Predicting the Risk of Compassion Fatigue: An Empirical Study of Hospice Nurses By Maryann Abendroth, MSN, RN Executive Summary September 1, 2005 Compassion fatigue (CF), is a secondary traumatic stress reaction resulting from helping, or desiring to help, a person suffering from traumatic events (Figley, 1995). Caregivers experiencing CF may become preoccupied with their patients and develop symptoms/behaviors not conducive to optimal patient care. Caregivers may re-experience their patients trauma, and may exhibit symptoms of avoidance of reminders, numbing in response to reminders, anxiety, confusion, helplessness, and a sense of isolation from supporters (Figley, 2005). This clinical phenomenon has emerged as a topic of concern because it negatively can affect a caregiver s ability to provide services and maintain personal and professional relationships (Collins & Long, 2003). Ignoring the reality of this phenomenon may lead to higher turnover rates, loss of productivity, diminished public opinion, and increased fiduciary risk to organizations. Additionally, the acute effects of Compassion Fatigue may impair nurses physical, and mental health, and may contribute to tension, and strain outside of their work environment (Badger, 2001). Compassion fatigue has shown to be worthy of study in medicine, psychiatry, emergency management, and religious ministry; however, its effects on nursing, and more specifically, on the population of hospice nurses, is virtually unknown (Davis, 2003; Huggard, 2003; McCann & Pearlman, 1990; Roberts, Flannelly, Weaver, & Figley, 2003; Wastell, 2002). Background In April 2005, the author completed an empirical study of compassion fatigue risk among Florida s hospice nurses. The inquiry utilized descriptive and inferential statistics to accomplish two primary objectives: (1) an estimation of the prevalence of CF and Burnout risk among Florida s hospice nurses and (2) a determination of the demographic, work-related, and personal health factors which, when included in a multiple regression model, would best predict the risk of compassion fatigue. Study participants completed a demographic tool and a CF risk (ProQOL) behavioral assessment instrument (Stamm, 2002, 2005). All 40 not-for profit and for-profit hospice 1
organizations were queried for participation in the study. Seventeen not for-profit hospices initially agreed to participate in the study through mailed surveys. Nurses from an additional four not for-profit and one for-profit hospice participated through surveys completed during the State Hospice Symposium in December 2004, providing a 55% facility participation rate across the state of Florida. A response rate of 37% resulted from a total of 583 surveys distributed through the combined venues. The 37% (n = 216) response rate exceeded the minimally adequate sample size of 178 by 20%, and it exceeded the 20% average response rate for mailed surveys (Norwood, 2000). A final, stratified random sample of 216 usable instruments was returned from all 11 health-planning districts across the state giving the study results good generalizability. The demographic and work-related profile of the nurses in the study is shown in Table 1. Table 1 Demographic and work-related characteristics of hospice nurses (n =216) Age Gender Race Marital Status Education 51 yrs Female 94% Caucasian 82% Married 60% Associate 47% (median) Divorced 23% Bachelor s 21% Vocational 12% Licensure RN 85% LPN 13% Hospice Certifications Case load per week Nurse / patient ratio per shift 20% 13 patients 1 nurse to 6 patients Patient deaths per month 5 (median) Full time Years nursing Years hospice Work Setting employees experience experience 85% 20 (median) 4 (median) Field 60% Inpatient unit 23% Caseloads for this sample of nurses were higher than the national median hospice nurse case load (md = 10) as reported by the National Trend Summary Report for 2000-2003 (NHPCO, 2004). The nurse-to-patient ratios were higher in this study than the one-to-four ratios recommended by the Center to Advance Palliative Care (2002). Participants were asked personal health-related questions. Their responses were represented by the following: Diagnosed with depression and/or Post Traumatic Stress Disorder 22.2% (n = 48) Frequent headaches 28.2% (n = 61) 2
Diagnosed with hypertension 30.1% (n = 65) Had stress from personal finances 53.7% (n = 116) Had a tendency to sacrifice their own personal and psychological needs for their patients needs 63.8% (n = 136) Results Findings of the study revealed that nearly 80% of the sampled hospice nurses were at moderate-(52.3 %, n = 113) to-high (26.4%, n = 57) risk for compassion fatigue. The age of the participants in the low, moderate, and high risk categories showed little variability (Median low = 52, Median moderate = 51, Median high = 50). There was also very little difference among the groups with respect to nurses years of professional experience (Median low = 16, Median moderate = 20, Median high = 20) and years of hospice experience (Median low = 4, Median moderate = 4.5, Median high = 3.0). The Pro-QOL also measured burnout risk and provided percentile bands for Low, Moderate, and High risk classifications (see Table 2.0). Burnout is the physical, emotional, mental exhaustion caused by long term exposure to emotional demanding situations, and can be considered a precursor or risk factor for compassion fatigue. Symptoms of CF and burnout are similar; however, CF has a more sudden and acute onset, resulting from specific exposure to trauma and suffering (Figley, 1995, 2002). The results of the prevalence data indicated that Florida Hospice nurses are an at-risk population for burnout and compassion fatigue with 91% of those in the moderate-to-high risk category for burnout, being also classified moderate-to-high risk for compassion fatigue. Table 2 Burnout and Compassion Fatigue risk frequencies for Florida hospice nurses Low Risk Moderate to High Risk High Risk Burnout n = 84 38.9% n = 132 61.1% n = 22 10.2% Compassion Fatigue n = 46 21.3% n = 170 78.7% n = 57 26.4% An Ordinary Least Squares (OLS) multiple regression analysis was conducted utilizing variables obtained through a stepwise variable selection process. All variables (demographic, personal health, and work-related) were considered for inclusion with zero-order, as well as semi-partial correlations, being used as selection criteria. The final model included seven 3
independent variables accounting for 91% (p <.001) of the variance in CF risk. Trauma, anxiety, life demands, and excessive empathy (leading to blurred professional boundaries) were key determinants of CF risk. Additionally, several nurses wrote comments on their surveys reflecting the personal effects of stress which were revealed by examples such as, no relief when you have multiple deaths in a day or week, not recognizing the nurse needs time to refill the well. Implications This research has shown that hospice nurses are at a moderate-to-high risk for Compassion Fatigue. They experience, on average, five patient deaths per month, and must communicate compassionately and professionally with distraught families before, during, and after the dying process. Therefore, these nurses may be at risk for increased absenteeism, and an exodus from the profession resulting in lost revenue for the organization. The financial cost, and cost effectiveness, of having to train continually new hospice nurses may be easily measured and should be of concern to hospice organizations. More difficult to measure is the loss when an experienced hospice nurse leaves the profession. On average, hospice nurses have more than 20 years nursing and hospice nursing experience. These professionals have highly trained skills that encompass in-depth knowledge of complex symptoms of multiple diseases that affect the body, mind, and spirit. Not only is there a financial impact to the organization when they leave the profession, there is a huge loss of mentorship to newer nurses, as well as a loss of established relationships with physicians. This research has revealed also a theme of excessive empathy leading to blurred professional boundaries among the nurses. There have been cases of nurses crossing these boundaries by lending money to patients and performing other activities outside the realm of nursing care. This lack of professional behavior may, not only impact the nurse s career, but may prove to have deleterious fiduciary effects on the hospice organization, and a diminished reputation in the community. A precursory view of an organization may reveal that employees are cared for by one-day retreats, workshops, debriefing sessions, and accolades from patients and their families. These are appropriate temporary intervening measures; however, there is a need for an organizational 4
focus, utilizing a cohesive approach toward compassion fatigue (CF) and burnout prevention/intervention. Advanced Practice Nurses (APNs) may play a key role in CF risk assessment, employee yearly evaluations, supervisory training, hiring and retention policy development, intervention maintenance, and outcome evaluation coordinated through interdisciplinary teams and educational directors. Many organizations utilize APNs as directors of education, managers, and administrators. Compassion fatigue is a preventable and treatable phenomenon. Hospice organizations with policies, interventions, and evaluation methodologies that address CF risk may result in substantial employee benefit cost savings, uninterrupted professional nursing care, increased patient family satisfaction, and may continue to be regarded highly in communities as an optimal choice in end-of-life care. 5
References Badger, J.M. (2001). Understanding secondary traumatic stress. American Journal of Nursing, 101(7), 26-32. Collins, S., & Long, A. (2003). Too tired to care? The psychological effects of working with trauma. Journal of Psychiatric and Mental Health Nursing, 10, 17-23. Center to Advance Palliative Care (2002). CAPC Manual: Acuity. Retrieved March 2005 from http://64.85.16.230/educate/content/elements/inpatientunitacuity.html Davis, S. (2003). Can caregivers care too much? Studies assess relatively new condition known as compassion fatigue that can emotionally drain benevolent practitioner. DVM Newsmagazine, 34(8), 58-59. Figley, C.R. (Ed.) (1995). Compassion fatigue : Coping with secondary traumatic stress disorder in those who treat the traumatized. New York: Brunner/Mazel. Figley, C.R. (2002). Compassion fatigue: Psychotherapists chronic lack of self care. JCLP/In Session: Psychotherapy in Practice, 58(11), 1433-1441. Huggard, P. (2003). Compassion fatigue: how much can I give?. Medical Education. 37, 163-164. McCann, L., & Pearlman, L.A. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3(1), 131-149. National Hospice and Palliative Care Organization (2004). National Trend Summary Report. Author. 1-24. Retrieved March 1, 2005 from http://www.nhpco.org/files/public/nds00_03trendsstats101904.pdf Norwood, S.J. (2000). Research strategies for advanced practice nurses. Upper Saddle River, NJ: Prentice Hall Health. Roberts, S.B., Flannelly, K.J., Weaver, A.J., & Figley, C.R. (2003). Compassion fatigue among chaplains, clergy, and other respondents after September 11 th. The Journal of Nervous and Mental Disease, 191(11), 756-758. Stamm, B.H. (2002). Research information on the ProQOL-CSF-R-III. Retrieved March 22, 2004 from http://www.isu.edu/~bhstamm/testsproqol_psychometric.htm Stamm, B.H. (2005). The ProQOL Manual. The professional quality of life scale: Compassion satisfaction, burnout, compassion fatigue/secondary trauma scales, 1-24. Retrieved March 18, 2005 from http://www.isu.edu/irh/documents/proqol/proqol_manual.pdf Wastell, C.A. Exposure to trauma: The long-term effects of suppressing emotional reactions. The Journal of Nervous and Mental Disease, 190(12), 839-845 6