Stress and Compassion Fatigue of Nurses on an International Service Trip: A Mixed-Methods Study

Saturday, 21 July 2018

Caroline Warren, BSN, RN, CHES
Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
Diana Lyn Baptiste, DNP, MSN, RN
Department of Acute and Chronic Care, Johns Hopkins University School of Nursing, Baltimore, MD, USA
Rebecca Wright, PhD, BSc (Hons), RN
Community and Public Health, Johns Hopkins School of Nursing, Baltimore,, MD, USA

Purpose: Nurses throughout the world are at risk for developing compassion fatigue from their frequent exposure to persistently difficult situations in patient-care settings. Even in the developed world’s hospital clinical settings with every available resource, the nursing staff cares for patients in high stress circumstances that can result in a despondent nurse who suffers from emotional and somatic symptoms including fatigue, resentment, and anxiety. There is limited research about USA nurses’ experiences working in lower middle income countries and the impact it may have on stress and compassion fatigue.

The phenomenon of compassion fatigue results from the repeated stress of a clinical setting and can have physical, emotional, and spiritual impact on nurses. Nurses often experience compassion fatigue while working with high risk populations in emergency, trauma, and critical care areas. Previous studies have reported that compassion fatigue and increased stress among nurses can lead to burnout, and negative outcomes for patients. The aim of this research is to establish a baseline stress, compassion satisfaction, burnout, and secondary trauma stress for a group of USA hospital-based nurses; and analyze their perceptions after exposure during a short-term peacetime international service experience in rural Nicaragua.

Methods: A descriptive, mixed methods study was conducted with a small group of nurses who were employed in the adult emergency department at a level-one urban academic medical center in the Northeastern region of the United States. We employed two valid instruments, the Holmes-Rahe Life Inventory prior to departure and the Professional Quality-of-Life Scale (ProQOL) before and after volunteering for a Non-Governmental Organization (NGO) in rural Nicaragua. A paired t-test was performed to determine differences between pre and post ProQOL scores. Holmes-Rahe Life Inventory scores were examined, reporting low, moderate, or high scores. A short open-ended qualitative questionnaire was used to examine nurses’ perceptions of their experience during the one-year follow-up, utilizing thematic analysis.

Results: Demographics for the (N=7) nurses was collected through surveys. Of the seven nurses, five actively worked in an emergency department, one in intensive care and one on a general medical floor. Education levels among nurses ranged from bachelor’s to master’s degree levels; five nurses having less than 5 years and two with more than 10 years of clinical nursing experience. The group consisted on one male and six females ranging from 18 to 54 years of age. The majority of participants (86%) had never traveled to a lower middle income country, nor have they ever participated in an international service experience.

Holmes-Rahe Life Inventory scores (N=7) were highest among two nurses who reported difficult events such as a death of a close family member, change in responsibilities at work, or changing their line of work within the previous year. Lower Holmes-Rahe Life Inventory scores (<150) among three nurses were attributed to life events related to changing to a new school, change in living conditions, a major change in social habits, or changing their dressing or eating habits within the last year. Moderate scores (150-300) among four nurses reflect a 50% chance of health breakdown. None of the participants achieved higher scores (>300) which reflect higher levels of stress and an 80% chance of health breakdown.

ProQol scores were analyzed for (N=6) nurses who responded at the baseline and follow-up period. There was no significant difference in the pre and post mean scores within the three categories of compassion satisfaction, burnout, and secondary trauma stress.

We used simple qualitative questions to explore the nurses’ reflections about the international service trip and perceptions about how their role may have changed after the experience. Six nurses provided qualitative responses one year after the trip. We identified several themes that emerged from the evaluation. When asked about their reflections for the trip, nurses responses were thematically focused on 1) learning about new culture, 2) they found the experience enjoyable or fulfilling and, 3) concerns about making a sustainable difference among the population. When asked about how the international service trip impacted their current job or role, the following themes emerged: 1) increased consciousness or knowledge about vulnerable populations and, 2) improved sense of cultural competence

Conclusion: Our data suggests that nurses who travel to lower middle income countries may already have a moderate level of stress and varied interpretation of perceived quality of life. Nurses traveling to lower middle income countries for medical missions, service trips, and working with NGOs to must consider how compassion fatigue and levels of stress can have an impact on their current nursing practice within their clinical settings and when they are volunteering abroad. All nurses should be provided the opportunity to reflect on their own stress levels and perceived quality-of-life prior to departure. Further investigation is necessary to explore correlations between the Holmes-Rahe Life Inventory and ProQOL scores.