Concept timeouts for nurses working in high acuity

Concept Analysis
Christine Johnson
Chamberlain College of Nursing
NR 501: Theoretical Basis for Advance Nursing Practice
September 2018

Concept analysis is a way to examine an idea of interest. The concept is broken down into smaller parts to make it easier for nurses to understand (Walker & Avant, 2011). The concept presented in this paper, compassion fatigue, is the state of exhaustion related to prolonged exposure to difficult patient situations. It involves a decline in a person’s energy, the ability to empathize with a patient’s suffering and a loss of personal satisfaction. (Harris & Griffon, 2015). This paper will address compassion fatigue through the lens of Watson’s Caring Theory (1997). A literature review will discuss researched themes and facts about the topic and empirical referents will be identified. Common attributes, antecedent and consequences of compassion fatigue will be discussed, and three case studies will be presented to illustrate the concept.
Literature Review
In the article by Harris and Griffin (2015), compassion fatigue was further defined, and recommendations were made. The article focused on making changes at the structural level. They suggested having specific education about compassion fatigue, timeouts for nurses working in high acuity areas, sharing the care of critical patients, and quiet rooms for staff as protective mechanisms to avoid compassion fatigue.
An international study was done by van Mol, Kompanje, Benoit, Bakker and Nijkamp (2015) of compassion fatigue in intensive care nurses. Nurses working on the ICU are exposed to high stress daily and are exposed to suffering frequently. Although ICU nurses are challenged both emotionally and physically, the study found that a lower percent of compassion fatigue was found in the ICU compared to other hospital units (van Mol et al., 2015). The article suggested that this contradictory result might be due to personal factors like emotional intelligence and resilience, and/or through environmental factors, like education, organizational culture or the differences between countries.
Kelly, Runge and Spencer (2015) in their research on predictors of compassion fatigue, found the nurses from the “Millennial” generation were more likely to experience compassion fatigue than their colleagues in the “Baby Boomer” generation. The fact that younger generations of nurses are suffering from compassion fatigue may be contributing to them leaving nursing early in their career. This article showed that compassion satisfaction can be increased with meaningful recognition by leaders. Recognition leads to increased job satisfaction which has the potential to fight compassion fatigue.
Prevention against and management of compassion fatigue was discussed in a research project by Nolte, Downing, Temane and Hastings (2017). Lack of support and poor coping skills were identified as precursors to compassion fatigue. The metasynthesis identified strategies for prevention that included selfcare, mindfulness and the development of compassion fatigue resiliency. The authors suggested their theoretical model could guide future research.
Many studies have investigated the harmful impact of compassion fatigue on professional nurses’ well-being, but very few address the impact compassion fatigue has on nursing students. In a study of undergraduate nursing students conducted by Michalec, Diefenbeck and Mahoney (2013), students were asked about their experiences with compassion fatigue. Students scored low to average in all of the predictors of compassion fatigue. The data found that students in the protected environment of nursing school are not as exposed to the harmful effects of compassion fatigue.
Stamm’s (2010) Professional Quality of Life Scale is frequently used to measure the risk of compassion fatigue. Kate Shepperd (2014) in her two-part research argues that this measure may not properly measure compassion fatigue. The study suggest that only secondary traumatic stress and compassion satisfaction are factors in compassion fatigue. Since the ProQOL measures burnout a new measure needs to be used.
Empirical Referents
The most common empirical referents used to identify compassion fatigue are emotional exhaustion, depersonalization, and personal accomplishment (Maslach, 1986). The Maslach Burnout Inventory is a tool, commonly used to measure these referents and experiences of burnout. The Professional Quality of Life Scale (ProQOL) is a 30-item questionnaire that measures the positive and negative effects nurses feel when caring for patients who are suffering. It is a tool that assesses the empirical referents of compassion satisfaction and compassion fatigue through questions measuring secondary traumatic stress and burnout.

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Defining Attributes
Nolte, Downing, Temane and Hastings (2017) attribute emotional exhaustion, depersonalization, reduced work performance, and loss of personal accomplishment to compassion fatigue. Emotional exhaustion is a feeling of being overextended or overwhelmed in the workplace. Depersonalization has been described as “unfeeling” or a sense of seeing patients as objects instead of humans. The loss of personal accomplishment relates to feelings of incompetence and in inability to perform as a nurse (Nolte et al., 2017). According to Harris and Griffin (2017), attributes related to compassion fatigue are a low energy, low desire, and the inability to nurture, care for, or empathize with patients who are suffering which often leads to a loss of work-related satisfaction.
Antecedents are defined as events that must happen before the existence of the concept. The most common antecedent to compassion fatigue is the prolonged witnessing of suffering, grief and despair of patients (Nolte et al., 2017). Other researchers identify a nurse’s spirituality, emotional investment and high use of self, as key antecedents (Harris & Griffin, 2015).
The most obvious consequences of compassion fatigue are poor performance at work and health related issues (Harris & Griffon, 2015). More specific consequences include inability to sleep, hyper-vigilance, fear, anxiety, difficulty concentrating, tight muscles, fatigue, hopelessness and isolation. A decreased sense of fulfillment, spiritual emptiness, helplessness, feeling disconnected, dissatisfaction with nursing and a lack of motivation are also identified (Nolte et al., 2017). Since compassion fatigue negatively affects the physical and mental health and job performance of nurses, patient care and safety become a factor.
Case Models
Beth has been a registered nurse on a demanding and continuously high stress intensive care unit for eight years. Coworkers characterize Beth as kind and empathetic with a unique ability to bond with her patients. In the past week Beth has had two patients die on her shift. Both patients had been on the unit for several weeks with Beth as one of the primary caregivers. Since the death of the second patient, Beth has had trouble sleeping, so at work, she fatigued and has difficulty concentrating. She started referring to patients by diagnosis and room number instead of name as before. She began refusing to take the most critically ill patients for fear she would “kill” them. She told coworkers that she was thinking of leaving the unit and was fed up with nursing. In this model case, Beth exhibits many of the attributes and consequences of compassion fatigue. Her long term, continuous exposure to the suffering of patients meets the criteria for an antecedent of compassion fatigue. Attributes and consequences of compassion fatigue are expressed in exhaustion from lack of sleep, depersonalization of her patients by referring to them as a diagnosis and fear of critical patients. She also speaks of leaving nursing and does not trust herself.
Mark is a nurse on the same intensive care unit. He has been on the unit for one year and is one of the other nurses who took care of the two patients who died last week. After the patients died, Mark became emotional and felt sadness for the families. He went home feeling tired and was able to sleep as usual. The next day he began referring to patients as “bed 3 or the sepsis patient” because he heard Beth use this kind of language. He remained confident about his abilities as a nurse and was looking forward to a long career. Although exposed to the same high stress environment, Mark has only been on the unit a short time. His exposure to suffering is much less than Beth’s, but still fulfills one antecedent of compassion fatigue. Mark did begin to show signs of depersonalization as he referred to his patients in terms of diagnosis, but it may have been in response to Beth’s description. In this borderline case, the attributes that were missing were, emotional exhaustion and loss of personal confidence.
Betty is a senior nurse on the intensive care unit. She has been on the unit for her entire career and is ready to retire. Last week when the two patients died, Betty was at the bedside and helped Beth and Mark with the post mortem care. Through self-reflection and a high self-efficacy, Betty has developed strategies to cope with the loss of patients. She feels privileged to assist patients at the end of their lives and is expert at consoling families and coworkers in distress. When Betty went home after the incident she felt satisfied that she had given her best that day and will continue to do so. In this contrary case, Betty had the antecedent to compassion fatigue because she had prolonged exposure to suffering but had none of the attributes. She did not depersonalize, did not feel emotional exhaustion and even had increased feelings of personal accomplishment.
Theoretical Applications
The relevant theory addressed in compassion fatigue is Watson’s (1997) Theory of Human Caring. According to Watson caring is a relationship in which the nurse and the patient are fully present and feel a connection. The “transpersonal caring relationship” is a special kind of relationship that goes beyond detached assessment to a deeper meaning (Bayuo, 2017). Compassion fatigue can be caused by a natural and intrinsic response of the nurse to the alleviate pain and suffering of a patient with whom he/she has a relationship. When the nurse can’t protect or save the patient from suffering or death, compassion fatigue can be the result. (Michalec, Diefenbeck & Mahoney, 2013).
In summary, Watson’s (1997) theory of caring helps us understand that nurses develop compassion fatigue because they genuinely care for their patients and find it difficult to watch them suffer. Researchers have identified the specific attributes, antecedents and consequences of compassion fatigue. Strategies have been suggested to predict and alleviate the harmful effects of compassion fatigue on nurses. It was also found that a nurse’s age may affect the development of compassion fatigue. As a future nurse educator, I was particularly interested in the article about nursing students and compassion fatigue written by Michalec et al., (2013) that suggested introducing students to the concept of compassion fatigue could help them identify and be prepared for the concept in their future practice. I feel that the research I have done and the strategies I have learned in this paper will give me the advantage to be an effective coach of this topic.


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