Compassion Fatigue Oncology Nursing

Compassion fatigue [CF] was initially described in the professional healthcare literature by Joinson in 1992 as a “loss of the ability to nurture” (Boyle, 2011). Since the initial conception, the concept of compassion fatigue has evolved (Coetzee & Klopper, 2010). Compassion fatigue can be identified in a variety of nursing care arenas. For the purpose of this literature review, compassion fatigue will refer to emotional, physical, and spiritual depletion resulting from the prolonged, repeated vicarious experiencing of suffering and pain that occurs during provision of care and that can result in a debilitating weariness and eventual emotional exhaustion (Aycock & Boyle, 2008; Cieslak, et al., 2013; Coetzee & Klopper, 2010; Melvin, 2015; Perry, Toffner, Merrick, & Dalton, 2011).

Particular attention has been focused on those nursing practice areas where patient suffering and loss are most paramount. Evidence in the literature supports these specific arenas. A systematic research analysis indicated the presence of compassion fatigue in forensic, emergency department, oncology, pediatric, and hospice nurses (Dominguez-Gomez & Rutledge, 2009). Most notably, emergency room nurses reported an experience rate of 85%. Additionally, Beck (2011) notes observed rates of 25% to 78% across seven studies that considered nurses in forensics, pediatrics, emergency medicine, hospice, intensive care unit [ICU]. Moreover, an investigation of hospice workers discovered that 78% of the nurses were classified as a moderate to high risk of experiencing compassion fatigue (Abendroth & Flannery, 2006). The nurse in the field of oncology, where patient suffering and loss is great, may therefore be particularly vulnerable to developing compassion fatigue, due to their repeated exposure to intense and protracted losses and resulting feelings of ineffectiveness, futility, and failure (Potter, et al., 2010; Najjar, Davis, Beck-Coon, & Doebbeling, 2009; Wenzel, Shaha, Klimmek, & Krumm, 2011).

According to Potter, et al., it is unclear how frequently compassion fatigue occurs among oncology nurses (2010). Therefore, the purpose of this literature review is to compile and evaluate the evidence regarding the prevalence of compassion fatigue among oncology nurses and examine potential self-care strategies that may facilitate prevention, reduction, and potential reversal of the negative impacts of compassion fatigue on nursing practice, effective delivery of care and resultant adverse patient care outcomes.

A study in 2010 concluded that roughly 86% of oncology, emergency, nephrology, and intensive care nurses indicated moderate to high levels of compassion fatigue, without any significant difference between the groups; however, oncology nurses demonstrated a higher risk for compassion fatigue (on a subscale) than the other specialty groups (Hooper, Craig, Janvrin, Wetsel, & Reimels, 2010).  Another study investigating the prevalence of compassion fatigue among oncology nurses concluded that 38% of the nurses manifested compassion fatigue (Melvin, 2015).  Though the specific estimates of prevalence of compassion fatigue vary, even the lowest estimates suggest that a substantial portion of oncological nurses do appear to be at risk of developing compassion fatigue. 

In regards to basic self-care strategies, the literature review revealed many practices that can be employed to combat compassion fatigue though the effectiveness of these strategies appears to be impacted by individual differences among nurses, such as professional experience, personal belief systems, personality type, etc.  In general, these strategies may be placed into two major categories: strategies employed by individuals or strategies engaged in collectively.

Multiple research studies demonstrate that routine engagement in basic self-care activities, such as exercise, nutritious eating, adequate rest, and healthy sleep habits can prevent compassion fatigue (Houck, 2014; Melvin, 2015). Similarly, relaxation and stress-reduction strategies, including breathing techniques, body movement meditation, art therapy, guided imagery, self-massage, and mindfulness-based-stress reduction [MSBR], are effective means to reduce adverse symptoms of compassion fatigue (Houck, 2014; Melvin, 2015; Sanchez, Valdez, & Johnson, 2014).  Appropriate boundary setting and assertiveness are also essential self-care skills for maintaining wellness and avoiding compassion fatigue (Melvin, 2015).  In addition, educational programs intended to develop or enhance coping strategies to manage stress, enhance interpersonal relations, and regulate emotions are beneficial (Aycock & Boyle, 2009; Houck, 2014; Melvin, 2015).  Engaging in professional and/or spiritual counseling are further means to facilitate caring for oneself and preventing compassions fatigue (Aycock & Boyle, 2009; Houck, 2014; Melvin, 2015; Sanchez, et al., 2014).  Moreover, nurses can benefit from participating in forms of play (such using a hula-hoop dancing) to promote positive moods, self-expression, and enhance personal wellbeing, thereby counteracting the deleterious effects of compassion fatigue (Sanchez, et al., 2014).  Finally, specifically-tailored social supports may contribute to decreased rates of compassion fatigue in oncology nurses through the management of loss and bereavement specific to patient care (Aycock & Boyle, 2009; Houck, 2014; Wenzel, et al., 2011). 

Aside from basic self-care strategies pursued by the individual nurse, there are other variables that have a significant impact on the development of compassion fatigue.  For instance, research demonstrates that team collaboration, organizational commitment, group cohesion, formal debriefing, and mentoring have an inverse correlation with compassion fatigue (Li, Early, Mahrer, Klaristenfeld, & Gold, 2014; Melvin, 2015; Wenzel, et al., 2011).  Moreover, personality traits, personal attitudes, interpersonal styles, and other internal factors may mitigate the deleterious effects associated with compassion fatigue (Melvin, 2015). 

Overall, the literature review highlights the complexities involved with potential prevention, development, and/or amelioration of compassion fatigue.  Although beneficial, self-care practices cannot entirely predict, prevent, or alleviate compassion fatigue alone.  The experience of compassion fatigue is a result of interplay between a unique set of internal states and external conditions.  Thus, the likelihood that a person experiences compassion fatigue is determined by the sum total influence of the effects of numerous variables. It is important to note, however, that risk factors such as the specific arena in which a nurse works can be offset in a probabilistic fashion by utilization of protective strategies such as those described above.           

In conclusion, this project highlights the need for increased awareness and training in regards to compassion fatigue, with an emphasis on protective self-care strategies.  Nurses need to be able recognize states associated with compassion fatigue within themselves and in peers.  They should understand the full extent and impact of this phenomenon, including which nurses are most at-risk and the necessity to seek early intervention should problems arise.  It is also critical that nurses routinely practice basic self-care activities, which include seeking social support. Organizations should consider creating opportunities to do so at a system level; thereby contributing to the improvement and alteration of organizational cultures.  This reflects the premises of Ray’s Theory of Bureaucratic Caring (Parker & Smith, 2015, pp. 461-482).

However, awareness, education, and encouragement to practice techniques known to reduce rates of compassion fatigues are not enough to eliminate the problem.  The literature review revealed that simply raising awareness about the importance of regular self-care practices, including emotional and psychologically interventions, and highlighting protective factors is not sufficient to combat compassion fatigue.  Identification of detrimental outcomes associated with compassion fatigue also fails to stimulate widespread change.  For nurses to realize the benefits of enacting this body of empirical evidence, they must take translate knowledge into action. 

To date, inadequate efforts have been made to address an encroaching epidemic of debilitating psychological and emotional distress among oncology nurses. Unfortunately, despite the evidence, there continues to be a collective failure among nurses to routinely practice appropriate methods of care for themselves. A radical shift in the collective mentality of nurses is necessary to bring about lasting change. Watson’s Theory of Human Caring needs to genuinely become a set of governing principles for managing personal and patient care behaviors and subsequent compassion for Self and Other.  The ultimate priority must be the nurse, without negotiation, because wounded caregivers are less able to facilitate healing in others.  Irresolute boundaries, lack of supports, overextensions, deficits in assertiveness, and “endlessly giving” compromise the core being of a nurse.  Without an unwavering commitment to the self as an instrument of beneficence that must be cared for to be effective, compassion fatigue will remain a risk for every nurse involved in patient care.

Moreover, devoted attention is needed to develop a theory that can adequately account for the complex nature of compassion fatigue, including the interaction of variables that influence overall outcomes.  Further research is need also needed to determine which methods are most effective at staving-off compassion fatigue as well as means to ensure interventions and/or self-care strategies have enduring effects.