Running head: BURNOUT & COMPASSION FATIGUE LITERATURE REVIEW. Burnout and Compassion Fatigue Literature Review. Barbara J. Henry

Transcription

1 1 Burnout and Compassion Fatigue Literature Review Barbara J. Henry Northern Kentucky University

2 2 Introduction Burnout and compassion fatigue are conditions that occur in many professionals, particularly nurses working in high trauma specialties such as oncology. The purpose of this paper is to review the literature and briefly describe the conceptual framework for burnout and compassion fatigue in oncology nurses. The literature search was conducted using CINAHL, MEDLINE, and PSYCHInfo databases along with articles obtained from Really Simple Syndication (RSS) feeds and hand selection using the search terms of burnout. compassion fatigue, burnout and compassion fatigue in nurses, and burnout and compassion fatigue in oncology. Findings were grounded in the literature from nursing, medicine, psychology, social work, and palliative care professions. The literature review was limited to the past 10 years except for older original works on burnout and compassion fatigue. Articles on related topics were also reviewed. Articles selected for the literature review are directly urelated to the research question: how does a therapeutic retreat effect burnout and compassion fatigue in oncology nurses? Background and Conceptual Framework In Boyle s review of literature, antecedents to burnout and compassion fatigue included the following: 1.) exposure to traumatic care of cancer patients, 2.) vulnerable individual personality traits and lack of coping skills, or 3.) lateral violence from others (2011). Bush, like Boyle, is a nursing author who has written extensively on burnout and compassion fatigue in oncology nurses. Bush noted that burnout and compassion fatigue occur when emotional boundaries are blurred and the nurse absorbs distress, anxiety, fears, and trauma of the patient, (a concept called countertransference in psychiatry), (2009). Collins & Long reported a consequence of compassion fatigue and burnout is unresolved emotional pain that caregivers

3 3 store away (2003 p 18). Difficulty balancing work and life outside work may be an antecedent to or consequence of burnout and compassion fatigue as well. Many articles define and describe the concepts of burnout and compassion fatigue. The concept of burnout was first conceptualized by Christina Maslach who developed the Maslach Burnout Inventory (MBI) tool to measure burnout in healthcare and other professional workers (Maslach,& Schaufeli, 1993). Compassion fatigue was first introduced by Joinson in 1992 during an investigation of burnout in emergency nurses. Joinson never formally defined compassion fatigue and in 1995, it was adopted by psychologist Charles Figley as a term for secondary traumatic stress disorder (Figley, 1995). Pilkington suggested a conceptualization of burnout and compassion fatigue from the perspective of the Neuman systems model (2008). Jean Watson s seven assumptions of nurse caring provide the theoretical underpinnings of potential for burnout and compassion fatigue (Current Nursing, 2012). Burnout, compassion fatigue, and related concepts have been topics of interest in nursing literature, particularly in the past five years (Knobloch Coutzee & Klopper, 2005). The concept of lateral violence has emerged in the literature as both an antecedent and consequence of burnout and compassion fatigue (Sheridan-Leos, 2008). Description and Critique of Scholarly Literature There are very few randomized clinically controlled trials (RCTs) examining burnout and compassion fatigue in oncology nurses or healthcare professionals. Most articles are reviews of RCTs, review of literature, and qualitative studies. A 2010 study utilized a two arm randomized controlled mixed methods trial using 65 medical personnel with direct patient contact as participants (Brooks, Bradt, Eyre, Hunt, &

4 4 Dileo, 2010). Results showed no statistically significant difference in change scores between the control and experimental groups for self-reported burnout, sense of coherence, and job satisfaction (Brooks, et al., 2010). Qualitative findings indicated that music imagery and creative mandala drawings helped participants relax, rejuvenate, and refocus enabling them to complete their shifts with renewed energy (Brooks, et al., 2010). A limitation of this study was the sample size and that shortly after the study began a major restructuring at one of the hospitals resulted in layoffs, increased shifts, and fear of termination for open admission of feeling burned-out during the process, and many planned music-imagery sessions were cancelled affecting study findings (Brooks, et al., 2010). 16 participants in a brief mindfulness intervention for nurses and nurse aids experienced significant improvements in burnout symptoms, relaxation, and life satisfaction compared to 15 wait list control participants (Mackenzie, Poulin, & Seidman-Carlson, 2006). Each week, participants from large urban geriatric teaching hospital attended one of 6 sessions held during the day and evening shifts and received a CD of guided mindfulness exercises, which they were instructed to practice for at least 10 minutes per day 5 days per week along with a manual summarizing key points from the sessions and homework assignments (Mackenzie, et al., 2006). Mackenzie and colleagues utilized the MBI, Smith Relaxation Dispositions Inventory, and Intrinsic Job Satisfaction subscale from the Job Satisfaction Scale, Satisfaction with Life scale, and 13 item version of the Orientation to Life Questionnaire to measure quantitative data (2006). An obvious limitation of this study was the sample size, but results of the study support the feasibility and potential effectiveness of brief mindfulness training in reducing burnout and improving morale in nurses (Mackenzie, et al, 2006.)

5 5 Marine, Ruotsalainen, Serra, & Verbeek conducted a review of RCTs on interventions aimed at prevention of psychological stress and burnout in healthcare workers (2009). Authors presented a meta-analysis and qualitative synthesis of 14 RCTs, 3 cluster randomized trials, and 2 crossover trials with a total of 1,564 participants in intervention groups and 1,248 participants in control groups (Marine, et al., 2009). The main limitation of these studies were that only two of the trials were of high quality. Interventions were grouped into person-directed and workdirected. One trial showed stress remained low a month after the intervention, another showed a reduction in emotional exhaustion and in lack of personal accomplishment maintained up to two years post-intervention with refresher sessions (Marine, et al., 2009). Two studies showed a reduction in anxiety maintained up to a month post-intervention (Marine, et al., 2009). The authors recommended larger and better quality trials and concluded that person-directed interventions including cognitive behavioral approaches like coping skills training combined with relaxation techniques can be effective in reducing burnout in healthcare workers compared to no intervention (Marine, et al., 2009). Najjar and colleagues reviewed 57 studies with healthcare workers and found a variety of terminology used to describe burnout and compassion fatigue (Najjar, Davis, Beck-Coon, & Carney Doebbling, 2009). The authors described 14 studies on compassion fatigue with various healthcare professionals, the largest sample being 336 county child protection staff and one clinical trial examining the treatment effectiveness of the Certified Compassion Fatigue Specialists Training (CCFST) for mental health professionals (Najjar, et al., 2009). The authors acknowledged that conceptual and methodological research on the problem is lacking, and summarized personal, professional, and organizational strategies to manage and treat compassion fatigue (Najjar, et al., 2009).

6 6 In a study on nurse practice environments and patient outcomes, Friese (2005) used a large sample of 1956 registered nurses including 305 oncology nurses. The study was a secondary analysis of survey data collected in 1998 using statistical analysis instruments including logistic regression (Friese, 2005). Though the data was old, a limitation of the study, the author found that oncology nurses had superior patient outcomes compared to non-oncology nurses and that emotional exhaustion was significantly lower for nurses working in magnet hospitals compared to those working in non-magnet hospitals (Friese, 2005). Friese s key points were that nurse concern with practice environments was reflected by their job dissatisfaction, burnout, and perceived quality of care, and to improve outcomes, practice environments should be assessed routinely to optimize the success of nursing interventions (2005). Kash, Holland, Breitbart, Berensen, Dougherty, Ouellette-Kobasa, and Lesko identified the concept of a hardy personality, social support, and relaxation methods as moderating variables that may decrease burnout and compassion fatigue in oncology professionals (2000). Three attributes of a hardy personality found to be buffers against stress were: commitment to self and work, a sense of being able to control or influence events, and a sense of challenge in the face of a changing environment (Kash, et al., 2000). The cross-sectional survey data from 83 nurses and 178 oncologists at Memorial Sloan Kettering Cancer Center (MSKCC) was studied over a two year period (Kash, et al., 2000). The MBI, demoralization scale of the Psychiatric Epidemiology Research Interview (PERI), somatization scale of the Hopkins Symptom Checklist, Kobasa personality scale, peer cohesion subscale of the Work Environment Subscales, perception of religious person scale, and a stress questionnaire were used to quantify results (Kash, et al., 2000). Nurse sense of accomplishment was much lower than house oncology medical staff, which the authors attributed to nurses seeing patients with cancer when they are

7 7 most ill, a sense of futility about cancer treatment, anger and cynicism about limited role of nurses in the overall treatment trajectory (Kash, et al., 2000). Stressors that contributed most to burnout and demoralization were negative work settings, high number of patient deaths, and struggling over a DNR decision with another colleague or family member (Kash, et al., 2000). These psycho-oncology expert authors concluded that cancer centers must explore means of reducing work stress in order to emotionally equip professionals to effectively communicate and provide support to patients (Kash, et al., 2000). In a study of emergency nurses and nurses from three other specialty hospital units: oncology, nephrology, and intensive care, the authors found a risk for higher risk for burnout and compassion fatigue in oncology nurses (Hooper, Craig, Janvrin, Wetsel, Reimels, Anderson, Greenville, & Clemson, 2010). Findings failed to support the hypothesis that emergency nurses are at greater risk for burnout and compassion fatigue compared to nurses from other specialties (Hooper, et al., 2010). Compassion satisfaction, burnout, and compassion fatigue scores were measured using the Professional Quality of Life, Fourth Revision (ProQOL R-IV) instrument. Limitations of the study were the small sample size of 109 respondents chosen from one 461 bed acute care hospital in the Southeast measured at a single point in time. Despite study limitations, authors concluded that raising the awareness of the emotional impact on nurses of caring for patients will lead to the development of ongoing support programs for hospital nurses (Hooper, et al., 2010). Yoder also utilized the ProQOL scale to measure compassion fatigue, compassion satisfaction, and burnout in nurses employed at a 123 bed Midwest Magnet community hospital (2010). Yoder found that 15% of participants had ProQOL scores indicating risk for compassion fatigue, 2010). In addition to the Pro-QOL scale, Yoder solicited qualitative data by asking

8 8 participants to describe a situation where you experienced compassion fatigue and burnout and what strategies did you use to deal with the situation? (2010, p.193). 71 nurses completed the narrative portion and described trigger situations for burnout and compassion fatigue: 1.) patient condition/status, 3.) challenging behavior, 4.) futile care, 5.) workload, 6.) management decisions, 7.) personal limits, and 8.) personal experiences (Yoder, 2010). Coping strategies included: a.) change personal engagement, b.) change nature of work involvement, c.) debrief informally, d.) take action to change/manage current situation, e.) develop ritual, f.) life outside work, g.) spiritual or religious, h.) introspection, and i.) attitude modification (Yoder, 2010). Yoder s study limitations were small sample size from one hospital taken at one point in time. Edmunds provided further detail on Yoder s findings that compassion fatigue was triggered by patient care situations in which the nurse 1.) believed their actions would not make a difference or not be enough, 2.) had problems with the system-high census and acuity, heavy patient assignments, overtime and extra work day(s), 3.) had personal issues such as inexperience or inadequate energy, 4.) identified with the patients, or 5.) overlooked serious patient symptoms (2010.) Contrary to most studies, Barnard, Street, & Love found that there was no statistically significant relationship between level of perceived work supports and level of burnout (2006). Barnard, et al., 2006 surveyed 101 cancer nurses working at a specialist oncology metropolitan Australian hospital. More than 50% of participants experienced a list of 50 stressors from an amended version of the Stressor Scale for Pediatric Oncology Nurses and found that most work support came from peers rather than supervisors or the organization (Barnard, et al., 2006). In addition to the stressor scale, burnout was measured by the MBI. According to Barnard, et al., 94% participants indicated that 2 items in particular were sources of stress: when nurses and

9 9 doctors are not communicating well about patients, and feeling I can t get all my work done (2006). Nurses were also given a free response comment section concerning support required from the organization, which listed the following as the most important needs: 1.) further nursing education, 2.) nursing administration/management support, 3.) recognition, rewards, and support, 4.) regular staff counseling and debriefing, and 5.) services for staff (Barnard, et al., 2006). The strength of this study is the use of two quantifiable and one qualitative tool, though a weakness is the small sample size from one institution collected at one point in time. There has been a great deal published about the prevalence of burnout and compassion fatigue in oncology nursing, but less on interventions to decrease the problem. Compassion fatigue is amenable to intervention; with therapeutic support programs and retreats, nurses may continue to work in their chosen field (Sabo, 2011). Sabo s extensive review of literature, similar to that of Boyle (2011), presented a recommendation that more energy should be focused on psychosocial health and well-being of nurses (2011). In a quasi-experimental RCT among staff of 29 hospital oncology units in the Netherlands, Le Blanc, Hex, Schaufeli, Tarsi and Pesters evaluated the effects of a team-based burnout intervention program combining a staff support group with a participatory action research approach. Nine oncology units were randomly selected to participate (2007). Before the Take Care program started (Time 1), directly after the program ended (Time 2), and 6 months later (Time 3), participants filled out a questionnaire on their work situation and well-being (LeBlanc, et al., 2007). Staff who participated in the program experienced significantly less emotional exhaustion at both Time 2 and Time 3 and less depersonalization at Time 2, compared with staff who did not participate in the program (LeBlanc, et al., 2007). Often in the formal training of oncology nurses, there is no solid basis of psychosocial awareness, knowledge, and

10 10 skills to facilitate coping (LeBlanc, et al., 2007). Participants in the Take Care program experimental group felt significantly less exhausted than those in the control group immediately after the program and again six months later (Le Blanc et al., 2007). Medland, Howard-Rubin, and Whitaker (2004) identified psychosocial wellness and the avoidance of burnout as key to retention of oncology nurses, and described a program to enhance oncology nurse coping skills. Turnover rates on the oncology units was greater than 40% compared to a hospital average of 14.2%, which lead to the study (Medland, et al., 2004). Five full day Circle of Care retreats with 150 oncology staff members were held away from the clinical area in a relaxed setting in a large Midwest cancer center (Medland, et al., 2004). The retreats offered interactive and informal presentations on wellness, bereavement, developing stress management skills like relaxation, journaling, cultivating team effectiveness, and art making activities (Medland, et al. 2004). Participants viewed a videotape on a positive management philosophy and discussed the CARES philosophy, a framework for incorporating stress management and self-care into practice (Medland, et al. 2004). Practice changes to decrease burnout and increase ongoing focus on staff support at the facility were implemented based on ideas generated at the retreats (Medland, et al. 2004). Though the study and intervention provided valuable data on a burnout and compassion fatigue intervention, the authors did not utilize any quantitative data or tools to measure the effects. Adcock and Boyle examined existing interventions to manage compassion fatigue in oncology nurses (2009). They surveyed 231 Oncology Nursing Society chapter presidents in 2007 and received 103 responses. 22% or fewer respondents had on-site resources such as: employee assistance programs (EAPs), pastoral care, counselor or psychologist, psychiatric clinical nurse specialist, and support group (Adcock & Boyle, 2009). The authors found that

11 11 those with EAPs have three free visits available per year with discount for ongoing services, and that a barrier to obtaining other counseling services was the lag time between request and scheduled time available for an appointment (Adcock & Boyle, 2009). Only 5% of respondents reported exposure to staff support groups and that the groups were rarely continued over time (Adcock & Boyle, 2009). Though off-site retreats to promote renewal were experienced by only a few respondents, qualitative data reflects the value of these retreats to participants (Adcock & Boyle, 2009). A weakness in this study is that no quantitative data or measures were obtained. Hayes and colleagues wrote about retention strategies implemented at large Eastern U.S. cancer centers that decrease burnout and increase support for oncology nurses (Hayes, Reid Ponte, Oakley, Stanhellini, Gross, Perryman, Hanley, Hickey, & Somerville, 2005). Strategies included: a New Graduate Development Program, Support Mentorship and Respect Together in Nursing (SMaRT) a mentoring program designed to support minority nurses entering oncology, Oncology Nursing Leadership Advisory Group with cross institutional participation, oncology nursing grand rounds and educational programs, Spirit Rounds, Reflective Practice rounds, narratives for individual reflection on practice, ambulatory nursing retreats for reflection and renewal, and individual meetings with a psychiatric clinical nurse specialist for new graduates, all with favorable outcomes despite some initial implementation difficulties (Hayes et al., 2005). This study reported qualitative but not quantitative data. Bauer Wu and colleagues facilitated overnight staff renewal retreats with oncology nurses from a large Eastern U.S. cancer center in 2005 (2005). Goals of the retreats included bringing staff together outside the work setting to relax, have fun, revisit self-care and selfreflection as well as rekindling spirit in order to feel rejuvenated and professionally re-inspired (Bauer Wu, 2005). The retreat theme was Creating Balance and Peace in a Life of Blessings

12 12 and Losses, with participant choice of four experiential break-out sessions: Keeping the Hope using art, imagery, and story to restore hopefulness as a self-care practice, Coming Home to Your Body, using therapeutic movement, Being Peace using mindfulness meditation to foster peace and balance in everyday life, and What Matters Most for self-reflection and expression through collage and writing (Bauer-Wu, 2005). Though no quantitative evaluation tools were used, the author reported that participants acknowledged appreciation for the unique experience of fun, personal growth, and knowledge (Bauer Wu, 2005). Potter and colleagues studied prevalence of burnout in a large Midwest U.S. cancer center, and an intervention based on the needs of the center that did not have an existing program in place. Staff facilitators were trained to meet the unique needs of the staff and presented a series of four 90-minute training sessions and a four hour retreat designed to help RNs gain skills to reduce burnout (Potter, et al., 2010). The ProQOL R-IV was administered pre and postintervention, along with qualitative measures reflecting positive outcomes for program participants. There was no wait list control group. An 8-week mindfulness-based stress reduction program was offered to 25 nurses at an Eastern U.S. hospital and health network funded by the organization and the senior VP for clinical services who was one of the study investigators (Cohen-Katz, Wiley, Capuano, Baker, Deitrick, & Shapiro, 2005). Qualitative and quantitative data from the study found the intervention to be effective in improving relaxation, self-care, work and family relationships, though the process at times generated challenges like restlessness, pain, and dealing with difficult emotions (Cohen, et al, 2005).

13 13 Inferences for Future Research Further research is needed to develop a theory of compassion fatigue for nursing practice (Knobloch Coutzee & Klopper, 2010). Additional research may determine factors that contribute to the progression from compassion discomfort to compassion stress, and compassion fatigue, and determine time line involved in this process (Knobloch Coutzee & Klopper, 2010). More studies are needed that evaluate interventions for preventing and reducing nursing burnout compassion fatigue as well (Knoblach Coutzee & Klopper, 2010). Randomized clinical trials conducted at multiple sites on the effect of therapeutic interventions on oncology nurse burnout and compassion fatigue are needed to establish empirical data on solving the problem. Studies show that the effects of these interventions may last 6 months to 2 years (Marine, et al., 2009) demonstrating cost savings to healthcare organizations providing regular burnout and compassion fatigue interventions to recruit and retain nurses and improve patient outcomes. Conclusions Fatigue, stress, sadness, decrease in morale, and poor work performance, are all influenced by psychosocial factors that have often been ignored by nurses and healthcare administration (Boyle, 2012). Klobach Coutzee & Klopper (2010) believed that increased knowledge of compassion fatigue and its manifestations may enable nurses to become aware of others who might be suffering and facilitate the development of a peer support network, making it possible for nurses to seek assistance in dealing with the detrimental effects of compassion fatigue. An employee assistance program should be established in every health-care institution, with free counseling and life skills education services allowing nurses to seek assistance in dealing with the emotional burden of their work (Klobach Coutzee & Klopper, 2010).

14 14 Burnout and compassion fatigue impact recruitment and retention of oncology nurses and may influence patient satisfaction and patient safety (Potter et al., 2005). Encouraging self-care strategies and offering interventions within and outside the workplace address a key distinction of nursing practice, namely that of holistic care for patients and nurses (Boyle, 2011). With experience, self-care, and support from peers and healthcare organizations, competent oncology nurses learn to establish appropriate boundaries that are more semipermeable than other clinical specialties. Because of the semi-permeable boundaries unique to oncology nursing and high risk of developing burnout and compassion fatigue, oncology nurses need annual therapeutic programs in addition to more frequent support outlets. Compassionate nurses are an essential and dwindling resource in today s healthcare system, and nurses must be supported and cared for by providing nurses with time to share feelings and develop coping strategies (Edmunds, 2010).

15 15 References Graded references are listed according to the following legend from O Neil, Dluhy, Fortier, & Michael (2004) and Polit (2012) : Legend Type: R= Research L= Literature N= National Guideline Levels: I= Systematic Review of RCT, Systematic Review of Non-Randomized Trial II=Single RCT, Single Non-Randomized Trial III= Systematic Review of Correlational or RCT, Observational Studies IV= Single Correlational or Observational Study V=Systematic Review of Descriptive/Qualitative/Physiologic Studies VI=Single Descriptive/Qualitative/Physiologic Study VII=Opinion of Authorities, expert committees Strength: A= Good evidence to support a recommendation B= Moderate evidence to support a recommendation C= Poor evidence to support a recommendation O'Neill, E.S., Dluhy, N.M., Fortier, P.J., & Michael, H.E. (2004). Knowledge acquisition, synthesis, and validation: A model for decision support systems. Journal of Advanced Nursing, 47 (2), Polit, D. F. (2012). Evidence-based nursing: Translating research evidence into practice. In D. F. Polit, Nursing Research: Generating and Assessing Evidence for Nursing Practice (pp ). Philadelphia, PA: J. B. Lippincott Company. Aycock, N. & Boyle, D. (2010). Interventions to manage compassion fatigue. Clinical Journal of Oncology Nursing, 13(2), R IV A National survey to determine resources available to oncology nurses for dealing with burnout and compassion fatigue (B&CF). Barnard, D., Street, A., & Love, A. (2006). Relationships between stressors, work supports, and burnout among cancer nurses. Cancer Nursing. 29(4), R IV B Pilot study of 101 Australian oncology nurses using self-report questionnaires and Maslach Burnout Inventory, moderate to low burnout results.

16 16 Bauer-Wu, S. (2005). Seeds of hope, blossoms of meaning. Oncology Nursing Forum, 32(5), R VI B Summary of B&CF programs for oncology nurses. Brooks, D.M., Bradt, J., Eyre, L., Hunt, A., & Dileo, C. (2010). Creative approaches for reducing burnout in medical personnel. The Arts in Psychotherapy, 37, R II B RCT using music and art therapy to reduce burnout in 65 medical professionals at an urban hospital. Boyle, D. (2011). Countering compassion fatigue: A requisite nursing agenda. Online Journal of Issues in Nursing, 13(1). R I A Review of current literature and research and need for B&CF. Bush, N.J. (2009). Compassion fatigue: Are you at risk? Oncology Nursing Forum, 36(1), R VII B Case studies on B&CF, differences/similarities between B & CF, and self-care. Cohen-Katz, J., Wiley, S., Capuano, T., Baker, D., Deitrick, L., & Shapiro, S. (2005). The effects of mindfulness-based stress reduction on nurse stress and burnout a qualitative and quantitative study, part III. Holistic Nursing Practice. March/April, R IV B 8 week MBSR program for 25 nurses improved relaxation, work & family relationships, caused restlessness, emotional pain dealing with difficult emotions in group discussions.

17 17 Collins, S. & Long, A. (2003) Too tired to care? The psychological effects of working with trauma. Journal of Psychiatric and Mental Health Nursing, 10, R III B Review of literature on B&CF in several areas of nursing specialties including emergency, oncology, and psychiatry. Current Nursing. (2012b). Jean Watson s Philosophy of Nursing. Retrieved from: _theory/watson.html L VII C Website describing nursing theory that can be applied to a theoretical model and research on nursing B&CF. Edmonds, M.W. (2010). Caring too much: Compassion fatigue in nursing. Applied Nursing Research. 23, L VII B Editorial on nursing B&CF and summary of Yoder study and implications. Figley, C. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. Brunner/Mazel: New York. L VII B Expert textbook/guide on compassion fatigue. Hayes, C., Reid Ponte, P., Coakley, A., Stanhellini, E., Gross, A., Perryman, S., Hanley, D., Hickey, N., & Somerville, J. (2005). Retaining oncology nurses: strategies for todays nurse leaders. Oncology Nursing Forum. 32(6), R VII B Leaders from 3 hospitals collaborated on retention of oncology nurse strategies like creating nursing advisory groups, supporting new grads, & meeting emotional needs of nurses at all levels.

18 18 Hooper, C., Craig, J., Janvrin, D.R., Wetsel, M.A., Reimels, E., Anderson, Greenville, and Clemson, S.C. Compassion satisfaction, burnout, and compassion fatigue among emergency room nurses compared with nurses in other selected inpatient specialties. Journal of Emergency Nursing. 36(5), R IV B Failed to support hypothesis that emergency nurses had higher compassion fatigue than other specialties and found that oncology nurses had higher compassion fatigue; used cross sectional survey & ProQOL tool. Joinson, C. (1992). Coping with compassion fatigue. Nursing, 22(4), 116, R IV B Original mention of B&CF in nursing literature as observed in emergency nurses losing their capacity to care. Kash, K.M., Holland, J.C., Breitbart, W., Berenson, S., Dougherty, J., Ouellette-Kobasa, S., & Lesko, L. (2000). Stress and burnout in oncology. Oncology, 14(11), R IV B Psycho-oncology experts study of burnout in oncology professionals using a variety of quantitative measuresfound nurses sense of accomplishment lower than MDs. Knobloch Coetzee S.K., & Klopper, H.C. (2009). Compassion fatigue within nursing practice: A concept analysis. Nursing and Health Sciences, 12, R III B Concept analysis paper including literature review on B&CF as well as concept map on CF.

19 19 LeBlanc, P.M, Hox, J.J., Schaufeli, W.B., Taris, T.W., & Peeters, M.C.W. (2007). Take care! The evaluation of a teambased burnout intervention program for oncology providers. Journal of Applied Psychology, 92(1), R II A RCT quasi experimental study of staff from 29 oncology wards, 9 wards randomly selected to participate in the program measured over timedirectly after, 6 months after and 2 years after. Mackenzie, C.S., Poulin, P.A., & Seldman-Carlson, R. (2006). A brief mindfulness-based stress reduction intervention for nurses and nurse aides. Applied Nursing Research 19, R II B RCT with mixed methods analyzing a MBSR intervention for nurses and nurse aides. Marine, A., Ruotsalainen, J.H., Serra, C., & Verbeek, J.H. (2009). Preventing occupational stress in healthcare workers (review). The Cochrane Library 2009, Issue 1. R I A Cochrane review of 14 RCTs and other lower quality trials with large sample and control groups recommending larger and better trials to improve QOL and decrease costs of B&CF. Maslach, C., & Schaufeli, W. B. (1993). Historical and conceptual development of burnout. In W. B. Schaufeli, C. Maslach, & T. Marek (Eds.), Professional burnout: Recent developments in theory and research (pp. 1 16). Washington, DC: Taylor & Francis. L VII B Expert textbook and guide on burnout.

20 20 Medland, J., Howard-Ruben, J., & Whitaker, E (2004). Fostering psychosocial wellness in oncology nurses: Addressing burnout and social support in the workplace. Oncology Nursing Forum, 31(1), R IV B Qualitative evaluation of a program developed because of high turnover rate in the oncology unit compared to the rest of the hospital. Najjar, N., Davis, L.W., Beck- Coon, K., & Doebbeling, C.C. (2009). Compassion fatigue: A review of the research to date and relevance to cancer-care providers. Journal of Health Psychology, 14(2), R I B Review of 57 studies identifying prevalence of compassion fatigue in oncology providers, instruments, and prevention and treatment. Pilkington, F.B. (2009). Theorizing the concept of burnout in nursing. Nursing Science Quarterly, 22, 199. L VII B Editorial and introduction to B&CF articles, suggested developing nursing model based on Neuman. Potter, P., Deshields, T, Divanbeigi, J., Berger, J., Cipriano, D., Norris, L., & Olsen, S. (2010). Compassion fatigue and burnout: Prevalence among oncology nurses. Clinical Journal of Oncology Nursing. 14(5):E56- E62. R IV B Descriptive cross sectional survey with moderate evidence to support the recommendations based on the outcomes. The main author is an expert on the topic. Sabo, B.M. (2011). Reflecting on the concept of compassion fatigue., Online Journal of Issues in Nursing, 16(1), R V B Review of literature with case scenarios, suggesting lack of theoretical clarity and need for quantitative and qualitative research on nurse B&CF.

21 21 Sheridan-Leos, N. (2008). Understanding lateral violence in nursing. Clinical Journal of Oncology Nursing, 12(3), L VII B Professional issues article on the related concept of nursing lateral violenceantecedent/consequence of B&CF. Yoder, E.A. (2010). Compassion fatigue in nurses. Applied Nursing Research, 23(4), R II A Quantitative and qualitative study on B&CF in nurses with narrative triggers and coping strategies.