Nursing critique the article

83International Journal for Human Caring, Volume 26, Number 2, 2022 © 2022 International Association for Human Caring http://dx.doi.org/10.20467/HumanCaring-D-19-00036

Relationships Among Self-Care, Compassion Satisfaction, and

Compassion Fatigue of Nurses in Community Hospitals in the

Southeastern United States

Katherine L. Rigdon, PhD, MSN, RN Karen Winters, PhD, RN

University of MS Medical Center, Jackson, Mississippi

Abstract: The purpose of this study was to determine the relationships among self-care, compassion satisfaction, and compassion fatigue of nurses in community hospitals in the Southeastern United States. A descriptive, nonexperimental, correlational, cross-sectional research design using purposive convenience sampling with primary data analysis was utilized in this study. Statistical analysis included descriptive statistics, simple linear regres- sion, and multiple linear regression. Statistically significant relationships were identified for self-care and compassion satisfaction and also self-care and compassion fatigue/burnout.

Keywords: caring; self-care; compassion satisfaction; compassion fatigue; burnout; second- ary traumatic stress

Background

According to the American Nurses Association (ANA) Code of Ethics, nurses owe the same duty to themselves as to others and should practice the same health promotion and maintenance behav- iors they teach their patients (ANA Code of Ethics, 2015). Self-care is essential for optimizing one’s health, enhancing caring relationships with others, and being a productive member of a health-care team (Lombardo & Eyre, 2011). However, many nurses do not practice self-care and suffer from insufficient sleep, have poor eating habits, smoke, get inadequate exercise, and have poor stress

management techniques that can be conducive to compassion fatigue (McElligott et al., 2010).

In 2005, the World Health Organization (WHO) recognized the significance of assessing and improving individuals’ quality of life. The focus has shifted from just studying causes of death and morbidity to learning more about the connec- tion of health to the quality of an individual life. This is further supported by the goals of Healthy People 2020 which focus on the achievement of high- quality lives for all groups to prevent injury, disease, disability, and premature death through

84 Rigdon and Winters

the promotion of healthy behaviors (Health and Human Services, 2010).

When nurses practice self-care, individual and professional commitments become more bal- anced and they are better able to take care of others (McElligott et al., 2010). Nurses often have a con- nection with their patients that promotes healing; therefore, it is important that nurses identify strat- egies that promote physical, emotional, and spiri- tual well-being so they can deliver optimum care to their patients (Todaro-Franceschi, 2013). Although the need for self-care is expressed in the literature, little emphasis has been placed on the relationship of nurses’ self-care, compassion satisfaction, and compassion fatigue. This study was conducted to address the question: Are there relationships among self-care, compassion satisfaction, and compassion fatigue of nurses in community hospi- tals in the southeastern United States?

The specific aims of the study were to: (a) Examine the demographic and work-related char- acteristics of nurses sampled in the study; (b) Describe the self-care behaviors, compassion sat- isfaction, and compassion fatigue among nurses in the southeastern United States; (c) Describe the relationship between self-care behaviors, compas- sion satisfaction, and compassion fatigue among nurses in community hospitals in the southeastern United States; and (d) Describe the relationship between demographic and work-related charac- teristics, compassion satisfaction, and compassion

fatigue among nurses in community hospitals in the southeastern United States.

Theoretical Framework

The theoretical framework for this study was based on the blended theories of Watson, Pender, and Stamm. In the theory of human caring, Watson and Woodward (2010) explained that nurses must prac- tice self-care when caring for others to prevent com- passion fatigue. If nurses do not care for self, it may make it difficult for them to compassionately care for others. Pender’s health promotion theory (Pender, 2011) is based on the belief that self-care is self- initiated health promotion behaviors that preserve or promote an individual’s health. Pender associ- ated these behaviors with physical activity, nutri- tion, spiritual growth, interpersonal relations, health responsibility, and stress management. Stamm built on the theory by Figley in the professional quality of life framework, that includes compassion satisfac- tion and compassion fatigue. Stamm (2010) defined compassion satisfaction as the feeling of fulfillment that results from helping others. Compassion fatigue includes two parts: (a) burnout and (b) second- ary traumatic stress (Stamm, 2010). Burnout is the gradual onset of feelings of hopelessness in dealing with work or in doing a job effectively. Secondary traumatic stress is about the rare but rapid onset of work‐related, subsequent exposure to extremely or traumatically stressful event (Stamm, 2010).

The theoretical framework created for this study (Figure 1) describes the relationship of

Figure 1. Theoretical framework on relationships among self-care, compassion satisfaction, and compassion fatigue.

85Relationships Among Self-Care, Compassion Satisfaction, and Compassion Fatigue

self-care on the caring ability of the nurse as related to compassion satisfaction, compassion fatigue, and the caring relationship between the nurse and the patient. Balancing the components of self-care can impact the nurse’s caring ability. Therefore, there is increased potential for compassion satis- faction to occur when components of self-care are achieved, thus resulting in a caring environment between the nurse and the patient. In contrast, when self-care of the nurse is not achieved, there is increased potential for compassion fatigue (burn- out and secondary traumatic stress) to negatively affect the caring relationship between the nurse and the patient. When one or more of the elements of self-care are not in balance, providing a caring environment for others may be difficult to achieve.

Method

Setting/Sample

The study took place over a 3-month period at seven community hospitals in the southeast- ern United States. The population targeted was 340 nurses (registered nurses [RNs] and licensed practical nurses [LPNs]) that worked in the clini- cal areas of critical and emergency care, medical, long-term acute care, maternal-child, and periop- erative care. To be included in the study, the nurses had to be full-time employees with direct patient contact responsibilities and had to have worked in their clinical area for a minimum of three months.

Data Collection

Following institutional review board approval and approval by the participating hospitals, fliers with information about the study were posted in the nursing units to recruit nurse participation in the

study. The fliers also provided contact information if the nurses had any questions. A portal link for the survey was placed on the employee intranet by administrative technical support staff for the hos- pitals. The three survey instruments used in the study included: (a) the Health Promotion Lifestyle Profile-II (HPLP-II), (b) the Professional Quality of Life 5 (ProQOL 5), and (c) a demographic ques- tionnaire created by the researcher based on the review of the literature. At the end of the survey, the nurses were directed to a web page where they had the option of entering their name into an anonymous drawing for a gift card.

Data Analysis

The data in the Excel file obtained from the survey portal were imported into an IBM SPSS (Armonk, NY) file for data analysis. An exploratory analy- sis was used to identify errors and missing data. Ninety-one individuals accessed the survey por- tal. Observations with missing data and those that did not meet the inclusion criteria were removed. The final sample consisted of 75 respondents which represented approximately 22% of the eli- gible nurses. An a priori power analysis indicated the sample size needed to achieve a significance level of .05, a power of .80, and a medium effect size was 76 participants.

Results

Demographic and Work-Related Characteristics

Frequencies and percentages were generated to describe the demographic (Table 1) and work- related characteristics (Table 2) of the sample. The mean age distribution of the participants was 41.6

Variable n %

Gender Female 61 81.3

Male 14 18.7

Education Diploma or Associate Degree 46 61.3

Bachelor or Graduate Degree 23 30.7

Licensed Practical Nurse 6 8.0

Dependent(s) Responsibility Yes 35 46.7

No 40 53.3

Primary Caregiver Yes 15 20.0

No 60 80.0

Chronic Condition Yes 21 28.0

No 54 72.0

TABLE 1. Demographic Characteristics of Participants (N = 75)

86 Rigdon and Winters

years with a range of 23 to 68 years. The sample for this study was predominantly female (n = 61, 81.3%). Less than half of the participants in this study had dependent responsibilities (46%), was a primary caregiver (20%), or had a chronic health condition (28%). The majority (61.3%) of the par- ticipants in this study had a diploma or associate degree and less than half (30.7%) had a bachelor or graduate level degree. The larger number of asso- ciate degree prepared nurses in this study may be attributed to the proximity of associate degree nursing programs near the hospitals included in this study.

Most of the participants reported they had work absences in the past 12 months. Participants who were absent in the past 12 months missed the following number of days: 1 day (n = 9, 12.5%), 2 days (n = 11, 15.3%), 3 days (n = 6, 8.3%), 4 days (n = 6, 8.3%), 5 or more days (n = 9, 12.5%). Most participants in this study (n = 41, 57%) reported they missed one or more sick days in the past 12 months, but the reasons for the absences were not addressed in this study.

The most frequently observed categories of assigned clinical areas in this study were critical and emergency care (n = 24, 32.0%), medical (n = 17, 22.67%), and long-term acute care (n = 15, 20.0%). Most nurses in this study had worked in their clinical area for more than 6 years (n = 39, 52.0%). However, almost half (n = 36, 48.0%), had worked in their clinical area for less than 5 years.

Self-Care Behaviors, Compassion Satisfaction, and Compassion Fatigue

The HPLP-II was used to measure the self-care behaviors of nurses (Table 3). The mean was close to the midpoint of 2.5 for the total and each sub- scale of the HPLP-II. The self-care total, health responsibility, physical activity, nutrition, and stress management were below the midpoint. Spiritual growth and interpersonal relations were above the midpoint. Higher scores indicate a healthier lifestyle.

The ProQOL 5 Scale was compassion satisfac- tion, compassion fatigue/burnout, and compas- sion fatigue/secondary traumatic stress in nurses

TABLE 2. Work-Related Characteristics of Participants (N = 75)

Variable n %

Professional Development Yes 8 10.6

No 67 89.3

Assigned Clinical Area Critical and Emergency Care 24 32.0

Medical 17 22.7

Long-Term Acute Care 15 20.0

Maternal Child 12 16.0

Perioperative 4 5.3

Other Work Areas 3 4.0

Time Worked in Clinical Area 16 years or more 16 21.3

6 to 15 years 23 30.7

5 years or less 36 48.0

Shift Description Days 40 53.3

Nights 24 32.0

Varies 11 14.7

Shift Length 12 hours or greater 51 68.0

Less than 12 hours 24 32.0

Overtime 12 hours or greater 46 61.3

Less than 12 hours 29 38.7

Other Job Yes 19 25.3

No 56 74.7

Absent Past Year Yes 41 54.7

No 34 45.3

Worked Sick Yes 47 62.7

No 28 37.3

87Relationships Among Self-Care, Compassion Satisfaction, and Compassion Fatigue

(Table 3). The scores for compassion satisfaction, compassion fatigue/burnout, and compassion fatigue/secondary traumatic stress are below the midpoint, which indicates less compassion satis- faction, compassion fatigue/burnout, and com- passion fatigue/secondary traumatic stress for the participants of this study.

Simple linear regression models were gen- erated to evaluate the individual relationships for self-care behaviors, compassion satisfaction, compassion fatigue/burnout, and compassion fatigue/secondary traumatic stress. The fit of each model was evaluated using R2 values and significance levels, where p < .05 was considered significant. An R2 value close to 1 indicates a bet- ter fit. Table 4 summarizes results of the R2 and p value of the simple linear regression. Except for health responsibility (which was not a significant predictor of compassion fatigue/secondary trau- matic stress), the self-care total and the self-care subscales each had statistically significant rela- tionships with each of the three outcomes of inter- est. The connotation of the statistically significant results for the self-care total may suggest that the

greatest benefit of self-care lies in the full partici- pation in a balanced approach to all the self-care subscales: health responsibility, interpersonal rela- tions, nutrition, physical activity, spiritual growth, and stress management.

The outcomes and the demographic (Table 5) and work-related characteristics (Table 6) were evaluated using frequency distributions, t tests for nominal variables with two categories, and ANOVAs for those with more than three catego- ries. Significant relationships were identified from the following characteristics: primary caregiver for someone else and compassion fatigue/burnout; no compassion fatigue professional development and compassion fatigue/secondary traumatic stress; 16 years or more of time worked in the clinical area and compassion fatigue/burnout; shift length of less than 12 hours and compassion satisfaction; absent from work at least once in the past year and burnout; worked sick at least once in the past year and compassion satisfaction; and worked sick in the past year at least once and com- passion fatigue/burnout. As seen in Table 5, those who were primary caregivers had significantly

TABLE 3. Self-Care (HPLP-II); Compassion Satisfaction, and Compassion Fatigue (ProQOL 5; N = 75)

Variable Mean (SD) Range

(HPLP-II) Self-Care Total 2.4 (0.4) 1.6–3.8

Health Responsibility 2.3 (0.5) 1.1–4.0

Physical Activity 2.1 (0.6) 1.1–3.8

Nutrition 2.2 (0.4) 1.3–3.5

Spiritual Growth 2.7 (0.5) 1.7–4.0

Interpersonal Relations 2.8 (0.5) 1.8–4.0

Stress Management 2.3 (0.4) 1.1–3.7

(ProQOL 5) Compassion Satisfaction 49.9 (10.2) 30.4–76.1

Compassion Fatigue/Burnout 50.4 (10.0) 21.2–72.3

Compassion Fatigue/Secondary Traumatic Stress 50.2 (10.1) 27.9–72.4

TABLE 4. Relationship Between Compassion Satisfaction, Compassion Fatigue/Burnout, Compassion Fatigue/ Secondary Traumatic Stress, and Variasbles for Self-Care

Compassion Satisfaction

Compassion Fatigue/Burnout

Compassion Fatigue/ Secondary Traumatic

Stress

R2 p R2 p R2 p

Self-Care Total .36 <.001* .30 <.001* .17 <.001*

Health Responsibility .20 <.001* .08 .019* .05 .069

Physical Activity .06 .041* .11 .006* .06 .037*

Nutrition .09 .015* .12 .004* .11 .005*

Spiritual Growth .55 <.001* .42 <.001* .22 <.001*

Interpersonal Relations .49 <.001* .39 <.001* .19 <.001*

Stress Management .29 <.001* .24 <.001* .10 .008*

*p < .05

88 Rigdon and Winters

TABLE 5. Relationships Between Demographic Characteristics and Outcomes

Compassion Satisfaction Mean (SD)

Compassion Fatigue/Burnout

Mean (SD)

Compassion Fatigue/ Secondary Traumatic

Stress Mean (SD)

Gender Female 49.8 (10.2) 50.8 (9.8) 50.9 (10.3)

Male 50.5 (10.4) 48.8 (11.0) 47.2 (8.7)

Education Diploma or Associate Degree 48.7 (10.1) 51.8 (9.1) 51.8 (9.6)

Bachelor or Graduate Degree 52.4 (11.3) 48.1 (11.3) 47.8 (10.7)

Licensed Practical Nurse 50.3 (6.1) 47.7 (11.8) 46.4 (10.3)

Dependent(s) Responsibility Yes 52.2 (10.0) 49.9 (10.1) 51.2 (9.8)

No 48.2 (10.0) 50.8 (10.0) 49.3 (10.5)

Primary Caregiver Yes 47.1 (9.1) 49.1 (5.6) * 52.2 (10.0)

No 50.7 (10.4) 20.8 (10.9) 49.6 (10.5)

Chronic Condition Yes 48.6 (12.0) 53.2 (8.7) 52.3 (7.4)

No 50.4 (9.5) 49.4 (10.3) 49.3 (10.9) *p < .05

TABLE 6. Relationships Between Work-Related Characteristics and Outcomes

Compassion Satisfaction Mean (SD)

Compassion Fatigue/Burnout

Mean (SD)

Compassion Fatigue/Secondary

Traumatic Stress Mean (SD)

Professional Development Yes 52.3 (12.6) 46.7 (13.2) 95.5 (10.5)

No 49.7 (10.0) 50.8 (10.4) 50.8 (4.5)*

Assigned Clinical Area Critical and Emergency Care 50.9 (8.6) 54.6 (8.0) 49.7 (8.9)

Maternal Child 52.0 (9.7) 49.9 (10.2) 48.1 (3.0)

Long-Term Acute Care 50.4 (11.2) 52.0 (9.9) 45.9 (9.1)

Medical 47.9 (13.2) 49.1 (10.5) 55.2 (12.2)

Perioperative 50.2 (6.2) 50.1 (9.9) 50.4 (10.0)

Other Work Areas 43.3 (2.7) 49.8 (11.7) 54.9 (9.6)

Time Worked in Clinical Area 16 years or more 52.0 (10.2) 46.6 (13.9)* 48.3 (12.3)

6 to 15 years 52.4 (11.7) 49.3 (9.3) 49.8 (8.9)

5 years or less 47.7 (8.9) 52.6 (8.3) 51.3 (9.9)

Shift Description Days 50.9 (10.3) 49.6 (10.1) 51.2 (9.8)

Nights 47.4 (10.3) 52.2 (9.8) 49.1 (9.9)

Varies 51.8 (9.4) 51.2 (10.5) 48.9 (10.9)

Shift Length 12 hours or greater 48.7 (7.3) 47.8 (9.6) 53.2 (10.8)

Less than 12 hours 50.6 (11.4)* 51.3 (10.2) 48.6 (9.4)

Other Job Yes 52.0 (10.7) 49.4 (12.4) 49.2 (12.2)

No 49.2 (10.0) 50.7 (9.2) 50.2 (9.4)

Absent Past Year Yes 51.3 (11.1) 50.2 (11.8)* 50.3 (10.5)

No 48.5 (9.0) 50.7 (7.9) 50.0 (9.8)

Worked Sick Yes 51.7 (10.9)* 50.0 (11.7)* 49.1 (10.8)

No 47.2 (8.4) 51.0 (7.0) 51.9 (8.8) *p < .05

89Relationships Among Self-Care, Compassion Satisfaction, and Compassion Fatigue

TABLE 7. Multiple Linear Regression

Unstandardized Coefficients

B Std. Error p

Compassion Satisfaction (Constant) 9.9 5.2 .063

Health Responsibility 1.9 2.5 .470

Interpersonal Relations 3.3 3.5 .346

Nutrition −3.9 2.9 .186

Physical Activity −2.1 2.3 .376

Spiritual Growth 10.5 3.8 .007*

Stress Management 3.9 3.5 .272

Worked Sick Last 12 Months 2.1 1.9 .288

Shift Length 1.4 1.9 .462

Compassion Fatigue/Burnout (Constant) 83.8 5.9 p <. 001

Health Responsibility 6.2 2.9 .044*

Interpersonal Relations −7.4 3.9 .064

Nutrition 2.0 3.5 .565

Physical Activity −3.6 2.6 .178

Spiritual Growth −6.7 4.4 .120

Stress Management −2.2 4.0 .587

Absent Past Year −1.4 2.5 .583

Primary Caregiver −1.0 2.3 .658

Worked Sick Last 12 Months 1.6 2.7 .561

Compassion Fatigue/Secondary Traumatic Stress (Constant) 76.7 6.9 p <. 001

Interpersonal Relations −2.6 4.6 .578

Nutrition 3.1 4.0 .452

Physical Activity −.1 2.9 .959

Spiritual Growth −6.5 5.0 .196

Stress Management 2.7 4.4 .538

Professional Development −.9 3.8 .813

Note. Compassion Satisfaction: [F(8, 58) = 11.18, p < .001], R2 = .61; Compassion Fatigue/Burnout: [F(9, 57) = 6.03, p < .001], R2 = .49; Compassion Fatigue/Secondary Traumatic Stress: [F(5, 62) = 3.22, p = .008], R2 = .24 *p < .05; Significant.

higher compassion fatigue/burnout. Results from Table 6 show that those who participated in pro- fessional development had significantly higher compassion fatigue/secondary traumatic stress, those who worked 16 years or more in a clinical area, had been absent in the past year, or worked sick had significantly lower compassion fatigue/ burnout, and those who worked shift lengths less than 12 hours or worked sick had significantly higher compassion satisfaction.

Variables with statistically significant rela- tionships for the demographic and work-related characteristics and the outcomes were evaluated further using multiple linear regression (Table 7) which identified a significant relationship (p ≤ .05) for compassion satisfaction and spiritual growth and for compassion fatigue/burnout and health responsibility.

Discussion

Statistically significant relationships for com- passion fatigue/burnout and health respon- sibility were identified in this study. Health responsibility is a sense of accountability for one’s own well-being (Walker & Hill-Polerecky, 1996). The literature suggests that the rigors of the nurs- ing profession may contribute to the difficulties nurses face for their own health responsibility. For example, the American Association of Colleges of Nursing (AACN, 2019) reports that nurses actively working in the profession are suffering stress from insufficient staffing (nurses retiring or leaving the profession) which can raise stress levels, impact job satisfaction, and lead to burnout (AACN, 2019).

Unfortunately, burnout among U.S. health-care employees is a growing problem with far-reaching

90 Rigdon and Winters

consequences (AACN, 2019). According to the WHO (2019), the term burnout has been included in the International Classification of Diseases as an occupational phenomenon, because it is a syn- drome resulting from chronic workplace stress that has not been effectively managed (WHO, 2019). Burnout can damage not only a nurse’s well-being, but also patient safety, outcomes, and quality of care. Employees who experience burn- out are 63% more likely to take a sick day (AACN, 2019). For health-care organizations, burnout translates to lost productivity, nurse turnover, and increased malpractice lawsuits (Gallup Wellbeing Index, 2018).

Statistically significant relationships were also identified for compassion satisfaction and spiri- tual growth in this study. This finding supports the importance of self-care for nurses and is discussed in Watson’s and Woodward (2010) theory of human caring that proposes that actualization of one’s spirituality is the most basic human need to which all other needs are subservient. Human car- ing, according to Watson and Woodward (2010), is based on human values that include love of self and others. Spiritual growth puts individuals in touch with their most inner self and allows peace and harmony by maximizing the human poten- tial for wellness and the achievement of life goals (Walker & Hill-Polerecky, 1996).

According to Pender (2011), spiritual growth includes more than religious practices, but relates to an individual’s existential beliefs regarding life, hope, love, and the connectedness and purpose of self and others. For instance, nurses in this study reported participating in actions that promote spiritual growth such as believing their life has a purpose, being aware of things in life that are important to them, feeling connected with some force greater than themselves, and looking forward to the future. Further investigation of the literature also suggests that nurses find it important to use spiritual growth for self-care in their practice such as Reiki energy therapy (Brathovde, 2006) and Jin Shin Jyutsu® (Lamke et al., 2014). In response to the findings of this study, nurses should identify opportunities to engage in spiritual growth to promote their own self-care. Spiritual growth can be accomplished with any activity that promotes inner peace such as yoga, meditation, journaling, and engaging in meaningful activities with others.

Limitations

A limitation of this study that may limit the gen- eralizability of the findings was the potential for self-selection bias. Nurses suffering from compas- sion fatigue may have chosen not to participate in this study because they did not want to remem- ber traumatizing events. Generalizability may also have been limited because of the small sample size and because the nurses who participated in this study were predominantly married White females with associate degrees. The study should be rep- licated to improve external validity. The potential for threats to internal validity included historical events, maturation, testing effects, and the length of the survey (Trochim & Donnelly, 2008).

Recommendations and Conclusion

Further research is needed to identify self-care variables that will increase compassion satisfaction and prevent compassion fatigue among nurses in all practice settings. Future studies should include longitudinal studies and intervention studies to evaluate the relationship of self-care, compassion satisfaction, and compassion fatigue and to further evaluate spiritual growth and compassion satisfac- tion. Future studies can also investigate concepts within the subscale of spiritual growth; examine the relationship of nurses’ self-care and patient sat- isfaction; explore the relationship of nurses’ self- care, sick leave, and nurse retention; and examine nurses’ self-care and quality improvement.

Nurse administrators should consider provid- ing resources such as employee health clinics to support health responsibility within their nursing workforce. Consideration should also be given to support flexible work schedules and assignments within the organization to prevent compassion fatigue and burnout. Nurse educators should con- sider providing foundation courses that address self-care, conflict resolution, and ethical issues to prevent burnout and secondary traumatic stress among nurses. Professional development oppor- tunities are also important to promote self-care and prevent compassion fatigue in the quest for a healthy work environment that is conducive to nurse and patient well-being.

It is vital that we ensure the resiliency of the nursing workforce through opportunities for self- care now and in the future. Self-care barriers must

91Relationships Among Self-Care, Compassion Satisfaction, and Compassion Fatigue

be investigated and strategies to promote optimal health should be promoted at individual and orga- nizational levels. The findings of this study suggest that self-care has the potential to prevent compas- sion fatigue and promote compassion satisfaction. Professional nursing practice can flourish within the milieu of the caring relationship that occurs between the nurse and the patient when nurses practice self-care.

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Disclosure. The authors have no relevant financial inter- est or affiliations with any commercial interests related to the subjects discussed within this article.

Correspondence regarding this article should be directed to Katherine Louise Rigdon, MSN, University of MS Medical Center, Jackson, Mississippi, USA. E-mail: krigdon@umc.edu

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