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BM Sabo

International Journal of Nursing Practice 2006; 12: 136–142

✠ R E S E A R C H PA P E R ✠

Compassion fatigue and nursing work:


Can we accurately capture the consequences
of caring work?
Brenda M Sabo RN BA MA PhD-student
Adjunct Professor, School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada

Accepted for publication October 2005

Sabo BM. International Journal of Nursing Practice 2006; 12: 136–142


Compassion fatigue and nursing work: Can we accurately capture the consequences of caring work?

Health outcomes and, in particular, patient health outcomes have become a driving force within health-care delivery. Little
emphasis has been placed on the potential health consequences for nurses providing care and caring within the health-care
system. Compassion fatigue (or secondary traumatic stress) has emerged as a natural consequence of caring for clients who
are in pain, suffering or traumatized. This paper sheds light on how nursing work might impact the health of nurses by
exploring the concept of compassion fatigue. Limitations of current instruments to measure compassion fatigue are high-
lighted, and suggestions for future direction are presented.
Key words: compassion, compassion fatigue, empathy.

INTRODUCTION communication, coordination of care, assessment) and


Changes in accreditation practices during the mid- to organizational structures (i.e. staff mix, work load,
late 1980s, coupled with health-care restructuring, work environment) to patient outcomes, it would seem
downsizing and fiscal restraint policies, have resulted in reasonable to assume that nursing practice and work
the re-emergence of outcome-based or evidence-based environment could be commensurate with health out-
nursing practice.1–4 The need for effective instruments to comes for nurses. It is my hypothesis that, in caring
monitor and evaluate nursing care,5,6 government for patients experiencing trauma, pain and suffering,
requests for health-care accountability,2,7,8 professional nurses’ health can be profoundly affected, resulting in a
legitimacy4,7,9,10 and policy reform1,2,4,5,8,11,12 has shifted phenomenon such as compassion fatigue (CF) (second-
the focus from primarily pathophysiological or disease- ary traumatic stress (STS)). Outcomes research has his-
based to outcomes interconnected with organizational torically focused on patient and pathology in relation to
structure and nursing processes. the work of health-care providers. Little research has
Although emphasis has been on the interrelationship explored the consequences of ‘caring work’ on the
between nursing processes (i.e. nursing interventions, health of providers such as nurses. The following dis-
cussion will explore the potential benefits and limita-
tions of attempting to quantify compassion and caring
Correspondence: Brenda M Sabo, 7B-112 CEN, QEII Health Science within an outcomes model. In particular, do we run
Centre, 1278 Tower Road, Halifax, NS, B3H 2Y9, Canada. Email: the risk of pathologizing a quality of nursing that forms
brenda.sabo@cdha.nshealth.ca its foundation?

© 2006 The Authors


Journal compilation © 2006 Blackwell Publishing Asia Pty Ltd doi:10.1111/j.1440-172X.2006.00562.x
Compassion fatigue and nursing work 137

UNDERSTANDING COMPASSION Accurate empathy involves more than just the ability of the
AND EMPATHY therapist to sense the client’s ‘private world’ as if it were his
own. It also involves more than just the ability of the therapist
Blum refers to compassion as the experience of feeling to know what the client means. Accurate empathy involves the
with another while recognizing that the feelings of one are sensitivity to current feelings and the verbal facility to com-
not the same as another. Compassion promotes equality as municate this understanding in a language attuned to the
experiencing compassion suggests an inherent regard and client’s feelings.27
respect for the other as a fellow human being.13 Compas-
sion is often understood as an emotion. In understanding Truax emphasizes empathy as a way of perceiving and
compassion as emotion, Oakley refers to the affective communicating that is consistent with Morse et al.’s
dimension reflected within feeling including a psychic cognitive-behavioural components.
dimension; it can be understood in terms of ‘the mental Similarly, Rogers perceived empathy as an attitude
tone which affects us and which characteristically perme- thus emphasizing communication. Furthermore, he felt
ates our perceptions, our desires and actions in ways that empathy was a learned skill if one was to communi-
which we are not always aware of’.14 This psychic quality cate warmth and genuineness and achieve the ability to
suggests that compassion affects our lives over extended successfully understand the client’s perspective. Other
periods of time, not just in the moment, and can exist in theorists have argued that empathy is an interpersonal
the absence of feeling. For example, ‘the nurse who exhib- concept comprised of a learned set of skills as opposed to
its compassion will therefore not simply respond with an innate ability reinforcing the cognitive-behavioural
feelings at the time of the patient’s suffering, but will care approach.23
for this patient in an ongoing way that might not always be Perhaps the most relevant definition of empathy is the
expressed in terms of feeling’.15 Furthermore, evidence following, which reflects the communication skills of
of compassion includes displays of character such as virtue nurses:
leading to concern for the good of others, an awareness of
the other’s suffering and a desire to act to relieve that Empathy signifies a central focus and feeling with and in the
suffering.15–19 client’s world. It involves accurate perception of the client’s
Central to the relationship between individuals is a world by the helper, communication of this understanding
need to understand and be understood; furthermore, it to the client, and the client’s perception of the helper’s
forms the foundation on which the nursing relationship is understanding.28
built.20 The most critical element within the therapeutic
or helping relationship is empathy.16,21–24 In the ever This definition includes perceptional and interactional
increasing complex, technological world of health care, empathy highlighting empathy as more than ‘a way of
‘technical competence is necessary, but must be combined being’29 but a communication tool that validates the world
with interpersonal skills such as empathy, warmth and as perceived by the client.23
respect, before the patient feels health professionals Empathy has been conceptualized as a human trait
care’.21 (innate natural ability), professional state (learned
Difficulties lie with ‘the nature of empathy and whether communicative skill comprised of cognitive-behavioural
it is innate or learned, a personality dimension, amenable components), communication process (exchange where
to change through experience or an observable skill’.25 It the professional perceives, expresses understanding and
may be best considered as a multidimensional, multiphase the client perceives this understanding), caring (compul-
construct that consistently appears to be interpreted sion to act because of understanding the experience of
within a narrow one-dimensional frame. The extent to the client) and, finally, special relationship (reciprocity
which the various elements are interrelated appears to be requiring time).22 Empathy requires that the individual
a source of much disagreement among theorists.23 In a perceive the world as the other, be non-judgmental,
review of the literature, Morse and colleagues identified understand the other’s feelings and communicate this
four components of empathy: moral, emotive, cognitive understanding.30
and behavioural.26 Caring, compassion and empathy might exhort a cost
Definitions of empathy include: from practitioners, reducing ‘our capacity or our interest

© 2006 The Authors


Journal compilation © 2006 Blackwell Publishing Asia Pty Ltd
138 BM Sabo

in bearing the suffering of others’.31 Compassion fatigue, tional contagion’,47 an affective process wherein the indi-
also described as secondary victimization,32 STS32–36 and vidual’s responses parallel those of actual or anticipated
vicarious traumatization,37,38 has been associated with the emotions; counter-transference,48 an unconscious attune-
‘cost of caring for others in emotional pain.39 Underlying ment to and absorption of a client’s trauma; and burnout,
the effectiveness of therapy or caring is the ability to a gradual progression or wearing down of the individual
empathize, understand and help the client. Empathy resulting from an imbalance between their expected and
becomes a double-edged sword for the nurse or clinician: actual outcomes in the workplace.49–53 All involve interac-
on the one hand, empathy facilitates caring work; on the tion with another, generally clients in the context of care
other hand, the act of caring leaves the nurse or clinician and caring, and are considered a natural consequence of
vulnerable to its very act: caring. To varying degrees, empathy appears to be an inte-
gral component underlying all of the identified concepts,
We all feel or have felt the distress and the isolation. Ulti- probably because of its facilitative nature in developing the
mately, I believe, there is no solution to the problem. All of us therapeutic relationship.
who attempt to heal the wounds of others will ourselves be Compassion fatigue is a relatively recent term, first
wounded; it is, after all, inherent in the relationship.40 used by Joinson in 1992 while studying burnout in nurses
working in emergency departments. The term conveys a
Although research evidence supports the assumption more user-friendly construct and framework than the
that empathy is a necessary component of the helping rela- more highly pathologized secondary traumatic stress disorder
tionship,22,23,25,26,41–43 little is known about the impact of identified in Diagnostic and Statistical Manual of Mental
the role empathy might play on the health of nurses. Disorders, Fourth Edition (DSM-IV).54 Compassion
Before that can occur, an operational definition of the con- fatigue can be described as:
cept is required that is relevant to nursing and the helping
professions. Natural consequent behaviors and emotions resulting from
knowing about a traumatizing event experienced by a signif-
HELPER STRESS OR icant other—the stress resulting from helping or wanting to
COMPASSION FATIGUE help a traumatized or suffering person.34
As recognition for traumatology and the need for early
intervention for victims of trauma grew in the late 1970s Compassion fatigue is thought to be a combination of
and early 1980s, it became apparent that those providing secondary traumatization and burnout precipitated by the
assistance were themselves experiencing adverse effects care delivery that brings health-care professionals into
arising out of their work.44 Early conceptualizations of the contact with the suffering.55
phenomenon experienced by health-care professionals Compassion fatigue differs from post-traumatic stress
and first responders included a form of burnout or ‘sec- disorder (PTSD) in that the individual is exposed to the
ondary victimization’,32 later referred to as STS and sec- traumatized or suffering person rather than the traumatic
ondary traumatic stress disorder.45 Compassion stress and event itself. Burnout is described as ‘a process in which the
CF have since emerged as acceptable substitutes for STS professional’s attitudes and behaviour change in negative
and secondary traumatic stress disorder given the empha- ways in response to job strain’56 arising out of work envi-
sis on the ‘cost of caring’ for health-care professionals.46 ronment triggers such as ‘frustration, powerlessness, and
Health-care professionals find the term to be more reflec- an inability to achieve work goals’.57 Essentially, a discon-
tive of their lived experiences in working with clients who nect exists between the expectation of the individual
are in pain, suffering or traumatized. around role performance and the structure of the organi-
Related terms include vicarious traumatization, which zation to support the professional role. Furthermore,
refers to the cumulative effect of the client’s traumatic burnout involves a gradual wearing down of the individual
material that affects and is affected by the health-care pro- over time whereas CF has an acute onset. Compassion
fessionals’ world view.37 Vicarious traumatization differs fatigue results from the ‘natural’ consequence of caring for
from CF in that the individual undergoes a ‘transforma- people who are suffering rather than a response to the
tion’ in their personal and professional belief systems. work environment. The presence of burnout increases the
Other terms used interchangeably with CF include ‘emo- likelihood of developing CF.34,39

© 2006 The Authors


Journal compilation © 2006 Blackwell Publishing Asia Pty Ltd
Compassion fatigue and nursing work 139

MEASURING THE COST OF CARING include: a comparison of CSF Test with other measures of
traumatic stress such as the Secondary Trauma Scale64,67
Although the body of literature on STS/CF continues to and the Secondary Traumatic Stress Scale (STSS);58 is the
grow, a paucity of empirical evidence underscores the test sensitive over time to change (paucity of longitudinal
need for reliable, validated instruments to accurately mea- studies); how do CF/STS, burnout and compassion satis-
sure the concept. Most of the instruments used to mea- faction relate to each other; and can the relationship
sure STS were developed to measure symptomatology in between the constructs of CF/STS, burnout and compas-
trauma survivors (direct exposure) as opposed to that sion satisfaction be quantified and used to identify poten-
arising because of indirect exposure to trauma, pain and tial risk or protective factors?
suffering experienced by health-care professionals.58 A More recently, Bride and colleagues have developed the
variety of survey methods have been used to gain an STSS to measure STS symptoms in social workers and
understanding of the demographic indices and levels of other health-care professionals working with the trauma-
stress inherent in work with the traumatized. These tized.58 To maintain congruence with the DSM-IV,68 the
include: Impact of Event Scale;59 Brief Symptom Inven- STSS did not include characteristic symptoms of PTSD
tory;60,61 Penn Inventory of PTSD;62 and Trauma Symptom such as distressing emotions and functional impairment. It
Checklist-40.63 These studies focused on response pat- was hypothesized that these characteristic symptoms,
terns of health-care workers providing information on taken together, might correspond with burnout blurring
levels of stress experienced. the ability to clearly distinguish between STS and burn-
A significant limitation within the STS research is a lack out. Secondary traumatic stress was operationalized as
of psychometrically reliable and valid instruments to mea- intrusion, avoidance and arousal symptoms.58 The final
sure STS.64 Motta and colleagues found that many of the version is a 17-item self-report instrument to assess the
scales used lacked cut-off scores and/or were not amena- frequency of intrusion, avoidance and arousal symptoms
ble to implementation across a wider population and associated with STS. A Likert scoring scale was used (1—
variety of traumatic experiences (most have been tested never to 5—very often).
on specific populations such as mental-health workers, Although the STSS provides a quick and easy assess-
therapists and social workers).64 For example, the Com- ment of the presence of STS and might serve to guide the
passion Satisfaction-Fatigue (CSF) Test has been used pre- evaluation of intervention strategies to reduce the likeli-
dominantly with mental-health workers although more hood of STS occurring, several limitations are apparent.
widespread use has emerged.65 The CSF is a self-report As with many of the other instruments, the target popu-
scale comprising three subscales (estimate of compassion, lation is a specific subset of health-care providers, social
risk of burnout and CF, and degree of satisfaction derived workers, suggesting a lack of adaptability to accommodate
from helping others) with a total of 66 items scored using a variety of STS exposures. Furthermore, the ability to
a Likert scale (0—not at all to 5—very often). The mod- discriminate between whether the individual is experi-
ification to include compassion satisfaction was deemed encing STS, depression, burnout or PTSD has not been
necessary to address inherent shortcomings within the clearly demonstrated. For instance, a subset of the items
original CF scale that focused solely on the negative con- also measure symptoms of depression and overlap with
sequences of compassion when working with clients ex- symptoms of PTSD (given that the instrument was based
periencing pain, suffering and trauma. Being exposed to on PTSD, this is not surprising).58 Further studies are
traumatic stressors does not guarantee that an individual required before this instrument can be considered a reli-
will manifest symptoms of either CF/STS; nor does tar- able and valid tool for the assessment of the presence of
geting the negative aspects and symptomatology provide STS in health professionals.
answers as to what, why and how it is that some health- Another instrument that has emerged in an effort to
care providers achieve satisfaction from this very work. assess the frequency and presence of STS is the Secondary
Focusing on negative symptoms might create a response Trauma Scale.64 Developed to address criticisms related to
bias that artificially inflates or deflates reports of CF.65 a lack of cut-off scores (degree of STS, or the score above
Despite widespread use of the CSF scale, little empir- which we can be sure of STS) and measurement of the
ical research has been published.66 More questions need to severity of effect of various secondary traumatic experi-
be answered before the CSF Test achieves reliability. These ences across different health professional groups, Second-

© 2006 The Authors


Journal compilation © 2006 Blackwell Publishing Asia Pty Ltd
140 BM Sabo

ary Trauma Scale is an 18-item self-report scale using a more clearly understand the aetiological process of CF
Likert scoring scale (1—rarely/never to 5—very often). (STS)—in particular the link between the empathic sen-
It too suffers from a lack of reliability and validity in dis- sitivity of the health-care professional and their vulnera-
criminating between levels of severity of STS, or between bility to experience secondary trauma. Longitudinal
constructs such as STS, dissociation, anxiety and depres- studies should be undertaken to explore the development
sion; inability to isolate causal factors; and a lack of gen- of symptoms in relation to such factors as chronic expo-
eralizability across various traumatic experiences. sure to traumatized clients, lack of institutional support,
presence of empathy, burnout, type of traumatic expo-
WHERE TO FROM HERE? sure, years of experience, level of education and personal
In reviewing CF (STS), what becomes apparent is an history of traumatic events. Finally, further empirical
attempt to theoretically reflect the pathology (physical studies are required to operationalize instruments such
and psychological) arising out of the secondary stress from as the CSF scale; rather than an instrument that focuses on
working with traumatized individuals.46 Compassion pathology and symptoms, an instrument that clearly
fatigue emerges suddenly, precipitated by exposure to a reflects the concepts of compassion and fatigue, strives to
client’s traumatic event with the affected exhibiting sec- differentiate causal factors, and draws clear distinctions
ondary PTSD symptoms. To date, no scientific evidence between CF and burnout needs development and
exists to support the notion that STS is identical to PTSD; validation.
however, this does not rule out the hypothesis that ongo-
ing, cumulative exposure to individuals who are in pain, ACKNOWLEDGEMENT
suffering or traumatized might not have effects similar to I would like to acknowledge the support and guidance of
PTSD.69 Compassion fatigue focuses largely on negative Dr Donna Meagher-Stewart, Professor, Dalhousie Uni-
symptomatology, rather than exploring contributing fac- versity School of Nursing whose course, Women’s Health
tors leading to its development or onset. Furthermore, Outcomes, was instrumental in the development of this
Figley suggests that empathy and emotional energy are the paper. Her patience and guidance have been greatly
underlying drivers in the development of CF.31,46 Extend- appreciated.
ing the concept beyond a one-dimensional approach
would appear to have more relevance, given that little
empirical evidence exists to support empathy or overcar-
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