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4 strategies to boost resilience of staff and improve patient care

By Parveena Mann, Kendra L. Rieger, & Barbara Astle
September 26, 2022

Understanding compassion fatigue is crucial given all that clinical nurses may endure during a global pandemic. The World Health Organization (WHO) declared 2020 to be the international year of the nurse and midwife — yet no one could have predicted what that year would hold.

In March 2020, WHO (2020) declared the novel COVID-19 outbreak a global pandemic, leading to abrupt changes in how nurses provided care. As nurses working during the pandemic, we can recall experiencing marked stress and fear as we learned more about this virus every day.

Nurses and other workers in direct care were experiencing challenges related to unknowingly contracting and spreading the virus, issues related to inadequate personal protective equipment (PPE), frequent policy and procedural changes, and isolation from family and friends.

In a recent survey, Statistics Canada reported that 70 per cent of health-care workers reported lower or worsening self-perceived mental health during the COVID-19 pandemic. While it is evident that nurses are more vulnerable — now more than ever — to developing various psychological disorders, it is reported that these issues are often overlooked, underreported, or unacknowledged in the workplace (Kelly, 2020).

To ensure the health and well-being of nurses who are providing direct care during this global pandemic, or those who are dealing with its after-effects such as addressing delayed care, awareness of compassion fatigue and evidence-based strategies to mitigate its detrimental effects are essential.

What is compassion fatigue?

Nurses are reported to be at a significantly higher risk of developing psychological conditions, such as compassion fatigue, owing to the empathetic and interprofessional nature of the nursing profession (Kelly, 2020).

The term “compassion fatigue” first emerged three decades ago and was considered a consequence of work-related stress among nurses and other allied health-care professionals (Xie et al., 2020). This term, however, has been redefined and is often referred to as the “cost of caring for others or their emotional pain, resulting from the desire to relieve the suffering of others” (Ruiz-Fernandez et al., 2020, p. 4322).

Understanding compassion fatigue is crucial

More specifically, compassion fatigue has been defined as the “acute loss of emotional and physical energy toward the self and work, with a hindered ability to provide compassionate care for patients experiencing suffering” (Sullivan et al., 2019, p. 338).

Compassion fatigue has detrimental effects on nurses’ physical, mental, spiritual, and emotional well-being; it also influences the quality of care that patients receive. Most nurses likely find it disconcerting that “the high risk of [compassion fatigue] ranges from 28.57% to 44.8% among psychiatric nurses,” echoing its high prevalence within the nursing profession (as cited by Xie et al., 2020, p. 1).

Nurses who are at a higher risk of developing compassion fatigue include those who have experienced past traumatic patient encounters, unclear emotional boundaries with patients, inadequate managerial support, limited self-care strategies, and having fewer than five years of clinical practice experience (Berger et al., 2015; Ruiz-Fernandez et al., 2020).

It is clear that compassion fatigue is prevalent among nurses and can have detrimental impacts on practice, yet it is not often discussed or even acknowledged.

Evidence-based strategies to mitigate the effects of compassion fatigue

While it is imperative for nurses to understand the concept of compassion fatigue and to be able to identify its common symptoms, it is even more vital for them to understand various evidence-based strategies that they can employ to reduce its occurrence and impact.

Nurses must be able to take action and diligently combat the effects of compassion fatigue. However, for long-term and lasting changes to occur, there needs to be systemic change at the micro, meso, and macro levels.

Fundamental structural issues — such as health-care funding, adequate nurse-to-patient ratios, safe work environments, and additional funding for nursing education — need to be addressed in order for the rate of compassion fatigue among nurses to decrease, as opposed to solely combating its effects. Only then will nurses be able to work in a genuinely healthy workplace environment, and therefore be less susceptible to developing compassion fatigue. Scholars have also identified various evidence-based strategies that individual nurses can employ in their everyday lives to reduce the implications of compassion fatigue and to promote their own resilience. These evidence-based strategies include:

• Practise positive self-care strategies and coping skills. These may include routinely engaging in beneficial hobbies and activities, such as exercise, yoga, journaling, and arts and crafts. It is also imperative to maintain a healthy support system and prioritize a work-life balance (Berger et al., 2015; Finley & Sheppard, 2017; Flarity et al., 2016). In addition, it is important to participate in various educational opportunities specifically related to maintaining one’s own mental health and well-being (Flarity et al., 2016; Sullivan et al., 2019). These may include engaging in seminars and workshops aimed at fostering nurses’ mental health by providing education on various topics and introducing stress management techniques.
• Engage in meditation and mindfulness activities. Some scholars found that certain mindfulness interventions increased levels of compassion satisfaction and lowered compassion fatigue scores (Delaney, 2018; Duarte & Pinto-Gouveia, 2016). These findings indicate that engaging in mindfulness activities may be significantly beneficial to nurses’ overall health and well-being. Mindfulness activities may range from a few minutes of deep breathing to intentionally practising mindfulness during an activity, such as hand washing. Regardless of the mindfulness activity, it is important to remain present in the moment and to focus solely on the physical sensations of the activity you are engaging in — only then can you practise true mindfulness.

In addition to the strategies that nurses may independently employ themselves, scholars have also identified specific actions that managers may use to further support nurses’ well-being, and ultimately mitigate the effects of compassion fatigue. These evidence-based strategies include:

• Introduce educational opportunities that focus on strategies to cope with the realities of nursing and stress management. Several scholars found that educational workshops on compassion fatigue were beneficial for nurses, as these improved their compassion satisfaction, increased their knowledge and awareness of this condition, and increased their understanding of evidence-informed strategies that eventually improved their burnout scores over time (Flarity et al., 2016; Sullivan et al., 2019). It is recommended that educational workshops specifically aimed at increasing awareness of compassion fatigue be routinely incorporated in the workplace not only for existing staff, but also for new graduate nurses during their orientation.
• Prioritize making existing resources and supports related to nurses’ well-being and mental health easily accessible and readily available to staff. These resources may include discussing and promoting existing counseling services, employee benefits, and contact information for various supportive services. As previously mentioned, despite the fact that compassion fatigue is highly prevalent within the nursing profession, it is often overlooked and unacknowledged in the workplace. Therefore, prioritizing staff’s awareness of existing supportive resources may initiate the conversation toward promoting nurses’ mental health (Kelly, 2020). 

Compassion fatigue may significantly affect nurses’ physical, emotional, and spiritual health.

Implications and conclusion

Nurses are often exposed to their patients’ past traumatic experiences, distressing or violent encounters with patients, and increasingly substantial workloads — making them vulnerable and susceptible to developing compassion fatigue. Over the past two years, nurses have experienced new challenges due to the global pandemic — leaving them in exceptional situations, where they are confronted with “far-reaching ethical and moral decisions,” causing them to be even more vulnerable and susceptible to psychological distress (Ruiz-Fernandez et al., 2020, p. 4322).

Based on the additional stressors that nurses are now experiencing, it is imperative that they accurately comprehend the concept of compassion fatigue, are able to identify early signs of this condition, and are also able to take action and engage in evidence-based strategies to reduce its severe implications. If we do not act, both nurses and patients will be at risk.

According to recent literature, compassion fatigue may significantly affect nurses’ physical, emotional, and spiritual health, and therefore have resulting detrimental implications for nursing practice, patients, and the overall public. For example, it has been reported that compassion fatigue may lead to increased rates of nurse burnout, staff turnover, and decreased productivity in the clinical setting (Berger et al., 2015).

In addition to the direct impact that compassion fatigue may have on nurses, it may also lead to “deficient patient care, callousness and indifference toward patients and co-workers, medical errors, poor patient outcomes and low patient satisfaction,” clearly highlighting the severe implications of compassion fatigue on the overall well-being of nurses, the quality of care patients receive, and organizational costs (Berger et al., 2015, p. 12).

Researchers have found that the implementation of evidence-based strategies — whether it be participating in a mindfulness activity or attending an educational workshop on self-care interventions — assists nurses in reducing their levels of psychological distress, as well as increasing their compassion satisfaction scores (Delaney, 2018; Sullivan et al., 2019). Multi-level-based strategies are needed that target personal, interpersonal, and structural concerns.

Although personal strategies, such as those listed above, are crucial, it is also important for managers to develop a supportive and positive work environment that prioritizes the health and well-being of their staff.

The implementation of these evidence-informed strategies would be vastly beneficial to nurses, but it would also improve the quality of care patients receive, reduce the overall nurse attrition rate, and lead to a more positive work environment.

A recent study found that the increased level of mental health symptoms among nurses during the COVID-19 pandemic may have a vast impact on the quality of care that patients receive, indicating the need for introducing new health-care policies aimed at preventing, detecting, and treating mental health issues within the profession (Havaei et al., 2022). These findings further highlight the positive impact that addressing mental health concerns, such as compassion fatigue, may have on the quality of care patients receive and the overall safety of the public.

References

Berger, J., Polivka, B., Smoot, E.A., & Owens, H. (2015). Compassion fatigue in pediatric nurses. Journal of Pediatric Nursing, 30(6), 11–17. doi:0.1016/j.pedn.2015.02.005

Delaney, M.C. (2018). Caring for the caregivers: Evaluation of the effect of an eight-week pilot mindful self-compassion (MSC) training program on nurses’ compassion fatigue and resilience. PloS One, 13(11). doi:10.1371/journal.pone.0207261

Duarte, J., & Pinto-Gouveia, J. (2016). Effectiveness of a mindfulness-based intervention on oncology nurses’ burnout and compassion fatigue symptoms: A non-randomized study. International Journal of Nursing Studies, 64, 98–107. doi:10.1016/j.ijnurstu.2016.10.002

Finley, B.A., & Sheppard, K.G. (2017). Compassion fatigue: Exploring early-career oncology nurses’ experiences. Clinical Journal of Oncology Nursing, 21(3), E61–E66. doi:10.1188/17.CJON.E61-E66

Flarity, K., Nash, K., Jones, W., & Steinbruner, D. (2016). Intervening to improve compassion fatigue resiliency in forensic nurses. Advanced Emergency Nursing Journal, 38(2), 147–156. doi:10.1097/TME.0000000000000101

Havaei, F., Tang, X., Smith, P., Boamah, S.A., & Frankfurter, C. (2022). The association between mental health symptoms and quality and safety of patient care before and during COVID-19 among Canadian nurses. Healthcare, 10(2), 314. doi: 10.3390/healthcare10020314

Kelly, L. (2020). Burnout, compassion fatigue, and secondary trauma in nurses: Recognizing the occupational phenomenon and personal consequences of caregiving. Critical Care Nurse, 43(1), 73–80. doi:10.1097/CNQ.0000000000000293

Ruiz-Fernandez, M.D., Ramos-Pichardo, J.D., Ibanez-Masero, O., Cabrera-Troya, J., Carmona-Rega, M.I., & Ortega-Galan, A.M. (2020). Compassion fatigue, burnout, compassion satisfaction and perceived stress in healthcare professionals during the COVID-19 health crisis in Spain. Journal of Clinical Nursing, 29, 4321–4330. doi:10.1111/jocn.15469

Sullivan, C.E., King, A.R., Holdiness, J., Durrell, J., Roberts, K.K., Spencer, C., Roberts, J. . . . Mandrell, B.N. (2019). Reducing compassion fatigue in inpatient pediatric oncology nurses. Oncology Nursing Forum, 46(3), 338–347. doi:10.1188/19.ONF.338-347

WHO. (2020). WHO director-general’s opening remarks at the media briefing on COVID19, 11 March 2020. World Health Organization. https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020

Xie, W., Wang, J., Okoli, C.T.C., He, H., Feng, F., Zhuang, L., Tang, P., . . . Jin, M. (2020). Prevalence and factors of compassion fatigue among Chinese psychiatric nurses: A cross-sectional study. Medicine, 99(29), e21083. doi:10.1097/MD.0000000000021083

Parveena Mann, RPN, MSN, is a staff nurse at Surrey Memorial Hospital.
Kendra L. Rieger, RN, PhD, is an associate professor at Trinity Western University and a Michael Smith Health Research BC Scholar.
Barbara Astle, RN, PhD, is a professor and director of the MSN program at Trinity Western University.

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