The true prevalence of compassion fatigue (CF) among mental health nurses remains open for discussion. Working with mental health patients is full of stressful situations and a growing literature is suggesting burnout among mental health nurses. CF is defined as a state of psychological or physical stress condition among nurses or caregivers that occurs due to consequences of snowballing and ongoing process in demanding relationship with mental health patients (Mendes 2014). This condition is also defined as ‘helper syndrome’ resulting from disappointing situations that give rise to loss of compassion and moral distress. CF is defined to result from deep involvement with mentally ill patients leading to suffering during caring for them (van Mol et al. 2015). Complex demands made from mental health nurses while caring for dementia patients place extraordinary stress marketing them feel overburdened in their profession. This has serious implications as inability to deliver proper care for patients leading to compassion and increased number of nurse turnover (Kelly, Runge and Spencer 2015). Therefore, the above discussion highlights that CF is reaching an alarming stage and require implementation of strategies for prevention, identification and mitigation of CF among mental health nurses. Taking this into consideration, the following paper will discuss and contribute to the understanding of CF among mental health nurses and ways to prevent it. Moreover, the paper will also discuss best evidence based literature available on the chosen topic. The rationale for choosing this topic is that nurses are the largest and single member of healthcare providers who are at the frontlines of care delivery. In addition, mental health nurses provide care for serious mentally ill patients having complex needs. Therefore, to reduce burnout and ensure quality of care in mental health nursing, there is urgent need for CF mitigation to provide best quality of received care.
Mental health nurses forms a crucial part of psychiatric workforce-mental health speciality and their role in caring for dementia patients is exhausting both mentally and physically. Caring for dementia patients is extremely stressful as patients lack the ability to communicate and this result in difficulty to manage patients that give rise to work-related stress among mental health nurses. CF not only impact mental health nurses in psychiatric speciality due to caring for dementia patients, but also due to pain experiences of patients suffering from dementia (Franza, Del Buono and Pellegrino 2015). Figley explained that CF is experienced by individuals who see others in pain and distress (Sheppard 2015). Similarly, when mental health nurses view their patients suffering from dementia experiencing pain, they get traumatized via their efforts to show empathy and compassion. This is the reason CF is designated as secondary traumatic stress that results from caring for dementia patients suffering from emotional and physical stress or pain (Hinderer et al. 2014). Another triggering factor for CF among nurses is work environment (Hunsaker et al. 2015). Due to shortage of mental health nurses, workload and poor support make them helpless and they are unable to escape situation giving rise to workplace-related stress and CF. Intense involvement of mental health nurses with dementia patients gives rise to CF or psychological stress and impairment of provision of care given to them leading to poor care delivery and management.
As suggested in literature, one of the main effects of dementia is losing control and behavioural changes that are sudden and challenging for mental health nurses to manage (Mitchell et al. 2014). Moreover, there are challenges to hydration, adequate nutrition, sleep patterns and difficulties with motivation demanding high amount of care from mental health nurses leave them devastated and stressed being a significant factor hampering patient safety. To adhere to these demands of dementia care, mental health nurses face state of exhaustion with losing coping ability. Various triggering factors are witnessed in CF that includes physical, work-related and emotional symptoms. There is less empathy towards them and avoidance of working with dementia patients, restlessness, mood swings, irritability, anxiety, poor judgment, depression and loss of objectivity (Sheppard 2015). These consequences give rise to CF including hyper-vigilance, sleep disturbance, anxiety, fear, physical sensations like feeling burdened, difficulty in concentrating, overwhelmed with feelings of hopelessness and isolation resulting in disengagement and disconnectedness (Hegney et al. 2014). These conditions not only affect nurses in terms of physical or emotional health, but also their job satisfaction and workplace environment decreasing organizational productivity and increasing nursing turnover.
Various theoretical perspectives are related to CF. Watson theory of human caring states that empathy and communication advocates for empathetic relationship-based nursing that is defined to understand feelings and situations from patient’s perspective and communicating accordingly to gain understanding of patient’s condition (Yeter Durgun Ozan 2015). Another perceptive put forward by Koloroutis is that healthy relationship with patients can only be advocated, if nurse’s relationship with self is established (Fitzpatrick 2014). However, due to CF there are imbalances in personal relationship and work-life that becomes a significant factor in CP. Physical and emotional factors triggering CF is hampering their relationship with self and in optimizing their health resulting in failure to provide compassionate care and being a productive member of mental health workforce (Drury et al. 2014). The emotional investment that mental health nurses invest is overextended that challenge their ability to manage demands of being empathetic and compassionate towards patients with dementia (Sorenson et al. 2016). This is a serious issue impacting adversely and directly on the nurses’ psychology, psychical and emotional health. Although, professional nursing thrives to provide care and develop empathetic relationship with patients, this relationship is not possible that is contributing to CF requiring conscious steps to lessen or avoid this condition. Therefore, there is an urgency to develop understanding and create awareness among the healthcare system to mitigate CF among nurses and reduce burnout and turnover.
The primary role of nurses is to provide high quality of care and work towards meeting the physical and emotional needs of patients. This role becomes immensely rewarding and challenging for nurses especially in mental health speciality while caring for dementia patients. This is explained by Compassion Stress/Fatigue Model that this highly specialized type of work is greatly demanding and challenging for them creating increased and continuous stressful workplace conditions for them. Moreover, it also creates increasingly heavy workload and cynicism due to dwindling resources, lack of support from co-workers and management team resulting in low job satisfaction and eventually CF (Melvin 2015).
Vast pool of literature is present to describe CF as ‘cost of caring’ for patients suffering from physical and emotional pain. A report published by Hospital Healthcare Bulletin, Australia states that CF is recognized since 1970s is defined as combination of emotional, physical and spiritual depletion that is associated while caring for people in physical distress and emotional stress. The prevalence in Australia has increased from 25% to 70% among mental health professionals while caring for patients with mental health problems repeatedly experiencing trauma and pain (Hospital Health Bulletin 2018). According to Ledoux (2015) CF is characterized by deep emotional or physical exhaustion being a pronounced change in order to help patients and feel empathetic towards them.
According to Ray et al. (2013) frontline mental healthcare professionals (FMHPs) including nursing perform variety of roles in providing high quality of care to suffering from psychological and physical complaints like dementia that give rise to CF. The cross-sectional and non-experimental study conducted was aimed at determining CF among mental health professionals including nurses. Various factors contribute to CF like work life dissatisfaction, lack of support and trauma experienced while caring for mentally ill patients. High levels of compassion dissatisfaction and fatigue increase the chances of workplace stress among mental health nurses giving rise to high levels of nursing burnout and turnover.
According to Morse et al. (2012) due to increasing fatigue among mental health professionals, burnout is increasingly viewed rising as a major concern in the mental nursing speciality. As mentioned in literature, patients suffering from dementia are unable to communicate well and perform self-care activities and as a result, they are unable to raise their concerns and needs to nurses. They work beyond their limits, however resulting in reduced sense of personal accomplishment or self-efficacy to perform their work. There is deceased overall job dissatisfaction and negative self-evaluation leading to nursing burnout in mental healthcare. Although, burnout is related to mental health conditions like depression and anxiety, research support the fact that it is construct that greatly occur from stress reaction and job dissatisfaction. Secondary traumatisation or compassion fatigue is related to burnout where nurses are unable care for the patients.
According to Whitebird et al. (2013) nurses working in hospice care (acute and emergency care) impart challenging work to the nurses overwhelmed stress and heavy workload. This lead to CF, depression and anxiety among nurses also affecting their mental health and face issues in coping up. After surveying 547 workers in hospice care in Minnesota, it was found that there were high levels of stress among the nurses and medical staffs reporting moderate to severe anxiety, depression and CF leading to burnout. They reported that to manage their stress, they seek physical support and physical activity suggesting opportunities while connecting with co-workers in order to decrease nurse burnout. This risk their mental health conditions increasing risk for burnout contributing to nurses leaving hospice care.
Zeidner et al. (2013) in their paper stated that both professional and personal factors contribute to CF among healthcare professionals. About 89 mental healths and 93 medical healthcare professionals participated in the research for measuring CF. The major findings of the study suggested that emotional intelligence like motivation, social and communications skills, self-confidence, self-awareness, empathy and self-regulation are inversely proportional to CF. While working with mentally ill patients, nurses are unable to communicate well and show compassion and empathy towards them that results in de-motivation and unwillingness to work. This over-demanding need of high degree of care greatly affects nurses leading to anxiety, CF and in severe cases, leads to depression. Furthermore, nurses’ inability to cope with problem mediate CF rising from emotional intelligence affect their quality of life and forms basis for early identification of CF to decrease nursing burnout and turnover.
According to Coetzee and Klopper (2010) the phenomenon where nurses lose their nurturing power towards their patients in their nursing practice results in CF acting as risk factor. As there is scarce literature present in terms of CF in nursing practice, there is still increase in knowledge where workplace stress and inability to perform care towards patients can give rise to CF. Peer support network and seeking managerial assistance can help to reduce the detrimental effects of CF among mental health nursing workforce. Programs that help nurses and other healthcare professionals to seek skill-education and free counselling along with services offered to nurses can seek them opportunity to cope and prevent CF enhancing their quality of life and professional development.
From the above literature, it is evident that prolonged and frequent exposure of mental health nurses in mental ward settings providing care for mentally ill patients exposes them to fatigue and depression. While understanding the complex needs of mental ill patients and inability to provide care triggers CF among them leading to reduction in motivation, resilience and ability to work in their nursing speciality.
In order to mitigate CF arising due to inability to care for patients with dementia, it is important to understand CF and most importantly, work towards fulfilling the health literacy needs for older adult dementia patients. Health literacy and cognition is reduced in dementia patients due to reduced working memory processing and inability to remember and process new information resulting in loss of self control and changes in behavioural patterns. This is the reason that makes them forget specific details being unaware of time and situation due to poor information comprehension. Therefore, health literacy needs of dementia patients and communicating effectively with them can help to reduce stress due to lack of care resulting in CF (McCaffery et al. 2013).
Various approaches are available that can help nurses to care for dementia patients and recognize the early signs of fatigue and stress. As dementia patients have memory problems, it is quite mandatory to repeat the essential information to them so that there is proper processing of information and meaning. It is not necessary that all dementia patients have severe symptoms, moderate symptoms can also occur, so while communicating, nurses should focus on important personal details that can help to minimize their distractions. Apart from verbal communication, non-verbal communication is also important where nurses should execute gestures to show that one is truthful and listening to them. Non-verbal communication comprises of four different cues playing various roles; repetition as it helps to convey message effectively, substitution as eye contact and accurate body posture can help to make patients understand conveyed message, complementing that can help to make the patient feel concerned and accenting or highlighting the important message (De Vries 2013).
Communicating through directions is important for dementia patients emphasizing on desired actions help to boost their working memory, reducing confusion and in taking appropriate action when required. Empathetic relationship is important as it helps to build rapport and trustworthy relationship with patients. It is also important to use plain language and simple words to make them understand the conveyed message. In this way, it is quite beneficial for mental health nurses to focus on their actions that can be helpful to make patients feel valued and respected reducing aggression in them. Aggression comes with mental illness and inability to perform self-care activities and so nurses need to consider the early signs of fatigue and stress (McEvoy and Plant 2014).
Similarly, to mitigate CF among nurses and enhance their literacy needs, it is important for them to get engaged in self care strategies. The elements of self-care involve adequate sleep, well-balanced nutritious diet, mindfulness including exercise and learning to stay optimistic can help to prevent CF (Dereen Houck 2014). Stress relief strategies like running, walking, meditation, yoga and meditation can help nurses to stay motivated and have balanced workplace and personal life. Nurses can also accomplish to meet the personal and professional demands by taking an active part in relaxation exercises like journaling and deep breathing. These activities can greatly allow nurses to keep their feelings of stress and fatigue aside and be focus and committed towards providing care (Mosadeghrad 2013).
From the above discussion, it can be concluded that CF is reaching an alarming stage increasing nursing burnout and turnover. Nurses working in mental health specialty areas are prone to develop CF due to inability to perform care with compassion and empathy. The stress and polarity that is experienced by nurses conflict with their caring values holding high potential for distanced and compromised care. They suffer from poor judgment, feeling of hopelessness, anxiety, unwillingness to work, depression, anxiety and stress affecting quality of care delivered and hampering patient safety. The above discussion also highlights that challenges faced by nurses in mental health settings across globe demand urgent need for research and further development of effective strategies for addressing CF and understanding of factors contributing to it. Self-care strategies employed by nurses and addressing health literacy needs of dementia patients can help to develop caring environment and support them. Apart from this, CF also needs attention from management regarding evolving nursing expectations that can help to address their stress and increase attention focusing on nurses’ personal and professional development in holistic care in the future years.
Coetzee, S.K. and Klopper, H.C., 2010. Compassion fatigue within nursing practice: A concept analysis. Nursing & health sciences, 12(2), pp.235-243.
De Vries, K., 2013. Communicating with older people with dementia. Nursing older people, 25(4).
Dereen Houck, R.N., 2014. Helping nurses cope with grief and compassion fatigue: an educational intervention. Clinical journal of oncology nursing, 18(4), p.454.
Drury, V., Craigie, M., Francis, K., Aoun, S. and Hegney, D.G., 2014. Compassion satisfaction, compassion fatigue, anxiety, depression and stress in registered nurses in Australia: Phase 2 results. Journal of Nursing Management, 22(4), pp.519-531.
Fitzpatrick, J.J., 2014. Relationship based care and the psychiatric mental health nurse. Archives of psychiatric nursing, 28(4), p.223.
Franza, F., Del Buono, G. and Pellegrino, F., 2015. Psychiatric caregiver stress: clinical implications of compassion fatigue. Psychiatr Danub, 27(Suppl 1), pp.S321-7.
Hegney, D.G., Craigie, M., Hemsworth, D., Osseiran?Moisson, R., Aoun, S., Francis, K. and Drury, V., 2014. Compassion satisfaction, compassion fatigue, anxiety, depression and stress in registered nurses in Australia: study 1 results. Journal of Nursing Management, 22(4), pp.506-518.
Hinderer, K.A., VonRueden, K.T., Friedmann, E., McQuillan, K.A., Gilmore, R., Kramer, B. and Murray, M., 2014. Burnout, compassion fatigue, compassion satisfaction, and secondary traumatic stress in trauma nurses. Journal of Trauma Nursing, 21(4), pp.160-169.
hospitalhealth.com.au 2018. Compassion Fatigue: The Cost Of Caring. [online] Available at: https://www.hospitalhealth.com.au/content/aged-allied-health/article/compassion-fatigue-the-cost-of-caring-1376472314#axzz55vlsdsdo [Accessed 2 Feb. 2018].
Hunsaker, S., Chen, H.C., Maughan, D. and Heaston, S., 2015. Factors that influence the development of compassion fatigue, burnout, and compassion satisfaction in emergency department nurses. Journal of Nursing Scholarship, 47(2), pp.186-194.
Kelly, L., Runge, J. and Spencer, C., 2015. Predictors of compassion fatigue and compassion satisfaction in acute care nurses. Journal of Nursing Scholarship, 47(6), pp.522-528.
Ledoux, K., 2015. Understanding compassion fatigue: understanding compassion. Journal of advanced nursing, 71(9), pp.2041-2050.
McCaffery, K.J., Holmes-Rovner, M., Smith, S.K., Rovner, D., Nutbeam, D., Clayman, M.L., Kelly-Blake, K., Wolf, M.S. and Sheridan, S.L., 2013. Addressing health literacy in patient decision aids. BMC medical informatics and decision making, 13(2), p.S10.
McEvoy, P. and Plant, R., 2014. Dementia care: using empathic curiosity to establish the common ground that is necessary for meaningful communication. Journal of psychiatric and mental health nursing, 21(6), pp.477-482.
Melvin, C.S., 2015. Historical review in understanding burnout, professional compassion fatigue, and secondary traumatic stress disorder from a hospice and palliative nursing perspective. Journal of Hospice & Palliative Nursing, 17(1), pp.66-72.
Mendes, A., 2014. Recognising and combating compassion fatigue in nursing. British Journal of Nursing, 23(21), pp.1146-1146.
Mitchell, A.J., Beaumont, H., Ferguson, D., Yadegarfar, M. and Stubbs, B., 2014. Risk of dementia and mild cognitive impairment in older people with subjective memory complaints: meta?analysis. Acta Psychiatrica Scandinavica, 130(6), pp.439-451.
Morse, G., Salyers, M.P., Rollins, A.L., Monroe-DeVita, M. and Pfahler, C., 2012. Burnout in mental health services: A review of the problem and its remediation. Administration and Policy in Mental Health and Mental Health Services Research, 39(5), pp.341-352.
Mosadeghrad, A.M., 2013. Occupational stress and turnover intention: implications for nursing management. International journal of health policy and management, 1(2), p.169.
Ray, S.L., Wong, C., White, D. and Heaslip, K., 2013. Compassion satisfaction, compassion fatigue, work life conditions, and burnout among frontline mental health care professionals. Traumatology, 19(4), pp.255-267.
Sheppard, K., 2015. Compassion fatigue among registered nurses: Connecting theory and research. Applied Nursing Research, 28(1), pp.57-59.
Sorenson, C., Bolick, B., Wright, K. and Hamilton, R., 2016. Understanding compassion fatigue in healthcare providers: A review of current literature. Journal of Nursing Scholarship, 48(5), pp.456-465.
van Mol, M.M., Kompanje, E.J., Benoit, D.D., Bakker, J. and Nijkamp, M.D., 2015. The prevalence of compassion fatigue and burnout among healthcare professionals in intensive care units: a systematic review. PloS one, 10(8), p.e0136955.
Whitebird, R.R., Asche, S.E., Thompson, G.L., Rossom, R. and Heinrich, R., 2013. Stress, burnout, compassion fatigue, and mental health in hospice workers in Minnesota. Journal of palliative medicine, 16(12), pp.1534-1539.
Yeter Durgun Ozan PhD, B.S.N., 2015. Implementation of Watson's theory of human caring: A case study. International Journal of Caring Sciences, 8(1), p.25.
Zeidner, M., Hadar, D., Matthews, G. and Roberts, R.D., 2013. Personal factors related to compassion fatigue in health professionals. Anxiety, Stress & Coping, 26(6), pp.595-609.