Predicting the Risk of Compassion Fatigue

Predicting the Risk ofCompassion Fatigue

A Study of Hospice Nurses

Maryann Abendroth, MSN, RNJeanne Flannery, DSN, ARNP, CNRN, CRRN, CCH

• There is a growing interest in the clinicalphenomenon of compassion fatigue and itsimpact on healthcare providers; however,its impact on hospice nurses is basicallyunknown. This study investigated theprevalence and the relationships betweennurse characteristics and compassion fatiguerisk. It also provided a model for predictingcompassion fatigue risk. A non-experimentaldescriptive design using cross-sectional dataand descriptive and inferential statistics wasused. Nurses (N = 216) from 22 hospicesacross the state of Florida participated in thestudy. Findings revealed that 78% of thesample was at moderate to high risk forcompassion fatigue, with approximately 26%in the high-risk category. Trauma, anxiety, lifedemands, and excessive empathy (leading toblurred professional boundaries) were keydeterminants of compassion fatigue risk in themultiple regression model that accounted for91 % (P< .001) of the variance in compassionfatigue risk. Knowledge of these variables mayhelp organizations identify nurses at risk andprovide interventions and preventions tomaintain optimal nursing care.

K W O R D

burnoutcompassion fatigue

hospice nursessecondary traumatic stress

There are nearly 20,000 registered nurses in thehospice setting in the United States, and they arepart of the aging nursing workforce. In 2000,

the national average age of all registered nurses was45.2 years, which, incidentally, has climbed steadily inrecent years.^ Hospice nurses are not immune to theaging nursing workforce, general population growth,and work-related stress that may be factors in futurenursing shortages.' '•^ In addition to these outsidefactors, caring for dying patients induces considerablestress, which includes the challenge of providingcomfort care to patients with complex disease processesand being empathic to families in psychosocial and

Maryann Abendroth, MSN, RN, is on faculty asAssistant Professor in Nursing, Florida StateUniversity College of Nursing, Tallahassee, FL.

Jeanne Flannery, DSN, ARNP, GNRN, GRRN,GGH, is a Professor, Florida State University Collegeof Nursing, Tallahassee, FL.

Address correspondence to Maryann Abendroth,MSN, RN, Florida State University College ofNursing, 419 Duxbury Hall, Tallahassee, FL 32306(e-mail: [email protected]).

346 JOURNAL OF HOSPICE AND PALLIATIVE NURSING • Vol. 8, No. 6, November/December 2006

spiritual crisis.'*' This study focused initially on arandom sample of Florida's hospice nurses and theirrisk of compassion fatigue (CF), which is a secondarytraumatic stress reaction resulting from helping, ordesiring to help, a person suffering from traumaticevents.^ Second, the study created models to predict CFrisk among this population.

The results of this study revealed that nurses in thisspecialty are especially vulnerable to the risk of CF. Vari-ables linked to work-related stressors, demographics,and health factors reflected the impact that stress hason CF risk, which is exacerbated when nurses exhibita lack of self-care. Many of these variables providedstrong correlational and predictive value in targetingindividuals at risk for this clinical phenomenon. Be-cause the risk is apparent, CF is a preventable and treat-able phenomenon. Understanding the prevalence of CFrisk and implementing a model that predicts this riskcould empower nurses and administrators to use pre-ventive measures tbat promote self-care, improve pa-tient outcomes, and enhance productivity.

• REVIEW OF THE LITERATURE

The literature reviewed for this study included numer-ous findings and recommendations related to tbeimpact of CF on healthcare workers.''"^° Studies alsobave been conducted on stress and burnout, which maybe precursors to CF in many professions, includinghospice nursing. ' ^ Nonetheless, nurses wbo work invarious settings and wbo are engaged in various levelsof trauma work have received little attention regardingthe effects of CF on their profession. ' "*

Qualitative studies revealed themes of stress wbennurses were exclusively involved witb tbeir terminalpatients and experienced a true sense of loss wben tbeirpatients died. ' ^ Tbe results of quantitative studiesnoted tbat bigb education levels, stress from continu-ously facing difficult family dynamics, and multiplepatients dying witbin a sbort period of time wererelated to high burnout scores. Otber studies alsoconfirmed tbat tbese factors had a cumulative effecton nurses' coping abilities. ' ' ^"^^

The finding tbat hospice nurses use bigbly structureddefense mecbanisms was supported by Payne, ^ wbonoted tbat bospice is a positive environment in wbicb towork, altbougb tbe nature of tbe work is difficult andmay lead to burnout. Tbis finding is supported furtberby Wrigbt,^° wbo researcbed tbe qualities of bospice

nurses and noted tbat tbese nurses bave a true sense ofcalling and are compassionate and accepting of tbecboices made by patients and tbeir families. Tbeaccumulated factors are tbere to predict CF risk;bowever, nurses' coping abilities, sucb as bealtbyprofessional distancing learned from years of nursingexperience, balanced out many of tbose stressors.Healtby distancing may be acbieved by a sense of self-care, as evidenced by consciously taking time off fromwork, especially wben stress begins to accumulate.

In tbis study, 17% {n = 37) of tbe nurses indicatedtbat tbey received no support from tbeir own definedprofessional support system (ie, peers, supervisors,administrators) after a patient's traumatic death. Oftbose participants, 83% (« = 31) were in tbe moderate-to-bigb risk CF category. An inability to debrief after atraumatic event diminisbed internal coping mecha-nisms. Tbis finding confirms tbe results of earlierstudies by Dean^^ and Mallet et al, ^ wbicb demon-strated tbat lack of support after experiencing apatient's traumatic deatb bad an impact on tbesenurses. More generally, tbe literature supports tbe belieftbat lack of support during occupational stress andtrauma leads to psycbological distress.^ ' ^

Bebaviors emanating from occupational stress andtrauma revealed a central tbeme of tbis study: tbat nurseswbo become overly empatbic witb tbeir patients are mostat risk for CF. Tbis central tbeme was higbly supportedby Riggio and Taylor, '*''' ^ ' wbo identified empatby asan essential aspect of bospice nursing wben it takes tbeform of "perspective taking" and "empatbic concern";bowever, once empatby becomes unbealtby it leads to"personal distress," wbicb negatively affects nursingcare and leads to stress and burnout. Tberefore, un-bealtby empatby leading to blurred professional bound-aries appeared as a major stressor in bospice nursing.

Tbe gaps in tbe literature were evident because vir-tually no studies evaluated bospice nurses and tbeir riskfor CF; however, tbe fact tbat CF may exist among tbispopulation was verified by literature, wbicb reportedtbat nurses wbo work in bospice care, emergency roomsettings, and psychiatric units are engaged in traumawork.''' '* Risk of CF among chaplains and otber re-spondents after tbe World Trade Center disaster onSeptember 11, 2001 in New York City was studied^ andit was reported tbat 55% of tbe sample {n = 403) \verein tbe moderate-to-bigb CF risk category, accordirig toRoberts et al.^ Anotber finding of tbe study noted tbatworkplace proximity to Ground Zero and lengtb oftime volunteering for a relief agency bad no effect on

JOURNAL OF HOSPICE AND PALLIATIVE NURSING • Vol. 8, No. 6, November/December 2006 347

•w-> t

CF risk.^ Tbese findings were similar to tbis study,wbicb reported tbat demograpbic and work-relatedvariables did not bave a major discriminating value onCF risk; bowever, 79% {n = 170) of participants(n = 216) in tbis study had a bigber probability ofbeing in tbe moderate-to-bigb risk category tbanindividuals in tbe aforementioned study. Tbe nurses intbis study were exposed to ongoing career stressors,sucb as patient deatb and family crisis, on a continuousbasis, wbereas participants in tbe previous study bad acontrolled period of episodic acute stress.

• PROBLEM AND SIGNIFICANCE

Tbere is a growing interest in understanding tbe clinicalpbenomenon of CF and its impact on bealtbcare pro-viders according to Huggard.^^ Altbougb tbis pbenome-non bas received considerable attention witbin otberbealtbcare populations, bospice caregivers bave not beenevaluated for risk. These end-of-life (EOL) caregiversare especially vulnerable because tbey can become over-involved due to tbe degree and lengtb of interaction witbtheir patients, their emotional investments, and frequentexposure to loss. ^ A study of CF risk in the populationof bospice nurses was not only warranted but alsoessential to tbe viability of tbe profession and tbe futureof optimal EOL care for an aging US populace.

According to tbe National Hospice and PalliativeCare Organization (NHPCO) 885,000 patients wereserved in 2002 by hospice affiliates, compared to246,000 served in 1992. Tbis number represented a259% increase in tbe 10-year period.^^ Because tbehospice census is expected to increase, it is important toattract and retain nurses in this specialty area; bowever,it is projected that the nursing population will fall 29%below demand in the year 2020.^^ According to theNHPCO,^ hospice nurses will not escape this shortage,which will have a direct impact on FOL care in the US.Studies have shown that stress from continuously beingfaced witb difficult family dynamics and multiplepatients dying witbin a sbort period of time bas acumulative effect on nurses' coping abilities.^ ' 'Consequently, this stress may lead to burnout andeventually CF, which can challenge a caregiver's abilityto provide services and maintain personal and profes-sional relationships. ** It is important to note thatburnout is tbe physical, emotional, and mental exhaus-tion caused by long-term exposure to emotionallydemanding situations and can be considered a precur-

sor or risk factor for CF. According tosymptoms of CF and burnout are similar; bowever, CFbas a more sudden and acute onset that results fromspecific exposure to trauma and suffering.

Reports from the National Center for Health Work-force Analysis^^ indicate that between 2000 and 2020,the nation's population is expected to grow 18%, andthe subgroup of individuals aged 65 years and older isprojected to grow 54%. As a result, tbere will be anincreased demand for nurses, especially in geriatricsand areas such as hospice care, across the nation. Anexample of this demand was seen in 2002, when 81%of hospice admissions were patients aged 65 years andolder. * Therefore, selecting Florida for the venue ofthis study was an optimal choice because of the state'saging population; however, all nurses could benefitbecause of tbe nation's aging populace projection. Tbisstudy calls attention to tbe risks of secondary traumaticstress reactions in bospice care in order to prevent animpact on tbe integrity of nursing and compromisepatient care.

• PURPOSE OF THE STUDY

Tbe purpose of the study was to describe the prevalenceof the risk of CF in hospice nurses in Florida andexplore the relationship between various nurse cbarac-teristics and CF risk. This study also sought to providea model for predicting the risk of CF from knowledgeof demographic and work-related factors.

Research Question 1: What are the demographic andwork-related characteristics of hospice nurses sam-pled for this study?

Research Question 2: What is the prevalence of the riskof CF among the hospice nurses in the state of Florida?

Research Question 3: What is the nature of therelationship between demographic, hospice work-related factors and the risk of CF?

Research Question 4: What demographic and bospicework-related factors predict the risk of CF?

• METHODS

Design

A non-experimental, correlational (descriptive) designwas chosen utilizing cross-sectional data. The design


also was predictive, because factors found to bestrongly associated with the risk of CF were used asindependent variables in a linear regression analysis.

Setting

At the time of this study there were 40 not-for-profitand for-profit hospice organizations in the state ofFlorida, all of which were queried for participation inthe research. Initially, 17 not-for-profit hospices agreedto participate through mailed surveys. Nurses from anadditional four not-for-profit and one for-profit hospiceparticipated later through surveys completed during theState Hospice Symposium in December 2004, whichprovided an overall 55% facility participation rateacross the state of Florida.

Sample

The target population for the present inquiry includedregistered nurses (RNs), advanced registered nursepractitioners (ARNPs), and licensed practical nurses(LPNs) who met the following inclusion criteria: (1) are18 years of age or older, (2) are employed by a hospiceorganization in Florida, and (3) interact directly withpatients and their families. This population worked inany area of the organization, such as (1) freestandinginpatient hospice facility care, (2) home care, and (3)hospice admissions.

The state of Florida is statutorily divided into 11health service planning districts that provide a frame-work for projections of need for beds or health services.Nurses from all 11 districts were eligible to participatein the study.

Study Variables

Several groups of variables, including demographic/informational, health, and work-related information,were used in this study. The demographic/informationalindependent variables included age, gender, ethnicity,marital status, children in the home, and the responsi-bilities of caring for an elderly or disabled parent orloved one. Health-related variables measured stressorsrelated to finances and the death of a loved one. Otherhealth-related variables questioned headache sympto-mology and diagnoses of hypertension, depression, orposttraumatic stress disorder (PTSD) and the tendencyto self-sacrifice for the needs of patients.

Work-related variables included level of education,licensure, certification, years in the profession and inhospice nursing, work setting, level of care (ie, primarycare, charge nurse), hours of weekly work, shift work,case load, patient-to-nurse ratios, exposure to trau-matic patient death, and number of cases of (directinvolvement with patient deaths per month. Finally,another set of variables measured participants' behav-iors that could lead to CF risk. Examples of thesevariables were "I feel as though I am experiencing thetrauma of someone I have helped" and "As a result ofmy helping, I have sudden unwanted frighteningthoughts."^*^

Data Collection Instruments and Procedures

Two instruments were used in data collection. A de-mographic questionnaire developed by the researcherfocused on demographic, work-, and health-relatedinformation that used theoretical concepts from nurs-ing, medicine, and the social sciences. ' ' ^ The secondinstrument was the Professional Quality of Life Com-passion Satisfaction and Fatigue Subscales: Revision-III(ProQOL-CSF-R-III) developed by Stamm,^° :whoestablished its reliability with a score of .80 forCronbach's alpha. The ProQOL used 30 statementsthat assessed behaviors that could lead to CF '• risk,which was the dependent variable. Participants wereasked to rate each statement as it applied to their cur-rent situation. Each statement was an independentvariable in the study that was analyzed and groupedto produce a CF risk score.

Designated contact persons from each of the 17initially participating hospice organizations distributedpackets containing the instruments, a cover letter, and apostage-paid return envelope to the randomly selectednurses in their respective agencies. The number ofpackets each facility received was based on the resultsof a proportional sampling procedure. Each hospiceprovided the principal investigator with the totalnumber of eligible nurses in the organization. Fromthese reports, each hospice organization's proportion ofthe total Florida eligible population was calculated,adjusted for response rates, and constituted eachorganization's contribution to the study sample. Hos-pice administrators had no access to the completedsurveys because the participants were able to returnthe documents directly to the researcher. Data collec-tion at the Hospice Symposium involved distributing acover letter and the two instruments to the 150 nurse


attendees. They were asked to complete the instrumentsand place them in a designated locked box at the con-ference site, where they were collected by the researcherand secured.

Each facility was identified by a coding process onthe survey forms; however, precautions were taken tomaintain the confidentiality of these mailings andconference surveys, and any identifying informationwas deleted during data entry. Precautions were takenduring the Symposium to prevent duplicate responsesfrom nurses attending the conference who mightalready have completed the instruments in the mail.Outcomes were analyzed and reported as region-specific results and aggregate group results. Individualfacilities were not identified in outcome measures,reports, or publications.

• RESULTS

A total of 583 surveys were distributed through thecombined venues. The mailed surveys yielded aresponse rate of 38.3% {n - 166), whereas thesymposium surveys yielded a response rate of 33%(n = 50). Data obtained from the two venues (mailversus conference) were reviewed using independentsamples t tests, and contingency tables using Chi-squareand Fisher's exact tests, to determine the extent towhich the data collection venue was differentiallyassociated with all relevant variables. Results of thesetests indicated that no factors could potentially con-found the final results.

Civen the foregoing results, data from the twovenues were combined into a single stratified randomsample of 216 usable instruments. This 37% {n = 216)response rate was representative of all 11 health-planning districts across the state of Florida, givingthe study results good generalizability.

Participants (N = 216) were predominantly female(n = 204, 94%) and white {n = 177, 81.9%). Theparticipants' ages ranged from 23 to 76 years, with themedian age being 50.5 years (M = 53.9, SD = 9.05).Most participants in the sample were married (59.7%,n = 129), and approximately a quarter (23.1%, n = 50)were divorced. The average number of years of nursingexperience for the entire sample was 20.19 {md = 20,SD = 11.37), and the average number of years ofhospice experience was 5.65 {md - 4, SD = 5.03).

Of all participating nurses, 101 (46.8%) of thenurses had Associate Degrees in Nursing, and the RNs

{n - 183, 84.7%) were the largest group represented inthe sample, which was not unusual, because this groupencompassed nurses with the associate, diploma, bac-calaureate, and master's degrees. Other licensed nursesincluded 13.4% {n = 29) LPNs and approximately 2%{n = 4) ARNPs.

The sample in this study had a higher proportion ofRNs compared to the licensure distribution of all nursesin Florida, which was RNs {n = 173,000, 62%), LPNs{n = 97,000, 35%), and approximately 9700 (3.4%)ARNPs.-' '-''* One would expect more RNs than LPNsin this field of nursing than in general nursing becauseof the heavy emphasis on case management withina multidisciplinary team setting. The sample in thisstudy can be considered nationally representative ofhospice nurses, because nationally, approximately 86%{n = 16,716) of hospice nurses are registered nurses,whereas 14% {n = 2628) are LPNs. ^

More than half {n - 130, 60.2%) of the nurses werefield nurses who provided hospice care in private homesand made visits to hospice patients in nursing homes orwere continuous care nurses. Approximately one quar-ter of the nurses in the study [n = 50, 23.1%) worked inin-patient hospice units. These nurses noted that theiraverage care ratio was one nurse to approximately sixpatients (M = 5.59, md = 6, SD = 1.31). The nurse-to-patient ratios were higher in this study than theone-to-four ratios recommended by the Center toAdvance Palliative Care.^^ The nurses who did notwork in an inpatient unit reported having an averageweekly caseload of 19.8 {md = 13, SD = 54) patients.Caseloads for this sample of nurses were higher thanthe national median hospice nurse case load {md = 10)as reported by the National Trend Summary Report for2000-2003.^^

The participants' (N = 216) average hours workedper week were 40.5 {md = 40, SD - 10.6); however, theweekly time worked ranged from 8 to 90 hours.Hospice nurses, in general, encounter more patientdeaths than nurses in many other specialties. Within a30-day period, they were exposed to an average ofseven deaths {md = 5.00, SD 8.85), and within the lastyear almost 42% {n = 90) experienced the death ofsomeone close to them.

Risk of CF was operationalized with the ProQOL, asevidenced by a process by which score ranges could becategorized into minimum (<7), moderate (8-17), andhigh (>18) levels for CF risk.-'" For the entire sample,the median score for CF risk was 14 (M = 13.6, SD =6.59). The minimum score was 1, and the maximum


score was 39. Results revealed that 57 (26.4%) of theparticipants were in the high-risk category, 113(52.3%) were at moderate risk, and 21.3% (n = 46)were at low risk. Consequently, nearly 80% (n = 170)of the sampled hospice nurses were at moderate to highrisk for CF.

The study analyzed the prevalence of CF risk for theentire sample and identified specific subgroups forwhich such risk exists. Table 1 identifies severalsubgroup characteristics and relates them to low,moderate, and high CF risk levels. Some of the

characteristics exhibited little or no variability amongthe three risk levels.

Personal health factors and their relationship withCF risk revealed that there was virtually no differencein CF risk categories between cigarette smokers andindividuals who cared for a loved one. However, 35%(M = 17) of individuals diagnosed with depression orPTSD were in the high-risk CF category, as opposed to24% {n - 40) among persons who did not havedepression or PTSD. A greater proportion of individu-als who had financial stress {n = 36, 31%) and persons

I f \« I a B I e" •'- Compassion Fatigue Risk Levels and Nurse Characteristics

! I

Characteristics

Compassion Fatigue Risk Levels

Low Risk Moderate Risk HighlRisk

Age: yearsYears of professional nursingYears of hospice experienceAverage hours worked per week

GenderMale (« = 12)Female {ft = 204)

EthnicityWhite/Non-Hispanic (« = 177)African American (n = 20)Hispanic (n = 6)Asian (n = 5)

Marital statusSingle {« = 24)Married (« = 129)Divorced (n = 50)Widowed (« = 8)

Nursing licensureLPN (« = 29)RN (n = 183)

Nursing educationPractical (« = 25)Diploma (« = 36)Associate (n = 101)Baccalaureate (n = 45)

Professional settingField {n = 130)Inpatient (n = 50)

Personal characteristicsSelf-sacrifice for others (« = 136)Diagnosed with depression/PTSD (« = 48)

Values are presented as median [SD] or n (%).Percent is within each individual characteristic.

52 [10.3]16 [10.8]4 [5.3]

40 [15.3]

3 (25.0)43 (21.1)

37 (20.9)7(35.0)0(0)0(0)

6 (25.0)27 (20.9)

9 (18.0)2 (25.0)

6 (20.7)38 (20.8)

6 (24.0)6 (16.7)

23 (22.8)8 (17.8)

25 (19.2)11 (22.0)

21 (15.4)4 (8:.3)

51 [8.7]20 [11.5]

4.5 [4.8]40 [9.6]

5 (41.7)108 (52.9)

95 (53.7)9 (45.0)4 (66.7)1 (20.0)

16 (66.7)67 (51.9)24 (48.0)

4 (50.0)

15 (51.7)98 (53.6)

11 (44.0)22 (61.1)55 (54.5)22 (48.9)

70 (53.8)26 (52.0)

68 (50.0)27 (56.3)

50'

44 |6'.7j

A I4(33.3)

53 (2^6.0)

45 (25.f)4 (2:0.0)2 (|3.3)4 (80.0)

i \

2 {i2\35 (%7.1)17 (3,4.0)2 (25.0)

8 (2^7.6)47 (2:5:7)

8(i2.0)8 (2^.0)

23 {±.8}15(43.3)

f i35 (Z6.^)13 (2%.O)

47 m.

JOURNAL OF HOSPICE AND PALLIATIVE NURSING • VoL 8, No. 6, November/December 2006 351

who experienced frequent headaches {n = 22, 36.1%)also was in the high-risk category for CF.

Nurses who are inclined to put their patients' needsahead of their own may be prone to paying attention totheir own needs last in other areas of their lives. Thischaracteristic can lead to stress. The subgroup ofparticipants who had a tendency to sacrifice their ownpsychological needs to satisfy the needs of their patients(Table 1) had a much higher proportion of nurses in thehigh-risk category for CF («high risk = 47, 34%) thanthose nurses who answered "no" to the self-sacrificequestion (whigh risk = 10, 13%).

The ProQOL also measured burnout risk andprovided percentile bands for low-, moderate-, andhigh-risk classifications. The results of the prevalencedata indicated that Florida hospice nurses are an at-risk population for burnout and CF, with 91% ofnurses in the moderate- to high-risk category for burn-out also being classified in the moderate- to high-riskcategory for CF. See Table 2 for score summariesamong various percentile bands.

Another component of the study analyzed therelationship between demographic, hospice work-related factors, personal health factors, and the risk ofCF. There was virtually no correlation between partici-pants' age and their scores on CF risk (r = -0.04).Marital status (r - 0.15) and ethnicity {n = 0.20) alsorevealed low correlations.

Correlations did exist between CF risk and whethernurses had experienced a patient's traumatic death(r = 0.24). Although this value was less than expected,the categorical (; = 3) nature of the traumatic deathvariable could have been partially responsible for sucha value. Studies have noted that stress levels rise whennurses do not receive psychological/social support afterthis type of stressor. ^

The investigator's review of the literature'''^^ re-vealed that nurses' work-related variables, such as longwork hours, high patient caseloads, multiple deaths oc-curring within a short period of time, and shift work.

have stressful effects on the individual, which then canlead to burnout and CF. The relationships betweenthese variables and CF risk in this study were positivelycorrelated but smaller than expected.

Five of the work-related variables were selected withinthe ProQOL instrument and analyzed for their associa-tions with the three ProQOL subscale variables. Thesefirst five variables, shown in Table 3, revealed highercorrelations than the other demographic, work-, andhealth-related variables. See Table 3 for correlationalvalues.

A final component of this study analyzed demo-graphic, hospice work-related, and personal healthfactors to predict CF risk. An Ordinary Least Squaresmultiple regression analysis was conducted using vari-ables obtained through a stepwise variable selectionprocess. All variables (demographic, personal health,and work related) were considered for inclusion, andzero-order and semi-partial correlations were used asselection criteria. The regression analyses initially gen-erated three regression models to predict CF risk amonghospice nurses. Subsequently, a total of seven variablesrepresenting each of the first three models were chosento build a composite multiple regression model to pre-dict CF risk. All four models were statistically significant(P < .001), and the seven independent variables ofthe composite model provided 91% {Radn - -907) ofthe information needed to perfectly predict CF risk witha prediction error of 2.01 units. Subglobal tests of theunique contributions of each of the seven variables inthe composite multiple regression model indicatedthat they were all statistically significant (P < .001)except for "feelings of being overwhelmed" (P = .433).Table 4 summarizes the regression models.

The study analysis revealed that stress, trauma,anxiety, life demands, and excessive empathy (leadingto blurred professional boundaries) were key determi-nants of CF risk. These basic themes were threadedthroughout the variables. The variables of each of thefour regression models represented these themes, which

T a b l e 2Burnout and Compassion Fatigue Risk Frequencies for Florida Hospice Nurses

Low Risk" Moderate to High Risk*

BurnoutCompassion fatigue

« = 84 38.9%21.3%

It = 132tt = 170

6L1"..78.7"..

Hmh1 •>

"•Score delineations: Low risk: < 7, moderate to high risk > 8, high risk > 18.

3 5 2 JOURNAL OF HOSPICE AND PALLIATIVE NURSING • Vol. 8, No. 6, November/December 2006

a b I e 3Correlations Between lndepen'deH|/a'and ProQOL Subscale Variabfes-^^

Correlations

Independent Variables

"Infected" by traumatic stressBeing "on edge" due to helpingLosing sleep over patients' traumaFeelings of being overwhelmed by

work and caseloadFeelings of being "bogged down" by

the systemSelf-sacrifice for patients' needs**Financial stress**Fxperienced patient traumatic death*Headaches**Depression/PTSD diagnosis**Ethnicity*Marital status*Average hours work per weekWork setting*Average nurse/patient ratio

*Eta correlation coefficients.**Point biserial correlation coefficients.All others are Pearson Product Moment Correlation Coefficients.

also were linked to theories from nursing, psychology,and biology.

• DISCUSSION

It is not uncommon for nurses in this specialty ofnursing to experience secondary traumatic stress; there-fore, it was not surprising that Florida hospice nursesare an at-risk population for CF. Nearly 80% (n - 170)of the total sample (N = 216) were in the moderate-to-high risk category for CF. The researcher found thatdemographics and work-related factors were of littlediscriminating value for describing the prevalence ofrisk for this phenomenon. This finding implies thatthese nurses possess intricate defense mechanisms tocope with caring for terminally ill patients and theirfamilies, who are often in a state of crisis. These copingabilities may be inherent or may have been learnedfrom years of nursing experience.

Many nurses indicated that they were undergoingfinancial stress or were diagnosed with depression/PTSD. Because PTSD is closely linked to CF,^ it wasnot unusual that participants exhibited higher riskscores, because their coping mechanisms may have beenaffected by their own trauma and health conditions.

The sampled nurses (n = 136, 64%) who tended tosacrifice their own personal and psychological needs forthe needs of their patients had a greater percentage ofsmoking behavior, financial stress, headaches, 'andhypertension than nurses who responded negatively tothat question. This result confirms similar findings inthe literature with respect to the personal healthbehaviors of selfless caregivers.

From a different perspective, 83% (n - 47) ofthesampled participants who were classified in the high-risk category for CF responded positively that they self-sacrifice for others' needs. This finding was importantbecause nurses who indicated that they self-sacrificealso admitted to other health problems resulting fromphysiological stress. This behavior of nurses caringmore for their patients' needs than for their own needsreflects an unhealthy level of empathy, which is a riskfactor for CF. Not only were the nurses who self-sacrificed in a high-risk category but they also exhibitedhigh-risk behaviors.

The researcher in the current study was able to claimthe alternate hypothesis because the results of this studyrevealed that one or more of the independent variablesprovided a significant contribution to the predictionof CF risk. These demographic, work-, and health-related variables reflected the impact that stress has onCF risk, which is exacerbated when nurses exhibit alack of self-care.

The seven variables that predicted CF risk in i thecomposite model were linked to behaviors that cbuldhave been influenced by the multiple independentvariables in this study. These behaviors also revealed acentral theme of the negative effects of overly identify-ing with patients, which resulted in unintentionally,vicariously experiencing their pain and anxiety.This finding was important because unhealthy levelsof empathy, coupled with life demands and healthfactors, are directly related to CF risk and distress.According to Selye,''^ unremitting stress is a cause ofadditional physiological and psychological health con-cerns. Being able to predict CF risk via these risk factorsis paramount to the health and welfare of hospicenurses and their ability to have effective therapeuticrelationships.


T a b l e 4Multiple Regression Model Summaries

Multiple Regression Model Summaries

Full Model Full Model Adjusted Standard ErrorR R^ R^ of the Estimate

Full Modelr Value

MODEL 1*Independent variables

(predictors)MODEL 2**Independent variables

(predictors)MODEL 3 " *Independent variables

(predictors)

COMPOSITE MODEL*Independent variables

(predictors)

0.702 0.493 0.481 4.78 39.705 < .001"Preoccupied with those I help"; feelings of being overwhelmed; bogged down by the system,

self-sacrifice for others' needs; stress from finances0.847 0.718 0.711 3.556 105.785 < .001

"On edge" due to helping; frightening thoughts due to work; memory loss; experiencefrequent headaches; full or part-time work

0.965 0.932 0.930 1.755 401.250 < .001Being "infected" by traumatic stress; "on edge" due to helping; depressed due to helping;

frightening thoughts due to work; situational avoidance; difficulty with personal andprofessional separation; "Preoccupied with those I help"

0.954 0.910 0.907- 2.01 295.874 < .001"Preoccupied by those I help"; difficulty with personal and professional separation; being

"infected" by traumatic stress; depressed due to helping; feelings of being overwhelmed;"on edge" due to helping; frightening thoughts due to work

Independent variable theoretical influences: * = Selye,''^ ** = Neuman,^

In this study, 17% (n = 37) of the nurses indicatedthat they received no support after a patient's traumaticdeath, and 83.3% (n - 31) of those participants were inthe moderate- to high-risk CF category. An inability todebrief after a traumatic event diminished internalcoping mechanisms. This finding confirms the resultsof earlier studies, ' ^ which demonstrated that lack ofsupport after experiencing a patient's traumatic deathhad an itnpact on these nurses. More generally, thehterature supports the belief that lack of support duringoccupational stress and trauma leads to psychological

Nurses who worked shifts (n = 86) in this study hadlower CF risk scores {md = 12.5) than nurses who didnot work shifts {md = 15.00). There was virtually nodifference between CF risk scores of nurses whoworked rotating shifts {md = 13.89) and nurses whodid not rotate {md - 13.62). This finding contradictedSelye,^^ who indicated that working shifts predisposesdifferent occupational groups, including nurses, tophysiological stress and health conditions. One of themain reasons why the findings in this study may haveturned out differently is the unique, highly structuredcoping mechanisms that hospice nurses may possess,which cannot be explained in a quantitative study. Theymay have lifestyles that lend themselves better toevening shift work, which otherwise can disrupt

*** = Figley, ' | = Selye, Neuman and Figley.

families with children. These nurses may be betterorganized to balance the stress of long, 12-hour shiftsand perhaps a rotating shift schedule, still find time tomaintain a household, and sustain their relationshipswith significant others. Stress also is muitifactoriai;each factor builds upon others differently in differentpeople, so an impact on CF may not be observed easilyby one or two variables alone.

This study measured the risk of CF at one point intime. There is a possibility that perceptions may havechanged over time due to individual circumstances.There also may have been a general disinterest in thestudy due to the focus on the aftermath of hurricanes in2004. All Florida hospice facilities were invited toparticipate in this study; however, no effort was madeto follow up with hospices in areas that may have beenmost adversely affected by these storms. Although theoverall response rate was 37%, it was not a truelimitation according to Norwood,^^ because the aver-age return rate for mailed surveys is 20%.

This research has shown that hospice nurses are ata moderate to high risk for CF. They experience,on average, seven patient deaths per month and mustcommunicate compassionately and professionallywith distraught families before, during, and after thedying process. Therefore, these nurses may be at riskfor increased absenteeism and an exodus from the


profession, which results in lost revenue for the or-ganization. More difficult to measure is the loss whenan experienced hospice nurse leaves the profession. Onaverage, hospice nurses have more than 20 years'nursing and hospice nursing experience. Not only isthere a financial impact on the organization when theyleave the profession but there is also a huge loss ofmentorship to newer nurses and a loss of establishedrelationships with physicians.''^

This study was able to fill some of the gaps inliterature; however, others still exist, such as compari-son studies of larger populations, analysis of existingpolicies in relation to CF risk, and implementation ofqualitative studies to provide greater depth to quanti-tative findings.

CF is a preventable and treatable phenomenon. Hos-pice organizations with policies, interventions, andevaluation methodologies that address CF risk mayresult in substantial employee benefit cost savings,uninterrupted professional nursing care, and increasedpatient family satisfaction and may continue to beregarded highly in communities as an optimal choice inEOL care.

Acknowledgments

The authors would like to thank Mr. Paul Ledford andthe staff at Florida Hospices and Palliative Care, Inc.for their support by promoting the study and providinga venue for this research. They also would like to thankDr. Charles Figley, PhD for his support and encourage-ment throughout this process and Mr. John Abendrothfor editorial feedback.

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Documents

Predicting the Risk of Compassion Fatigue