Compassion fatigue is a phenomenon that was first identified by Joinson (1992) who recognised it as a noteworthy emotional change in the nurses working within accident and emergency departments. This change was said to be caused by the high-pressure environment that the specialty demands and the frequent encounters with acute illness and death of patients (Joinson, 1992). Professionals suffering from this showed physical symptoms such as stomachache, headache, fatigue, lowered tolerance levels to stress, and low work efficacy (Joinson, 1992). It is important to raise awareness of this phenomenon among professionals so they can recognise and understand how it can be managed.
One area where compassion fatigue has not been reported is in community nurses (CN). However, in the UK, CNs provide care in the patient's home. In recent years, it has evolved and become more acute-based as patients are discharged earlier from the hospital and now remain at home for treatment. Such treatment was once formerly provided in an acute setting (The King's Fund, 2020). CNs provide care to patients with a range of medical conditions, including oncology, dementia, palliative and end-of-life care—where patients' preferred place of care is at home (The Queen's Nursing Institute, 2020). As discussed by Ruiz-Fernandez et al (2020), CNs are also likely to be more vulnerable to compassion fatigue when regularly caring for patients who are suffering from an acute or progressive illness and death. This article examines and discusses compassion fatigue in relation to the CN.
Method
Literature search
A scoping review with narrative analysis was undertaken through selected searches on compassion fatigue using CINHAL, ProQuest, Science Direct, and the Cochrane library. The Keywords used were ‘compassion fatigue’ and ‘community Nurs*’ (and combinations using AND). Search filters were applied (last 10 years, peer-reviewed, English, nursing, excluding newspaper articles), and results were reviewed for relevance using an inclusion criterion (community nursing, compassion fatigue, burnout). Additionally, resources were selected using reference searching from selected results such as NHS England and relevant professional bodies such as Queen's Nursing Institute (Figure 1).
An analysis of the results are presented in the conceptual diagram (Figure 2) that show compassion fatigue in different areas of nursing practices (e.g. oncology ICU, palliative and dementia care areas) and two dimensions, which are the context and the care organisation.
Definitions of compassion fatigue
The psychologist Figley (1995), defined compassion fatigue as:
‘A state of exhaustion and dysfunction, biologically, physiologically, and emotionally, because of prolonged exposure to compassion stress.’
However, its definition has changed over time as further research was undertaken, and it is still not clearly defined within the literature (Figley 1995; 2002; Coetzee and Klopper, 2010; Peters, 2018). Some have described it as a form of post-traumatic stress disorder (PTSD), with ‘compassion fatigue’ as a more user-friendly definition that professionals would be happy to use (Figley, 1995). Other researchers have linked it to different phenomena, for example, vicarious trauma (VT), as this occurs when a professional is repeatedly exposed to another person's trauma, which leads to the displaying of symptoms (Bride et al, 2007; Adams et al, 2008). It has also been called a form of burnout and secondary traumatic stress disorder (Figley, 2002). It was not until 2010 that compassion fatigue reappeared again in research as a phenomenon that requires further exploration in the nursing profession (Coetzee and Klopper, 2010). Coetzee and Klopper (2010) went a step further and developed a visual model of categories, characteristics and empirical indicators of compassion fatigue. Their model showed three factors that are significant in the causation of compassion fatigue: stress, patient contact, and the use of self (i.e. when the professional supports the patient emotionally with the trauma and/or illness that they are suffering). Given that nurses are expected to provide compassionate and empathic patient care (Nursing and Midwifery Council (NMC), 2018), it implies that all nurses are potentially prone to encounter compassion fatigue, rather than only those working in specialist fields mentioned above.
Coetzee and Klopper (2010) acknowledged two earlier stages that are seen in professionals prior to experiencing compassion fatigue. Before this, it was thought to be sudden in onset (Figley, 1995; 2002). Initially, when professionals encounter factors that challenge their compassion, they are said to experience ‘compassion discomfort’, which can progress to ‘compassion stress’ and finally, to ‘compassion fatigue’. Coetzee and Klopper (2010) described a three-step process of increasing the intensity of identified indicators. Each stage has physical, emotional, social, spiritual and intellectual effects, and represents compassion fatigue as cumulative and progressive across these stages. The length of time spent at each stage is unique to the individual, but it is unclear if every individual will progress through all three stages and what determines how long they will stay at a specific stage. However, they did identify some signs of compassion fatigue, such as a lack of energy, apathy, being prone to accidents, indifference towards patients, poor judgment and being callous. Interestingly, these have similarities to other descriptions of burnout. The visual model has improved the understanding of compassion fatigue since its initial identification (Figley, 1992). However, additional work and further exploration is required to better understand compassion fatigue and its effect on both staff and patients.
Defining compassion fatigue continues to be a challenge in research. Contributing to this challenge is that the terms ‘compassion fatigue’ and ‘burnout’ are often used interchangeably within research (Samios, 2018; Sprang et al, 2011; Sawatzky and Enns, 2012), when there is a clear difference between the two. This was identified by Figley (1995) who called compassion fatigue the ‘cost of caring’, and is seen in caring professionals (Figley, 2002; Stamm, 2005). McHolm (2006) also noted that compassion fatigue occurs when a professional provides compassionate care over a longer period without experiencing a positive result. Sacco et al (2015) explored this further and made a clear differentiation between burnout and compassion fatigue as an important step within research to understand the phenomena better. They stated that compassion fatigue occurs when a ‘helper’ (nurse) is unable to help or rescue a ‘victim’ (patient) from the suffering they are enduring; this causes intense guilt and sorrow for the professional, which leads to emotional distress and compassion fatigue. In contrast, burnout occurs when an individual is unable to complete their goals, causing emotional exhaustion. A reason why it may be defined as a form of burnout is that compassion fatigue shares a common presentation. However, given that some make a distinction between the two phenomena, they should be separated within future research. Nonetheless, it is important to state that compassion fatigue can still be classified as a form of secondary traumatic stress syndrome, as it can be seen in the caregiver (nurse) when supporting and empathising with the unwell patient, which can lead to sadness, emotional distress and compassion fatigue (Bride 2004; Adams et al, 2008; Chu, 2021).
Regardless of the distinction, there is evidence that compassion fatigue occurs in different areas of nursing practice.
Compassion fatigue in nursing practice
Compassion fatigue as a phenomenon has been researched in specialist areas such as oncology, intensive care, palliative care and dementia care nursing (Aycock and Boyle, 2009; Melvin, 2012; Todaro-Franceschi, 2013; Hussain, 2021). These studies agree that nurses are increasingly likely to suffer from compassion fatigue, particularly when caring for patients suffering an intense acute illness with disease progression having poor outcomes and death. This resonates with the causative factors identified in Corteeze and Klopper's (2010) model, as well as being increasingly exposed to patient trauma (Figley, 1995). Thus, several factors shape a CN's exposure to potentially experiencing compassion fatigue. Community nursing is a specialist area that sees a higher-than-average number of patients who fall into these categories (QNI, 2020). Therefore, nurses who work in the community are also increasingly likely to suffer from this fatigue.
Whilst there is limited research that included small samples of community practitioners in Spain, Taiwan, New Zealand and Australia, it showed that compassion fatigue is a cause of concern in those workforces (Samios, 2018; Ruzi-Fernandez et al, 2020; Pérez-García et al, 2021). Research within the UK has focused on the importance of compassionate leadership and the need to support the mental health and well-being of the community staff (Rogers, 2021; While and Clark, 2021), but there is a lack of evidence published about compassion fatigue and CNs.
Compassion fatigue as a growing cause for concern has been exacerbated by the 2020 pandemic (Shanafelt et al, 2020). The COVID-19 pandemic introduced several challenges, such as a lack of personal protective equipment, depleting staffing numbers, providing care for unusually larger numbers of patients, and witnessing a higher-than-normal number of deaths. This has led to an increase in compassion fatigue among healthcare professionals, as increased exposure to causative factors (Ruiz-Fernandez et al, 2020).
Despite the emotional exhaustion that professionals are experiencing, the satisfaction that they obtained from helping patients in their care is thought to act as a protective factor against compassion fatigue and burnout, and increase compassion satisfaction (Sawatzky and Enns 2012, Samios 2018). However, it remains unclear how this protection works as it is not apparent in all nurses and requires further research (Sacco and Coppel, 2018). It is also important to further our understanding of these protective factors as well as burnout, as they are included in research side by side.
Context of community nursing
Concerning CNs, some factors influence the extent to which compassion fatigue might be likely to occur. These include resourcing, knowledge, workload and skill mix. CNs have been under-resourced for several decades, which has been highlighted in reports published by the QNI. The QNI (2002) report highlighted issues such as poor skill mix, aging workforce, and lack of specialist qualifications. This workforce encountered patients with increasingly complex needs of the patients, who chose to remain at home for treatments that would traditionally have been provided in an acute setting. Additionally, increasingly early hospital discharge was a contributing factor to practitioner stress (QNI, 2002).
Subsequent QNI reports have highlighted the issues of poor staffing as numbers within the service have declined; despite this, the skill mix has improved since 2002, as the service has since employed healthcare assistants, nursing associates, staff nurses as well as nurses with the specialist district nursing qualification (Low, 2002). The decline in staffing is attributed to a high number of nurses who were at retirement age in 2002. The enduring challenges to recruitment in replacing those staff who have left the profession have contributed to a workforce reduction. This has caused additional pressures, where a lack of nurses with specialist skills and knowledge can lead to the absence of leadership to support the care team (QNI, 2006; 2015).
Increasing workloads linked to the implementation of the NHS's Long-Term Plan (2019) means that more care is provided within the patients' homes. According to the QNI (2016), this, coupled with an increasingly aging population has led to a greater strain on the service. During the 2020–2022 pandemic, pressure on the service amplified further as other community services were withdrawn. However, CN teams maintained their complex caseload of patients with strains created by additional referrals from health and social care providers who were not seeing patients face-to-face (While and Clark, 2021). One feature they reported on was the CN–patient relationship, which was being complicated by the COVID-19 restrictions in a patient's home.
Ruiz-Fernandez et al (2020) added that caring for patients within their environment leads to the patient-nurse bond becoming stronger. This care is often for longer periods than in an acute setting. When nurses are unable to provide the care and support that they would like (e.g. through workload pressures and barriers to personal care such as COVID-19 restrictions), this could contribute to compassion fatigue. Another factor is the care organisation in which the nurse works.
Context of the care organisation
The care organisation in which a nurse works shapes their experience. This includes the resourcing of care, staff support, and recognition and workload—features that shape the well-being of staff in the workplace.
Chu (2021) identified a correlating factor that increases compassion fatigue as poor job satisfaction. However, compassion fatigue does not directly lead to poor job satisfaction. Rather it is the stress, which contributes to poor job satisfaction that leads to the development of compassion fatigue. Factors such as nurses not being able to complete/provide the patient the kind of care they would like to due to limited resources and increasing workload pressures, have previously been reported. Consequential increases in stress can lead to a decrease in the motivational factor of accomplishment (Goehring et al, 2005; Chu, 2021). However, the frustrations felt can also lead to burnout (Benson et al, 2016). Together, these can lead to poor job satisfaction and may lead to the development of negative emotions toward the organisation. This. in turn, can influence poor performance and poor patient care (Benson et al, 2016). Compassion fatigue is an important phenomenon for organisations to be aware of alongside burnout, as it can be a contributing factor to achieving targets and can influence patient outcomes.
Organisational support is key and staff must feel valued and appreciated for the work that they are doing; this reward was notionally provided during the pandemic by the public with the ‘clap for carers’ (QNI, 2020). This supported nurses, enabling them to manage their compassion fatigue, as they felt valued for the work being undertaken during a global crises. Despite this, the community nursing workforce did not see the same media recognition for the work that they continued to carry out during the pandemic. This, along with the already identified poor organisational support, which was apparent before the pandemic, could have led to an increased level of compassion fatigue, as they felt further undervalued in comparison to the acute nursing workforce.
Further studies have explored factors that may support or hinder a professional from managing compassion fatigue. Areas that have been researched include age, level of education, experience, marital status, organisational factors such as staffing level, resources and more recently, the COVID-19 pandemic (The King's Fund, 2020). Findings in this area are conflicting. Hunsaker et al (2015) stated that a nurse with years of experience, an increased level of education, and in stable home life can manage their compassion fatigue better and show lesser signs of this fatigue. This is contrasted by Yu et al (2016) who noted that there are no correlations between age and compassion fatigue. One key aspect that all studies have shown is having a supportive network of colleagues at work can enable a professional to manage their compassion fatigue. Education and mindfulness training can also aid in supporting individuals to manage. compassion fatigue. Wider organisational support also plays an important role in the nurse's ability to manage this fatigue (Corso, 2012; Frey et al, 2018). Therefore, healthcare organisations need to improve their understanding of the phenomena and provide the education, tools and the environment required for the nursing staff to identify and manage their compassion fatigue.
Discussion
This review sought to identify the impact compassion fatigue potentially has on the CNs. It identified a limitation in research within the UK CNs. However, compassion fatigue has been a cause for concern within the nursing workforce for several decades and has been researched periodically within nursing since 1992. It remains poorly defined and has been used interchangeably with other definitions such as burnout. However, recent research has identified a difference between compassion fatigue and burnout—this needs to be taken into consideration, and a clear distinction should be made between the two. Therefore, compassion fatigue should be recognised as a separate phenomenon and researched independently (Figley 1995; 2002; Stamm, 2005; Sacco et al, 2015; Clarke, 2022). The protective factors that prevent compassion fatigue need further exploration as research is conflicting and findings are variable (Hunsaker et al, 2015; Yu et al, 2016). Therefore, an understanding of these factors needs further investigation to support the nursing workforce and improve retention.
The CN workforce is equally likely to suffer from compassion fatigue due to the patient groups that they look after in their daily workload, as well as workforce pressures, the nature of their work environment and the length of time they may nurse a patient (Ruiz-Fernandez et al, 2020; QNI, 2021). All of these are contributing factors in the development of compassion fatigue. The pandemic has further exacerbated the issue within the specialty due to a lack of resources, increasing workload pressure, and the care for patients who unfortunately died from COVID-19. It is key that the CN workforce is also recognised as other specialist areas have been within research (The King's Fund, 2020; QNI 2020).
Conclusion
CNs are an important part of the wider healthcare workforce within the NHS. Research within the UK needs to include this specialist group when exploring the impact of compassion fatigue on the NHS workforce. There is a pressing need to confront the issue of compassion fatigue as a phenomenon, as it is becoming a concern. As research has identified, providing timely and meaningful interventions, education and organisational support to manage this fatigue is crucial.
Further research is also needed so care organisations can develop policies to combat compassion fatigue and support their workforce. Research around compassion fatigue needs to continue as it remains poorly understood.
Key points
- Compassion fatigue occurs when a ‘helper’ (nurse) is unable to help or rescue a ‘victim’ (patient) from the suffering they are enduring; this causes intense guilt and sorrow for the professional, which leads to emotional distress and compassion fatigue
- Community nurses provide care for patients within the specialist area of oncology, dementia, and end-of-life care; therefore, they are also increasingly likely to suffer from compassion fatigue
- It is not clear if factors such as years of experience, level of education or age support the individual to manage compassion fatigue
- Organisations need to be aware of the correlating factors that increases compassion fatigue as poor job satisfaction
- Providing timely and meaningful interventions, education and organisational support are important to manage compassion fatigue
- Research within the UK needs to include community nursing when exploring the impact of compassion fatigue on the NHS workforce
CPD reflective questions
- What is compassion fatigue?
- What are the signs of compassion fatigue?
- Why is it important to identify compassion fatigue and what changes can you make to manage this fatigue if it has been identified?