Family Nurse Practitioner

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1 COMPASSION FATIGUE AND TRAUMA NURSING A Thesis Presented to the faculty of the School of Nursing California State University, San Marcos Submitted in partial satisfaction of the requirements for the degree of MASTER OF SCIENCE in Nursing Family Nurse Practitioner by Cassandra Lynn Prewitt SPRING 2018

2 COMPASSION FATIGUE AND TRAUMA NURSING Cassandra Lynn Prewitt ALL RIGHTS RESERVED

3 COMPASSION FATIGUE AND TRAUMA NURSING 3 Alham Abuatiq.PhD.MBA.RN 4/30/18 James Minor 4/30/18

4 COMPASSION FATIGUE AND TRAUMA NURSING 4 Abstract of Compassion Fatigue and Trauma Nursing by Cassandra Lynn Prewitt Statement of Problem Trauma nurses are at an increased risk of developing compassion fatigue from working in a high stress environment with at times undesirable patient outcomes. This type of nursing has increase and the stress that comes along with it can put a nurse at risk for psychiatric issues and or nurses leaving this particular type of nursing or nursing all together. No prior studies have focused on if there is a correlation between compassion fatigue and exposure to different types of trauma. Sources of Data Data was collected from a convenience sample of Registered Nurses at a large metropolitan hospital in the greater San Diego, CA area from the Surgical ICU and trauma bay. Students completed a demographic survey and the ProQOL V.5 (Stamm, 2010). Conclusions Reached There was no statistical significance of a relationship between having compassion fatigue and caring for patients affected by different types of trauma. ACKNOWLEDGEMENTS I have been indebted in the preparation of this thesis to my committee, Dr. JoAnn Daugherty, Dr. Alham Abuatiq of California State University San Marcos, and Professor Jim Minor of Grossmont Community College. Each contributed to this project in their own unique way. I wish to thank each one immensely for their support, kindness, and patience.

5 COMPASSION FATIGUE AND TRAUMA NURSING 5 I would also like to thank my Husband Martal Prewitt and my two children Hunter Prewitt and Hudson Prewitt for being the reason why I was able to complete this thesis. TABLE OF CONTENTS Preface Abstract Acknowledgments List of Tables List of Figures i iv v viii ix Chapters 1. INTRODUCTION 1 Background and Significance 1 The Problem 2 Purpose of the Research Research Question 3 Hypothesis Research Variables

6 COMPASSION FATIGUE AND TRAUMA NURSING 6 2. LITERATURE REVIEW 4 Introduction Major Variables Defined 7 Theoretical Framework / Conceptual Model (if applicable) 8 Summary 9 3. METHODOLOGY 11 Introduction Research Question Research Design Population and Sample Measurement Methods 12 Data Collection Process 14 Coding and Scoring Data Analysis 15 Bias Summary 16 Introduction 4. RESULTS 18

7 COMPASSION FATIGUE AND TRAUMA NURSING 7 Sample Data Collection and Preparation 21 Instruments Results by Research Question Summary DISCUSSION 28 Introduction Major Findings Other Study Comparisons 29 Limitations Generalizability 30 Implications for Research Summary 31 Appendix A. IRB Approval Letter 32 Appendix B. Informed Consent 34 Appendix C. SICU manager approval 37 Appendix D. SICU invite 38 Appendix E. Compassion fatigue and trauma nursing survey 39 Citations 56

8 COMPASSION FATIGUE AND TRAUMA NURSING 8 Tables LIST OF TABLES Page 1. Frequency of Nurses Who Cared for patients in the Last 30 Days 19 who were Injured by Accident 2. Frequency of Nurses Who Cared for Patients in the Last 30 Days who Purposefully Inured Themselves by Self 3. Frequency of Nurses Who Cared for Patients in the Last 30 Days 20 who were Purposefully were Injured by Another 4. Rn Experience Table 5. Chi- Square Analysis for Accidental Trauma Chi-Square Analysis for Purposeful Trauma to Self Chi- Square Analysis for Purposeful Trauma by Another 8. Independent Sample T Test for CF and Nursing Certification Independent Sample T-Test for CF and Religious Practice Compassion Fatigue Score and Marital Status 11. Pearson Correlation of Numeric Demographic Variables and CF Questions 26 Figures LIST OF FIGURES Page 1. Stamm s model of Compassion Fatigue and Compassion Satisfaction 9 2. G-Power Plot Compassion Fatigue Score 22

9 COMPASSION FATIGUE AND TRAUMA NURSING 9 Compassion Fatigue and Trauma Nursing CHAPTER ONE: INTRODUCTION Daily trauma nurses care for critically injured patients. Many of these patients arrive to the trauma unit with little notice of time yet potentially have life threatening injuries that might have poor outcomes. The exposure to this type of care has potential to cause the nurses to experience compassion fatigue (CF). Previous studies have researched the correlation of compassion fatigue while caring for trauma patients; however, there is a gap in the research of the correlation between compassion fatigue and exposure to particular types of trauma. This study was designed to determine if there is a correlation between compassion fatigue and exposure to different types of trauma. This research was based the theoretical framework of Beth Hudnall Stamm s Compassion Fatigue and Compassion Satisfaction model (2010). This model begins with three key components made up of environment. The first being work environment, the second being client/person helped environment, and the third being personal environment. These environments can influence the type of outcome a nurse may have in regard to having compassion satisfaction or compassion fatigue (Figure 1) i. This study will focus on the compassion fatigue portion of the model. Background and Significance Trauma nurses are at a great risk of developing compassion fatigue because of the tragic situations they provide care in and the tragic outcomes that can occur while caring for these patients. This type of work-related stress is almost inevitable in this type of

10 COMPASSION FATIGUE AND TRAUMA NURSING 10 nursing field ii. Due to the repetitive exposure of a high stressful environment, the nurse is at risk for physical, mental, and emotional health issues iii. Although there has been an adequate amount of literature on the subject of trauma nursing and compassion fatigue, there has been no research to evaluate the correlation of compassion fatigue with exposure to different types of trauma. By studying CF and its relationship to exposure to trauma, researchers may bring to the attention of managers, nurses, and other healthcare personnel potential high risk CF while caring for a particular type of trauma patient. One of the consequences of CF is nurses not staying on the unit or potentially leaving the profession of nursing all together iv. By being able to recognize a particular type of trauma and its potential to increase the nurses chances of developing compassion fatigue, management and or other healthcare staff could potentially develop a tool to cope in order to help retention within the trauma unit. The Problem Trauma nurses are at a constant risk of developing compassion fatigue while caring for trauma patients. Nurses who suffer from CF may have symptoms of annoyance, disconnection, intolerance, melancholy, depression, and lock of compassion and empathy to those in their care v. Currently, there have been no studies that have researched a correlation between compassion fatigue and exposure to different types of trauma. Purpose of the Research The purpose of this study is to see if there is a correlation between compassion fatigue and exposure to different types of trauma experienced by trauma nurses and

11 COMPASSION FATIGUE AND TRAUMA NURSING 11 Surgical ICU nurses whom care for trauma patients at one of the largest medical centers located in southern California. Research Question The research question is Is there a correlation between compassion fatigue and exposure to different types of trauma? The null hypothesis states that there is no difference in the level of CF and the exposure to a particular trauma. The alternative hypothesis states there is a difference in level of CF and the type of exposure to a particular trauma. Research Variables The dependent variable in the study is the level of compassion fatigue as calculated by using the Professional Quality of Life Scale Version 5. The independent variables are age, sex, marital status, religious beliefs, years of experience as a nurse, nursing certification, years of experience as a nurse working with trauma patients, hours worked in the Surgical Intensive Care Unit or trauma bay per week, exposure to caring for patients with accidental trauma, exposure to caring for patients with purposeful trauma to self, and exposure to caring for patients with purposeful trauma by another.

12 COMPASSION FATIGUE AND TRAUMA NURSING 12 CHAPTER TWO: LITERATURE REVIEW The databases used for this search was CINAHL, PubMed, and Google Scholar. Literature search terms included compassion fatigue (CF), stress, burn out syndrome (BOS), trauma, demographic, age, gender, marital status and religion. The search was limited to English, with an assortment of articles with the earliest dating The researcher focused on articles that involved contributing factors of compassion fatigue and in regards to exposer to two different types of trauma, accidental trauma and purposeful trauma. A study completed by Berg, Hershberger, Ahlers-Schmidt & Lippoldt vi conducted a qualitative study (n=12) to measure CF and BOS in a trauma team by allowing them to personally share experiences and triggers of stress with in their department. The study also examined coping strategies as well. This study concluded that more than half of the participants were at risk for CF and BOS do to the reported stressors. The instruments used in this study was The Holmes-Hae Life and Stress Inventory vii, The Professional Quality of Life Scales viii, a demographic survey, and questions from a focus group script. Another study completed by Sacco, Ciurzynski, Harvey, & Ingersoll ix looked at compassion satisfaction and compassion fatigue in adult, pediatric, and neonatal intensive care unit nurses. This was a cross-sectional design (n=221) that used a demographic questionnaire and the ProQol V. 5. This study concluded that there is a significant difference between compassion fatigue and compassion satisfaction in relationship to age, sex, educational level, unit acuity, recent change in nursing management, and any recent system changes.

13 COMPASSION FATIGUE AND TRAUMA NURSING 13 In 2014, Hinderer, VonRueden, Friedmann, McQuillan, Gilmore, Kramer, & Murray published a cross-section descriptive design study (n=128) that focused on trauma nurses and the relationship of BO, CF, CS, and secondary traumatic stress in relationship to personal characteristics and coping mechanisms x. This study concluded scores consisted with CF, but also there was a high percentage of CS with in this study as well. Instruments used in this study were a demographic/behavioral instrument developed with the use of a focus group at the facility where the study took place, Professional Quality of Life Scale (Stamm, 2005), and the Penn Inventory (Hammarber, 1992). Mason, Leslie, Clark, Lyons, Walke, Butler, & Griffin xi surveyed the effect of compassion satisfaction, compassion fatigue, moral distress, and level of nursing education on an ICU trauma unit. This study was a nonexperimental, descriptive, with a correlation design (n=26). This study concluded a higher level of compassion satisfaction than compassion fatigue among nurses on this particular unit. The instruments used in this study were a nursing demographic, Professional Quality of Life Scale (Stamm, 2009), The Utrecht Work Engagement Scale xii, and a Moral Distress Scale xiii. Wentzel & Brysiewicz xiv examined compassion fatigue in trauma nurses. These authors concluded the emotional and psychological issues the trauma nurses are exposed to trauma can lead to compassion fatigue. Models of interventions for compassion were given which included The Accelerated Recovery Program, Mindfulness-Based Stress Reduction (MBSR), The Academy of Traumatology/Green Cross, and The Creative Compassion Model. Sacco, Ciurzynski, Harvey, & Ingersoll xv completed a cross-sectional study with 221 participants. The purpose of the study was to evaluate and establish prevalence of

14 COMPASSION FATIGUE AND TRAUMA NURSING 14 compassion fatigue, compassion satisfaction, and burn out between three different Intensive Care Units, and describe demographics that could contribute to these variables. This study concluded a high level of compassion satisfaction and the positive impact of having an understanding of the elements of a professional quality of life can have within these ICU units. It also concluded more research is needed to be completed in this area. The instruments used were a demographic questionnaire and the Professional Quality of Life Scale. Beck (2011) examined the literature in secondary traumatic stress (STS) in nurses in various fields. The design was a systematic review that included seven studies. The conclusion of this review was STS is present in all the studies completed, higher instances was in forensic nurses, emergency department nurses, oncology nurses, pediatric nurses, and hospice nurses. The instruments used in this study was the Secondary Traumatic Stress Scale (Ting, Jacobson, Sanders, Bride, & Harrington (2005), Compassion Fatigue Self -Test for Helpers xvi and the Compassion Fatigue Scale Revised (Figley & Boscarino, 2008). Hunsacker, Chen, Maughan, & Heaston conducted a study to determine prevalence of compassion fatigue, compassion satisfaction, and burn out from emergency department nurses, as well to see which demographics might contribute to those variables. This was a cross-sectional nonexperimental, descriptive, and predictive study (n=1,000). This study concluded low to moderate level of compassion fatigue and burn out with a high level of compassion satisfaction. Instruments used in this study included a demographic questionnaire and the Professional Quality of Life Scale version 5 (Stamm, 2010).

15 COMPASSION FATIGUE AND TRAUMA NURSING 15 Major Variables Defined Demographic and Independent Variables The variables are defined as follows; Age refers to the chronological age of the participant. Gender is defined as self-reported male or female or other. Other refers to those who identify as intersex or transgender. A spiritual or religious practice is defined as whether the participants see themselves as spiritual or religious. Marital status is defined as being legally married/cohabitation, single or separated/divorced. Experience in nursing is defined as the year someone began to work as a registered nurse. Experience in trauma nursing is defined as the amount of years working with trauma patients within the trauma bay or the surgical intensive care unit. Hours worked per week refer to the amount of hours each participant works in the Surgical ICU or the Trauma Bay. Nursing certification is defined as a participant who has gotten an extra non-required certification to further educate themselves within nursing and medicine such as the Critical Care Registered Nurse (CCRN) certification. Exposure to accidental physical trauma is defined as being the primary nurse caring for a patient that has experienced physical trauma that was not purposeful by someone else or his or herself within the last 30 days, an example would be a patient who accidently slipped and fell. Exposure to purposeful physical trauma would be caring for a patient who was purposefully injured by self or by another within the last 30 days. An example of this would be someone who was physically assaulted.

16 COMPASSION FATIGUE AND TRAUMA NURSING 16 Compassion Fatigue (Secondary Traumatic Stress) Figley (1995) defines compassion fatigue as a negative consequence that occurs from the exposure to a traumatizing event that affects the nurse s capability of caring for and nurturing patients. Sabo (2011) xvii describes CF as exhaustion physically, spiritually, and emotionally from being exposed to the suffering and problems of caring for others Theoretical Framework The theoretical framework for this study is based off Stamm s Compassion Fatigue and Compassion Satisfaction model. This study will emphasize more on the compassion fatigue part of the model. This model is made up of three key elements and how those elements can affect the positive and negative aspects of helping other xviii. The three key elements include work environment, client/person helped environment, and personal environment. These spheres can affect the possible development of compassion fatigue. Compassion fatigue is seen as the negative aspect of helping (Stamm, 2009). According to the model, if the nurse has CF, this can lead to exhaustion and frustration. These feelings can then lead to the nurse becoming depressed and or distressed by being at work. The model indicates that there is a relationship between being traumatized at work and compassion fatigue. There are two types of traumatic exposures, primary and secondary. Primary would be the direct target of a traumatic event. An example of a secondary traumatic event exposure would be the nurse caring for the trauma patient whom just arrived at the trauma bay.

17 COMPASSION FATIGUE AND TRAUMA NURSING 17 Figure 1. Stamm s model of Compassion Fatigue and Compassion Satisfaction Figure 1. Theoretical Model of Compassion Satisfaction and Compassion Fatigue

18 COMPASSION FATIGUE AND TRAUMA NURSING 18 Summary The relationship between Stamm s Compassion Fatigue and Compassion Satisfaction model with the variables is as follows: Age, gender, marital status and religious beliefs, and nursing certification all fall within the Personal Environment section of the model. Years of nursing experience, years of trauma nursing and hours worked each week will fall under the work Environment section of the model. The variables of exposure to caring for patients who experience purposeful and accidental trauma pertain to the Client/person Helped Environment The review of the literature indicates how detrimental compassion fatigue can be on a nurse s work life. However, more trauma nurses have a higher instance of compassion satisfaction verses compassion fatigue. As for a correlation between compassion fatigue and exposure to types of trauma, there was no research previously done at this given time.

19 COMPASSION FATIGUE AND TRAUMA NURSING 19 Chapter Three: Methodology As previously stated there has been some research on the correlation between compassion fatigue and trauma nursing. There is a gap in the research of a correlation between compassion fatigue and exposure to different types of trauma. According to the literature review, many different instruments have been used to collect and measure data from various sample sizes. This chapter will review instruments that will be used, as well as research design, sample size and bias. Research Question Is there a correlation between compassion fatigue and exposure to different types of trauma? Research Design For this study, a cross-sectional design was implemented with the intent to explain if there is a correlation between compassion fatigue in nurses and exposure to different types of trauma patients. An online survey approach was used to collect selfreported information on trauma nurses demographics, and administration of the ProQol V. Population and Sample Size Participants were recruited using a convenience sample methodology from a large metropolitan hospital in San Diego, California. Nurses who work in the trauma and Surgical ICU were invited to partake in this study. Prior approval to approach the nursing staff in the Surgical ICU was received from the administrators for the Surgical ICU and trauma unit. The target population included 150 trauma and surgical ICU

20 COMPASSION FATIGUE AND TRAUMA NURSING 20 nurses. All employed nurses within this unit are over the age 18 and are proficient in English. The required sample size was calculated to be 42 out of the 150 nurses currently employed at the studied hospital in order to achieve a power of G-Power was used to obtain the calculated sample size (n=42). An exact test family was used, and a two tailed bivariate correlation normal model was chosen from G-Power (Appendix B). The literature review help to determine the effect size of 0.42 (Hinderer, 2014) and a significance level of 0.5. Figure 2. G-Power Plot Measurement Methods An online survey through Qualtrics was given to the participants. It covered the following demographic areas; age, gender, marital status, religion and spirituality, nursing certificate, years working in the nursing profession, years working as a trauma nurse, hours worked per week, exposure to caring for a patient with accidental trauma

21 COMPASSION FATIGUE AND TRAUMA NURSING 21 with in the last 30 days, and exposure to caring for a patient with purposeful trauma in the last 30 days. In addition to a demographic survey, the Professional Quality of Life Version 5 (Stamm, 2009) was also provided online for the participants. This instrument has good construct validity and has been used in a couple hundred papers. Stamm s (2010) reported psychometric properties with an alpha reliability ranging from 0.84 to 0.90, using the three different categories of compassion fatigue, compassion satisfaction, and burn out xix. This study focused on the information obtained from the survey in regards to compassion fatigue. Stamm (2009) also reported the following The inter scale correlations show 2% shared variance (r=.23;co σ =5%; n=1187) with Secondary Traumatic Stress and 5% shared variance(r=..14;co σ =2%;n=1187) with Burnout. While there is shared variance between Burnout and Secondary Traumatic Stress the two scales measure different constructs with the shared variance likely reflecting the distress that is common to both conditions. The shared variance between these two scales is 34% (r=.58;;co σ =34% ;n=1187) (Stamm, 2009). The ProQOL was first created and used in 1995, since then the survey has been revised and is currently in its fifth version. The instrument was created to measure three different sections, compassion fatigue, compassion satisfaction, and burn out (Stamm, 2010). The survey consists of a 30 item self-reported survey using a Likert five point scale for scoring, 1=never to 5= very often. A score ranging from 23-41indicates an average level of compassion fatigue. A score greater than 42, indicated a very high level of compassion fatigue (Hunsaker et al., 2015). According to Journal of Nursing Scholarship, the Cronbach alpha to measure internal consistency and reliability was 0.79

22 COMPASSION FATIGUE AND TRAUMA NURSING 22 for the CF subscale. Permission from the author was requested and general permission via the website was given. Data Collection Process IRB approval was obtained prior to beginning data collection (Appendix A). Institutional Review Board (IRB) approval was requested to complete an online survey with informed consent (Appendix B) as the first page of the survey. The manager of the unit was contacted (Appendix C) and gave permission to involve her staff in this study. The study was distributed via employee (Appendix D). The demographics and ProQOl survey (Stamm, 2010) were both included within the electronic survey. The online demographic portion of the survey covered age, sex, marital status, religious practices, nursing certification, years working as a registered nurse, years working with trauma patients, hours worked per week in trauma bay or surgical icu, how many patients the participant has cared for in the last 30 days who were injured either by accidental trauma, purposeful trauma to self, or was purposefully injured by another. The demographic factors listed are commonly included in other research studies and used to describe the populations being studied but have not been separately evaluated as to determine if there is a relationship between the demographic factors and compassion fatigue in regards to exposure to different types of trauma. Coding and Scoring The ProQol V. 5 has three different categories; Compassion Satisfaction, Burn Out and Compassion Fatigue. As mentioned previously, this study will focus on compassion fatigue, therefore the scoring was based on the average compassion fatigue score. This average is based on questions 13, 16, 1, 20, 22, 24, 25, 34, 36, and 39. Depending on how the participant answers each question determine the value of each

23 COMPASSION FATIGUE AND TRAUMA NURSING 23 question. The total values of each of the above-mentioned questions is added together to determine CF score. A low CF score is 22 or less, an average CF score is between 23 and 41, and a high CF score is 42 or more. Data Analysis After all data were collected, it was placed into Statistical Package for the Social Science (SPSS). Descriptive statics were using SPSS. Three chi square tests were completed to determine if there is a relationship between compassion fatigue and exposure to accidental trauma, purposeful trauma to self and purposeful trauma by another was completed. Next t-tests were completed comparing the mean CF score for religion, marital status, and nurse certificate status. Statistical significance was measure using an alpha level of 0.05 xx. A Pearson Correlation was completed to see if there is a relationship between CF and age, years working as a nurse, years working with trauma patients, and hours worked per week. Bias One particular bias for this study is the possibility of the Hawthorne Affect. Since participants will know that they are part of a research study on compassion fatigue, this could affect how they answer questions on the online survey. Another bias to be aware of is memory bias. Some participants may not accurately answer some of the demographic questions because time has lapsed and therefore their answers may not be accurate.

24 COMPASSION FATIGUE AND TRAUMA NURSING 24 Summary Data was collected from 42 trauma and surgical ICU nurses. The participants took an online demographic and the ProQOL version V survey. This data collected was assessed using chi square tests to see if there is a relationship between exposure to trauma variables and compassion fatigue. This process was done by using SPSS to reach conclusions for this study. Biases were taken into consideration, such as the Hawthorn Affect and memory bias.

25 COMPASSION FATIGUE AND TRAUMA NURSING 25 Chapter Four: Results Chapter 4 provides results of the research questions Is there a correlation between compassion fatigue and exposure to different types of trauma? G-Power was used to obtain the estimated sample size (n=42). An exact test family was used, and a two-tailed bivariate correlation normal model was chosen from G- Power (Figure 2) with a power of The literature review help to determine the effect size of 0.42 (Hinderer, 2014) and a significance level of 0.5. The data was analyzed using IBM SPSS Statistics Software xxi for frequency, mean, median, mode, and distribution if needed. Three separate chi square tests were used to analyze if there is an association between compassion fatigue and exposure to caring for patients that were injured by accident, purposefully by self and purposefully by another. The average CF score was Next multiple t-tests were completed comparing the mean score of CF to see if there was a relationship between the mean CF score for spirituality, marital status, nurse certificate, and years working with trauma patients. A Pearson Correlation was used to see if there was an association between CF and age, years of nursing experience, years working as a trauma nurse, and hours worked per week in the SICU and or trauma bay. Sample The estimated sample size needed was 42. While 42 participants responded, one person did not complete the ProQOL questionnaire and had to be eliminated from the analysis. The Final Sample size was 41.

26 COMPASSION FATIGUE AND TRAUMA NURSING 26 All variables were examined for normality using mean, median, and mode. Study participants were described using frequency distribution. The majority of participants were female n=38 (90.5%) compared to males n=4 (9.5%). The majority of the participants were married or cohabitating n=28 (66.7%), followed by single n=12 (28.6%), and separated/divorced n=2 (4.8%). The total of participants who follow a religious or spiritual practice was n=25 (59.5%) compared to those who answered no n=17 (40.5%). The majority of the participants answered yes to having some type of nursing certificate n=27 (64.3%) and those who answered no n=15 (35.7%). The participants frequently worked 36 hours per week on either the SICU or directly in the trauma bay n=23 (54.8%). Other participants worked 18 hours per week n=1 (2.4%), 20 hours per week n=1 (2.4%), 24 hours per week n=2 (4.8%), 30 hours per week n=2 (4.8%), 38 hours per week n=2 (4.8%), 40 hours per week n=7, (16.7%), and 42 hours per week n=2 (4.8%). The mean average of hours worked per week was hours with a standard deviation of According to Table 1, the largest number of nurses who cared for more than 20 trauma patients who were injured by accident in the last 30 days was n=14 (33.3%), those who cared for patients within this category was n=8 (19%), accidental trauma patients n=9 (21.4%), 6-11 n=6 (14.3%) and lastly 0-5 n=4 (9.5%).

27 COMPASSION FATIGUE AND TRAUMA NURSING 27 Table 1 Frequency of Nurses who Cared for Patients in the Last 30 Days Who were Injured by Accident Frequency Percent Valid % Cumulative Valid > than Total Missing System Total Per Table 2, the majority of the participants cared for 0-5 patients that were purposefully injured by self in the last 30 days n=37 (88.1%), the second highest amount of patients that were cared for by the nurses within this category was 6-11 patients n=3 (7.1%), and lastly had a frequency of n=1 (2.4%).

28 COMPASSION FATIGUE AND TRAUMA NURSING 28 Table 2 Frequency of Nurses who Cared for Patients in the Last 30 Days Who Purposefully Injured Themselves by Self Frequency Percent Valid % Cumulative % Valid Total Missing System Total Table 3 indicates the majority of nurses cared for 0-5 patients in the last 30 days who were injured purposefully by self n=27 (64.3%), those who cared for 6-11 patients within the 30 days n=10 (23.8%), patients cared for n=2 (4.8%), and n=2 (4.8%).

29 COMPASSION FATIGUE AND TRAUMA NURSING 29 Table 3 Frequency of Nurses who Cared for Patients in the Last 30 Days Who Were Purposefully Injured by Another Frequency Percent Valid % Cumulative % Valid Total Missing System Total Mean values of age in years of the participants (42.79 years), years of nursing experience as a registered nurse (17.40 years), number of years working with trauma patients with in the trauma bay or SICU (12.40 years), and hours worked per week in the SICU or trauma bay (33.90 hours) can be found in Table 4.

30 COMPASSION FATIGUE AND TRAUMA NURSING 30 Table 4 RN Experience Table N MINIMUM MAXIMUM MEAN STD. DEVIATION AGE YEARS OF RN EXPERIENCE YEARS OF RN TRAUMA EXPERIENCE HOURS WORKED PER WEEK VALID N 41 Data Collection and Preparation After two weeks of data collection, the survey was closed to new input. The data were exported from Qualtrics directly into SPSS 20 for analysis. The data were doublechecked to rule out any mistakes or flaws and to ensure accuracy. Once integrity was determined, data analysis was completed. Instruments As mentioned under Measurements and Methods section, the ProQol V. 5 instrument has good construct validity. The overall Cronbach s alpha reliability ranging from 0.84 to 0.90 (Stamm, 2010), using the three different categories of compassion fatigue, compassion satisfaction, and burn out (Hunsaker et al., 2015). This study focused

31 COMPASSION FATIGUE AND TRAUMA NURSING 31 on compassion fatigue and the Cronbach alpha to measure internal consistency and reliability was 0.79 for the CF subscale in the ProQol V. 5. Results by Research Question The research question was Is there a correlation between compassion fatigue and exposure to different types of trauma. The dependent variable (CF total score) examined and the mean was (Figure 3). Figure 3. Compassion Fatigue Score

32 COMPASSION FATIGUE AND TRAUMA NURSING 32 The first Chi Square test that was completed was to see if there was a correlation between compassion fatigue and caring for patients who were injured by accidental trauma. This test indicated that there is no correlation between compassion fatigue and caring for a patient injured by accidental trauma (Table 5). Table 5 Chi Square Analysis for Accidental Trauma Value Df Asymp. Sig. (2-sided) Pearson Chi-Square a Likelihood Ratio Linear-by-Linear Association N of Valid Cases 41 *Critical value is The second Chi-Square test that was completed was to see if there was a relationship between compassion fatigue and caring for patients who purposefully injured themselves (Table 6). This test showed that there is no relationship between compassion fatigue and caring for someone who purposefully injured themselves.

33 COMPASSION FATIGUE AND TRAUMA NURSING 33 Table 6 Chi Square Analysis for Purposeful Trauma to Self Value Df Asymp. Sig. (2-sided) Pearson Chi-Square a Likelihood Ratio Linear-by-Linear Association N of Valid Cases 41 *Critical Value of 9.49 The third Chi-Square test performed was to see if there was a relationship between compassion fatigue and caring for a patient who was purposefully injured by another (Table 7). This test showed that there is no relationship between compassion fatigue and caring for patients whom were purposefully injured by another. Table 7 Chi Square Analysis for Purposeful Trauma by Another Value DF Asymp. Sig. (2-sided) Pearson Chi-Square a Likelihood Ratio Linear-by-Linear Association N of Valid Cases 41 *Critical Value of 12.49

34 COMPASSION FATIGUE AND TRAUMA NURSING 34 T-tests were completed to see if there is a relationship between some of the demographic variables and having compassion fatigue. The first independent variable was whether a nurse had a nursing certification or not. Assuming all variances are equal the F score was with a significance of 0.708, a t score of and degrees of freedom (df) of 39, Sig. (2-tailed) of with a mean difference of and a standard error difference of Using a 95% confidence interval of the difference, the lower confidence interval is and upper was (Table 8). This test showed that there is no difference in CF score and having a nursing certification. Table 8 Independent Sample T Test for CF and Nursing Certification CF Questions Equal variances assumed Equal variances not assumed Levene's Test for Equality of Variances F Sig. T DF Sig. (2 - tailed) T-Test for Equality of Means Mean Difference SD 95% Confidence Interval of the Difference Lower Upper

35 COMPASSION FATIGUE AND TRAUMA NURSING 35 The second T-test completed was to see if there was a difference in CF score for those participants who did or did not follow a religious or spiritual practice. A Significance two tail of was shown, therefore this supports that there is no difference in compassion fatigue score for those who do or don t follow a particular religious or spiritual practice (Table 9). Table 9 Independent Sample T Test for CF and Religious Practice CF Questions Equal variances assumed Equal variances not assumed Levene's Test for Equality of Variances F Sig. T DF Sig. (2- tailed) t-test for Equality of Means Mean Difference Std. Error Differen ce 95% Confidence Interval of the Difference Lower Upper Another T-Test completed was to see if there was a difference in CF by marital status. The Significance two tailed was indicating that there is no difference in CF score by marital status (Table 10.).

36 COMPASSION FATIGUE AND TRAUMA NURSING 36 Table 10 Compassion Fatigue Score and Marital Status Equal variances assumed CF Questions Equal variances not assumed Levene's Test for Equality of Variances F Sig. T DF t-test for Equality of Means Sig. 95% Confidence Interval Mean Std. Error (2- of the Difference Difference Difference tailed) Lower Upper A Pearson correlation test was used to see if there was a correlation between CF and the numerical data placed which included age, years of nursing experience, years of trauma nursing experience, and hours worked per week in the SICU and or trauma bay. The only statistically significant correlation with CF was the negative correlation of CF decreasing as years of trauma nursing experience increased. All other correlations were not statistically significant (Table 11).

37 COMPASSION FATIGUE AND TRAUMA NURSING 37 Table 11 Pearson Correlation of Numeric Demographic Variables and CF Questions Total RN Years Trauma RN Years Hours Worked/ Week CF Questions Age CF Questions Pearson Correlation * Sig. (2-tailed) N Age Pearson Correlation **.788 ** Sig. (2-tailed) N Years of Nursing Pearson Experience Correlation ** ** Sig. (2-tailed) N Years of Trauma Nursing Pearson Experience Correlation *.788 **.847 ** Sig. (2-tailed) N Hours Worked Per Week Pearson Correlation Sig. (2-tailed) N *. Correlation is significant at the 0.05 level (2-tailed). **. Correlation is significant at the 0.01 level (2-tailed). Summary The three Chi-Square tests completed showed that there is no correlation between compassion fatigue and exposure to different types of trauma. The independent T-tests that were completed indicated that there is no correlation between CF and marital status, religious practice, and nursing certifications. However, a statistically significant negative correlation was found between CF and experience of years of trauma nursing by using a Pearson correlation analysis. Also, statistically positive correlations were found between age in years and years in nursing experience and years of trauma nursing experience.

38 COMPASSION FATIGUE AND TRAUMA NURSING 38 Chapter Five: Discussion Introduction According to the Chi-Square tests completed to there was no statistically significant correlation between compassion fatigue and exposure to different types of trauma, therefore the independent variables of the different types of trauma had no effect on the dependent variable of compassion fatigue. The rest of the independent variables such as age, sex, marital status, religious practice, nursing certification, years of nursing experience, and hours worked per week in the SICU or trauma bay had no statistically significant correlation to compassion fatigue. The only significant correlation was the negative correlation of compassion fatigue and years of experience working with trauma patients. Major Findings by Research Question The research question was Is there a correlation between compassion fatigue and exposure to different types of trauma? The data indicate that there is no correlation between a nurse having compassion fatigue and caring for a particular type of trauma patient effected by either accidental trauma, purposeful to self-trauma, and purposeful by other trauma. As for the demographic factors (independent variables), only years of experience working with trauma patients had a significant negative correlation. This showed that the longer one has worked as a trauma nurse the incidence of CF decreases. This may reflect that those who choose to continue working in this environment after so many years have developed effective coping mechanisms for dealing with this stressful work environment. This idea appears to be supported by the positive correlations between the number of

39 COMPASSION FATIGUE AND TRAUMA NURSING 39 years in nursing practice with the number of years of experience in trauma nursing. Furthermore, the strong positive correlation between nurses age and years in nursing practice and years in trauma may also reflect that older nurses, who have stayed in this area of practice, have developed coping mechanisms. Other Study Comparison Although there has been no other study that researched CF and exposure to different types of trauma. There have been other studies that researched critical care nurses and compassion fatigue and compassion satisfaction. One study was completed by Sacco, Ciurzynski, Harvey, & Ingersoll (2015) supported that the older the RN the less compassion fatigue was found. This is similar to the finding of this research study that showed the more experienced the trauma nurse was the less compassion fatigue they had. Sacco, Ciurzynski, Harvey, & Ingersoll suggest this finding could be contributed to older nurses have more work and life experiences and therefore possibly have better coping skills than their younger cohort (2015). Limitations Other demographic factors not listed in this study potentially could influence internal validity. There have been no other studies done like this one and limited studies done about compassion fatigue and trauma nursing that covered as broad of spectrum of the demographics covered in this study. There may be other specific demographic questions that could be used that could have statistical significance. A longitudinal repeat study is recommended to see if there is a change in the participants compassion fatigue level depending on a particular time of the year or what is occurring in the participants life in the moment while taking the survey. This design

40 COMPASSION FATIGUE AND TRAUMA NURSING 40 would increase reliability of the study. Lastly, a larger sample size would possibly allow statistical significance of some of the factors. Generalizability The research generalizability is limited to trauma nurses with similar demographic populations as the nurses from UCSD Medical Center s SICU and trauma. Implications for Nursing Research There is not sufficient evidence to change any policies or to design any interventions to reduce compassion fatigue of trauma nurses when it comes to caring for patients of the particular types of trauma researched within this study. This research adds to the body of knowledge of understanding that years of experience with trauma nursing has lower CF rates therefore interventions for less experience trauma nurses could be implemented to decrease their chance of experiencing compassion fatigue. Recommendations for Future Research As of writing this, there are no other studies that have been completed and published discussing a relationship between compassion fatigue and exposure to different types of trauma. Since there was a decrease in compassion fatigue with years of experience in trauma nursing, further studies could help identify why that is the case by doing a qualitative investigation on this particular subject. A qualitative study could help identify possible personality characteristics of those who are a good fit for trauma nursing and possibly stay in that particular nursing field longer. Therefore, management could use this information during their hiring process to help sustain nurses on their trauma unit. Completing the study with a larger sample size may elucidate more statistically significant relationships.

41 COMPASSION FATIGUE AND TRAUMA NURSING 41 Summary In conclusion, trauma nurses level of compassion fatigue is not associated with caring for patients with different types of trauma., but years of experience with in trauma nursing is associated with a decrease the incidence of compassion fatigue. In addition, other studies have shown that nurses who are more experienced in years appear to have less compassion fatigue. Further research is recommended to assess particular personality characteristics of nurses who tend to stay in the field longer and have statistically shown to have less compassion fatigue despite working in the nursing field for a more extended time compared to younger nurses.

42 COMPASSION FATIGUE AND TRAUMA NURSING 42 Appendix A UNIVERSITY OF CALIFORNIA, SAN DIEGO HUMAN RESEARCH PROTECTIONS PROGRAM TO: Dr. Cassandra Prewitt RE: Project # Compassion Fatigue and Trauma Nursing Dear Dr. Prewitt: The above-referenced project was reviewed and approved by one of this institution's Institutional Review Boards in accordance with the requirements of the Code of Federal Regulations on the Protection of Human Subjects (45 CFR 46 and 21 CFR 50 and 56), including its relevant Subparts. This approval, based on the degree of risk, is for 365 days from the date of IRB review and approval unless otherwise stated in this letter. The regulations require that continuing review be conducted on or before the 1-year anniversary date of the IRB approval, even though the research activity may not begin until sometime after the IRB has given approval. The Committee has reviewed this protocol in accordance with the guidelines on research involving pregnant women as research subjects and found that it meets the requirements as stated in 45 CFR Waiver of documented written consent has been granted for this study under CFR (c)(2) the research presents no more than minimal risk of harm to subjects and involves no procedures for which written consent is required outside the research for the survey portion of the study. Consent will be implied with the initiation and/or completion of the online survey after review of study information. The IRB determined that this project presents no more than minimal risk to human subjects in that the probability and magnitude of harm or discomfort anticipated in the research are not greater in and of themselves than those ordinarily encountered in daily life or during the performance of routine physical or psychological examinations or tests.

43 COMPASSION FATIGUE AND TRAUMA NURSING 43 Date of IRB review and approval: 12/12/2017 On behalf of the UCSD Institutional Review Boards, /mb Anthony Magit, M.D. Director UCSD Human Research Protections Program HRPP ( ); Note: IRB approval does not constitute funding or other institutional required approvals. Should your studies involve other review committees such as Office of Clinical Trials Administration (OCTA), Office of Coverage Analysis Administration (OCAA), Conflict of Interest (COI), Protocol Review Monitoring Committee (PRMC), and committees under Environmental Health & Safety (EH&S) such as Institutional Biosafety Committee (IBC), Human Exposure Committee (HERC), and RSSC (Radiation Safety and Surveillance Committee), it is the researchers responsibility to ensure that all approvals are in place prior to conducting research involving human subjects or their related specimens. Approval release date: 3/19/2018

44 COMPASSION FATIGUE AND TRAUMA NURSING 44 Appendix B Informed Consent University of California, San Diego Consent to Act as a Research Subject Compassion Fatigue and Trauma Nursing Who is conducting the study, why you have been asked to participate, how you were selected, and what is the approximate number of participants in the study? Cassandra Prewitt MSNc, RN, graduate nursing student and UCSD Health employee, is conducting a research study to find out more about the correlation between compassion fatigue and the effects of exposure to different types of trauma experienced by Trauma ICU nurses who care for patients at UCSD Medical Center. You have been asked to participate in this study because you are a Registered Nurse on the Surgical Intensive Care Unit at UCSD medical center who cares for various trauma patients. There will be approximately 75 participants at this site. This is the only site being researched at this time. Why is this study being done? The purpose of this study is to determine if there is a correlation between compassion fatigue and the effects of exposure to different types of trauma experienced by Trauma ICU nurses who care for patients at UCSD Medical Center. What will happen to you in this study and which procedures are standard of care and which are experimental? If you agree to be in this study, the following will happen to you: You will be sent an online survey to your work that will cover demographic information and the administration of the Professional Quality of Life version V (ProQOL V) survey will be included to measure professional compassion satisfaction and compassion fatigue. How much time will each study procedure take, what is your total time commitment, and how long will the study last? The survey is expected to last approximately 45 minutes and will be available for two weeks after the initial date of the being sent out. A reminder will be sent two weeks after the original to remind those to complete the study that hadn t already regardless if the person has participated in the study thus far or not. It s recommended to take the survey during your break or during non-working hours. By default, progress will be saved as you take the survey, so you can close the window and return to that same computer at a later date. What risks are associated with this study? Participation in this study may involve some added risks or discomforts. These include the following: