’ve done what I can”, and I will move on.’ (Participant 3)
‘I need to do my job, do it as best I can and move on and not dwell on [it].’ (Participant 5)
In the long term, this attitude may lead to compassion fatigue among ED nurses and reduce their resilience; however, this would be challenging to quantify. It could be suggested that this approach of ‘moving on’ was adopted as a coping mechanism to regain some control in an otherwise tumultuous working environment. Strategies such as formal debriefs could provide a format for coping with specific events for all staff involved. Further investigation of personality traits and deployed coping mechanisms may also be useful to provide appropriate support for each individual.
No respondents in phase one of this study had high levels of compassion fatigue, while phase two demonstrated that using the ProQOL-5 scale alone was insufficient to explore this complex subject. Although the prevalence of burnout and secondary traumatic stress was low to moderate in the study, this may change if repeated pressures affect the delivery of care.
Studies have used various tools to measure compassion satisfaction, compassion fatigue, resilience and mental health issues. Such tools include the seven-item Generalised Anxiety Disorder (GAD-7) scale (Spitzer et al 2006), Connor–Davidson Resilience Scale (Connor and Davidson 2003), Maslach Burnout Inventory (Maslach and Jackson 1981), Acceptance and Action Questionnaire II (AAQ-II) (Bond et al 2011) and the nine-item Patient Health Questionnaire (PHQ-9) (Kroenke et al 2001). Further exploration using these tools could provide a holistic understanding of emergency nurses’ experiences (Buselli et al 2020, Jose et al 2020, Jiménez-Fernández et al 2022).
Work-related stress is a major cause of sickness absence in the health and social care sector, leading to 2.9 million working days lost each year (Health and Safety Executive 2023). Hunsaker et al (2015) identified that the nursing profession needs to address support, strategies and solutions to increase work satisfaction among emergency nurses. To ensure staff have the support and capability to remain compassionate and focused on patients’ needs, systematic and strategic resilience development is required. Dixon et al (2022) suggested that ED staff are vulnerable and susceptible to burnout, suboptimal well-being and increased stress, affecting patient satisfaction, staff morale and retention. They asserted that programmes to promote well-being, personal resilience and self-care – together with personal and professional development – are necessary to increase individual capability and a culture of organisational resilience, particularly in the context of the COVID-19 pandemic and the subsequent system issues (Dixon et al 2022).
Individual coping mechanisms vary and, if harnessed, can provide personal resilience; however, it often takes years to learn how to cope with traumatic events, and resilience is also an organisational responsibility. Mealer et al (2014) explored the implementation of a resilience training programme for ICU nurses, which included counselling sessions, mindfulness exercises, practising cognitive flexibility, learning to be adept at facing fear, developing active coping skills, having a supportive social network, exercising and having a sense of humour. The programme was feasible and acceptable, suggesting that compassion fatigue can in part be addressed by strengthening personal resilience and promoting well-being.
During the height of the COVID-19 pandemic, Goktas et al (2022) trialled sending motivational messages to emergency nurses, finding that these increased job satisfaction, improved communication skills and reduced compassion fatigue. Therefore, promoting staff motivation is essential to increase employee satisfaction and subsequently improve patient care.
Wong et al’s (2022) study sought to examine the relationship between professional quality of life and resilience among ED staff. The results indicated that compassion satisfaction might be a protective factor for suboptimal psychological health due to its negative correlation with secondary traumatic stress and burnout. The researchers recommended the development of an educational programme that incorporates strategies to foster resilience among ED staff (Wong et al 2022).
One recommendation from the literature is to consider the use of a trauma risk management (TRiM) facilitator. TRiM is a trauma-focused, peer-support system designed for people who have experienced a traumatic event (March on Stress 2023). An ED staff member trained to observe and assess other staff members who have been exposed to traumatic events could potentially minimise the prevalence of compassion fatigue. The use of TRiM and other techniques is recommended in the National Institute for Health and Care Excellence (2018) guidelines on post-traumatic stress disorder. Using ‘in-house’ ED staff who have experienced the pressures, exposures and procedures is beneficial because they will have an understanding of the situation.
Debriefing after a sudden traumatic event can have positive effects, enabling staff members’ emotions to be managed directly. Schmidt and Haglund (2017) suggested that debriefs involving personal and group reflection can support emergency nurses to understand their emotions and experiences, thereby developing strategies for coping with future events. This form of learning through group sharing and bonding can be beneficial in overcoming compassion fatigue (Jackson et al 2007). Regular debriefing sessions should become standard practice and facilitated by a member of the team. Kessler et al (2015) stated that the timing of debriefings in the ED is crucial to promote adequate learning and understanding after an event. The debrief process should be flexible and consider whether the team will benefit from a ‘hot’ debrief immediately after an event or a ‘cold’ debrief several days or weeks after the event.
According to Jiang et al (2017), nurses’ professional satisfaction is crucial to maintaining quality of care. Measuring turnover intention can provide insight into workforce well-being and will determine whether staff wish to leave their job or the profession itself (Yu and Gui 2022). Contributing factors that can affect turnover intention among ED staff include compassion satisfaction, compassion fatigue and burnout (Jiang et al 2017, Yu and Gui 2022).
ProQOL – Core concepts handouts
NHS Employers – Beating burnout in the NHS
nhsemployers.org/articles/beating-burnout-nhs
Health and Safety Executive – Work-related stress and how to manage it
To maintain workforce stability, interventions that facilitate consistent compassion satisfaction levels and the delivery of high-quality care are essential. Compassion fatigue prevention should be incorporated into everyday practice, rather than being introduced as a reaction to events (Crowe 2016).
It is important for healthcare organisations to explore how to address and prevent compassion fatigue in front-line healthcare staff (Zhang et al 2020). Healthcare leaders in the ED setting should adopt an emotionally intelligent approach, using their skills to develop a supportive environment, empower staff and enhance well-being (Akerjordet and Severinsson 2008). Magnavita et al (2021) suggested that psychologists, counsellors and psychiatrists working in hospitals should pay attention to high rates of secondary traumatic stress symptoms and how these may be linked with increasing rates of depression, anxiety and suicidal ideation in staff. The high-intensity workload associated with emergency care, alongside the ongoing need to deliver safe, high-quality, compassionate care to an ever-increasing number of patients (Dasan et al 2015), may be putting the compassion satisfaction levels of staff at risk. The findings of this study do not reflect the potential manifestation of this risk, but the warnings should be heeded in light of the COVID-19 pandemic and other ongoing challenges.
One potential limitation of this study is that the researcher was known to all respondents, and this may have influenced their desire to take part in the project. However, the respondents’ desire to participate would not have affected their individual ProQOL-5 scores.
In phase one of the study, no respondents scored ‘low’ for compassion satisfaction. Therefore, the inclusion criteria for phase two were adapted, with the development of new low and moderate groups. These recalibrated groupings may have detrimentally affected the validity of the scores and could be a potential limitation.
No respondents indicated high levels of burnout or secondary traumatic stress, which was unexpected, and a larger study would be useful to explore this finding further. Additionally, this study involved staff from one ED so its findings may not be generalisable, and it would be beneficial to repeat the study post-pandemic to identify whether compassion satisfaction and compassion fatigue levels have changed.
The findings of this study showed that emergency nurses in one ED were not demonstrating signs of compassion fatigue, although some staff may require additional support to achieve a more stable level of compassion satisfaction. The participants revealed that they used various personal coping mechanisms to support them in managing traumatic events and challenges.
This study identified some of the conflicts and issues that emergency nurses frequently encounter in their practice, and how these may be linked to compassion fatigue. Preventing and addressing burnout and secondary traumatic stress in the ED is a shared responsibility that lies with all ED staff, managers, leaders and strategic leads, particularly in the context of the COVID-19 pandemic and ongoing operational pressures.
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