Research in Gerontological Nursing

Empirical Research 

Compassion Fatigue Among RNs Working in Skilled Nursing Facilities

Marlene M. Steinheiser, PhD, RN, CRNI; Janice D. Crist, PhD, RN, FWAN, FAAN; Kimberly D. Shea, PhD, RN, CHPN

Abstract

Nurses employed in skilled nursing facilities (SNFs) are at risk for developing compassion fatigue. Compassion fatigue negatively impacts patient outcomes and is associated with decreased quality of care. Some nurses leave the profession due to compassion fatigue. There are no published studies in the United States focused on compassion fatigue among SNF nurses. The purpose of this interpretive phenomenological study was to identify the shared meanings of compassion fatigue among RNs caring for residents in SNFs. Shared meanings among participants were identified as: (1) I feel conflicted, which causes my compassion fatigue; (2) I feel physical and emotional manifestations of compassion fatigue; (3) Compassion fatigue is infused in every aspect of my life; and (4) We are trying to cope with compassion fatigue. Of paramount importance was the desire to make a difference in the lives of residents. Three participants sought employment outside the SNF setting due to compassion fatigue. Further research and education are needed to improve knowledge, policy, and practice. [Research in Gerontological Nursing, xx(x), xx–xx.]

Abstract

Nurses employed in skilled nursing facilities (SNFs) are at risk for developing compassion fatigue. Compassion fatigue negatively impacts patient outcomes and is associated with decreased quality of care. Some nurses leave the profession due to compassion fatigue. There are no published studies in the United States focused on compassion fatigue among SNF nurses. The purpose of this interpretive phenomenological study was to identify the shared meanings of compassion fatigue among RNs caring for residents in SNFs. Shared meanings among participants were identified as: (1) I feel conflicted, which causes my compassion fatigue; (2) I feel physical and emotional manifestations of compassion fatigue; (3) Compassion fatigue is infused in every aspect of my life; and (4) We are trying to cope with compassion fatigue. Of paramount importance was the desire to make a difference in the lives of residents. Three participants sought employment outside the SNF setting due to compassion fatigue. Further research and education are needed to improve knowledge, policy, and practice. [Research in Gerontological Nursing, xx(x), xx–xx.]

Limited health care resources are placing greater demands on nurses to provide quality care for patients with complex needs (Nolte et al., 2017). As a result of these demands, nurses are becoming emotionally saturated, unable to nurture and care effectively for others (Nolte et al., 2017; Sheppard, 2016). As the population of older adults being cared for in skilled nursing facilities (SNFs) continues to rise, the shortage of trained nurses in SNFs is compounded when emotional saturation or compassion fatigue causes nurses to leave the profession (Hawkley et al., 2018; Sheppard, 2016). Because there are no studies inclusive of compassion fatigue among nurses working in SNFs, little is known about the meaning of compassion fatigue among this specialty of nursing. The purpose of the current interpretive phenomenological study was to discover the shared meanings of compassion fatigue among RNs working in SNFs. The specific aims were to identify: (a) contributors (triggers, situations, or patient characteristics) to symptoms of compassion fatigue, (b) associated physical and emotional symptoms, and (c) short-term out-comes for nurses and resident care of unresolved compassion fatigue.

Nurses are exposed to the suffering of their patients when caring for and spending time with them (Melvin, 2015). As a result of helping others who are ailing, nurses can develop positive feelings, such as compassion satisfaction, or they can develop negative feelings, such as compassion fatigue (Stamm, 2012). Compassion satisfaction is defined as the positive feelings related to helping another person and is vital to motivating an individual to help others (Figley, 2002). The opposite of compassion satisfaction is compassion fatigue, originally characterized as the cost of caring (Figley, 1995, 2002). Compassion fatigue is a stress response from being emotionally overwhelmed when providing care for others (Stamm, 2012). Compassion fatigue comprises two components: burnout and secondary traumatic stress (STS). Burnout involves negative feelings about the work environment, is associated with feeling as if one's efforts do not make a difference, and can be associated with a non-supportive work environment (Stamm, 2012). STS, also work-related, is an internal emotion associated with exposure to a patient's trauma or suffering (Stamm, 2012) (Figure 1).

Professional Quality of Life Model (Stamm, 2012). Reprinted with permission from The Center for Victims of Torture. (2019). Professional quality of life measure.https://proqol.org/Customize_a_Presentation.html

Figure 1.

Professional Quality of Life Model (Stamm, 2012). Reprinted with permission from The Center for Victims of Torture. (2019). Professional quality of life measure.https://proqol.org/Customize_a_Presentation.html

Compassion fatigue for nurses can manifest in physical, emotional, and psychological symptoms, such as headaches or gastrointestinal issues, anxiety, forgetfulness, feeling hopeless, reduced empathy, and a lost sense of pride as a nurse (Nolte et al., 2017; Sheppard, 2015, 2016). Nurses experiencing compassion fatigue may have decreased focus leading to patient errors, use sick time more often, become less engaged with patients and families, and even leave their jobs (Ariapooran, 2014; Hegney et al., 2014; Joinson, 1992; Sheppard, 2016). These physical, emotional, and work-related issues affect patient care, nurse–patient relationships, and nurses' professional quality of life (Sorenson et al., 2016).

Nurses caring for older adults in SNFs are faced with a variety of challenges, both organizational (e.g., lack of support, physically strenuous work, high quality of care demands with limited resources) and patient related (e.g., multiple comorbidities, emotional and cognitive struggles, losses of function, independence and health, end-of-life [EOL] care, feelings of inability to change some aging health outcomes), which are compassion fatigue risk factors (Huskamp et al., 2012; Kolthoff & Hickman, 2017; Kubicek et al., 2013; Mooney et al., 2017). Patients can be SNF residents for many years. The longer the duration of the nurse–patient relationship, the greater the chance the nurse may become overly involved with the patient, possibly leading to blurred professional boundaries (Melvin, 2012; Nolte et al., 2017). Prolonged, repeated, continuous, or intense exposure to suffering and relationship losses causes nurses to be more emotionally vulnerable (Melvin, 2012). Nurses who provide EOL care also report associated physical, emotional, and boundary-setting stresses (Melvin, 2012; Slocum-Gori et al., 2013). Repeated exposure to death strains nurses' professional quality of life, leading to greater emotional upheaval (Melvin, 2012). It is common for SNF nurses to experience these compassion fatigue risks repeatedly.

Although compassion fatigue and its consequences have been described in the literature as reported above, the literature review revealed that no studies inclusive of compassion fatigue within gerontological nursing in SNFs have been conducted. Findings from the current research study address this gap in the literature by providing a qualitative study with the purpose of understanding the experiences of RNs who care for older adults in SNFs and factors that contribute to compassion fatigue. The researcher (M.M.S.) chose the hermeneutic interpretive phenomenological methodology aimed at discovering the shared meaning of compassion fatigue among RNs caring for older adults in SNFs. Through increased understanding of the experiences of these nurses and contributors to compassion fatigue, tailored interventions can be aimed at improving professional quality of life and reducing the negative outcomes of compassion fatigue.

Method

Phenomenology, a philosophy and research method, can assist in the understanding of complex and situational nursing questions (Munhall, 2012). Hermeneutic phenomenology guides the discovery of a shared meaning co-created by participants and researchers (Fleming et al., 2003). The hermeneutic circle is the process of understanding the shared meaning by conducting multiple interviews, which assists in learning new ways of viewing a phenomenon as participants and researchers engage in dialogue over time (Annells, 1996). The past and present horizons of the research participants and researchers fuse over time to form a shared meaning (Annells, 1996; Crotty, 1998). The first author/researcher (M.M.S.) obtained human subjects' approval; recruited and consented participants; maintained a data trail and journal log; and collected and managed data. The researcher's dissertation chairperson contributed during the data analysis process by reviewing participants' audiotaped interviews, the researcher's journals, and the interview transcripts to help guide the researcher in development of themes.

Human Rights Protection

The study received approval from the University of Arizona Institutional Review Board (IRB).

Sampling

Inclusion criteria were English-speaking RNs, age ≥18, who had ≥1 year of experience caring for older adults in SNFs. Therefore, any RN meeting the inclusion criteria who consented to engage in a discussion about compassion fatigue was eligible to participate in the study. Directors of Nursing (DONs) who provide direct patient care were also included in the sample population. No one was excluded based on gender or ethnicity. The projected sample ranged from eight to 12 participants. After IRB approval, participants were recruited with the assistance of key nursing leaders and snowball sampling. Sampling continued until saturation occurred, as evidenced by no new contributors, symptoms of compassion fatigue, or short-term outcomes emerging during concurrent data analysis (Francis et al., 2010; Sandelowski, 2000).

Setting

Interviews were conducted in locations preferred by participants to foster privacy as they shared their experiences. Local library and hospital meeting rooms were used to conduct interviews for five participants. The remaining three participants chose to meet in office meeting rooms at their SNF.

Recruitment Procedures

After IRB approval, a list of SNFs and their associated leaders was obtained using public listings, such as in the Arizona Health Care Association and Arizona Department of Health Services directories. SNF leaders, DONs, and administrators who could help access nurses working in SNFs were contacted by email and telephone. The study purpose, intent for outcomes, and recruitment flyer were discussed. SNF leaders then distributed the recruitment flyer to RNs who they believed met the inclusion criteria and posted it in facility break rooms. Interested participants were screened for eligibility and provided study information during a 10-minute telephone interview. If the participant met eligibility and wished to participate, then a private meeting room in the participant's desired location was determined. During the first meeting, participants had opportunities to ask the researcher questions before review of the disclosure statement.

Data Collection

Prior to starting the interviews, the purpose of the study and human rights protections were reviewed, followed by a review of the disclosure statement. Data collection included three face-to-face open-ended audiotaped interviews, each lasting approximately 1 hour, using the hermeneutic approach, conducted with each participant. Open-ended questions fostered conversation and were designed not to be answered by yes/no responses (Percy et al., 2015). Participants were asked demographic information including an open-ended question to describe themselves personally and professionally. Participants were also prompted with a simple open-ended statement: “Tell me a bit about yourself and your current role in nursing.” This introductory statement was used with each participant. This brief background information was requested to gain an understanding of participants' work history and their personal lives.

Multiple interviews with each participant were conducted because understanding of the phenomenon could change over time and the participant–interviewer relationship could become more casual allowing further exploration of participants' meanings (Fleming et al., 2003; Koch, 1996). After participants described themselves personally and professionally, they were asked an overarching question to describe their meaning of compassion fatigue. During subsequent interviews, participants were asked questions about the key points from the first interview. During the final interview, interpretations of participants' central concerns were reviewed with each participant to see if experiences or thoughts from other participants had meaning to them. In addition, participants were asked how they felt about the term compassion fatigue and how they thought nurses move through compassion fatigue. Throughout the interview process, vocal fluctuations, facial expressions, body language, and gestures were documented in field notes and later integrated into the analysis of the text (Crist & Tanner, 2003; Fleming et al., 2003). Through feedback with participants and further discussion during subsequent interviews, the hermeneutic circle was entered to enable a shared meaning of compassion fatigue to emerge (Fleming et al., 2003).

Journaling was used to include the researcher's pre-understandings identified prior to data collection, during data collection, and with data analysis in an attempt to acknowledge preconceived notions and changing pre-understandings. Data collection and analysis were an iterative process (i.e., between interviews, data analysis included reflection upon field notes and interview transcriptions to formulate understanding of participants' experiences, directing lines of inquiry for subsequent interviews). Any inconsistencies between non-verbal observations and the text noticed in early interviews were explored with participants during later interviews. Data collection occurred over a span of 2 months.

Data Management

Data collection included audiotaped interviews and the corresponding transcription, field notes to include observations of non-verbal data, and the researcher's journal with acknowledgement of prior knowledge and post-interview reflection. Audiotapes were professionally transcribed verbatim immediately after each interview to assure accuracy and allow the researcher's immersion into the data. Atlas.ti version 8 software was used to review the interview transcripts, sentence by sentence, to identify participants' meanings of compassion fatigue. As meanings were coded as themes for later development of shared meanings, Atlas.ti software was used for data organization allowing for concurrent data collection, analysis and reflection, and to guide future interviews. The use of Atlas.ti also provided a clear audit trail contributing to trustworthiness and increasing the rigor of the research.

Data Analysis

Data sources were written text, documented observations, and the researcher's journaled self-reflections. The researcher used a simultaneous process of reflection during interviews and examination of the text, and interpretation was used to accurately illustrate the shared meaning of compassion fatigue (Gadamer, 2004). Data analysis moved from the whole to the part and back to the whole (Fleming et al., 2003). By gaining an understanding of the whole text, greater understanding of how the whole influences the parts was obtained. Every sentence or section was examined for meaning in understanding the phenomenon and to discover themes. During data analysis, the researcher's dissertation chair provided input by reviewing text with the corresponding themes. Continual self-reflection and journaling occurred throughout the data analysis process acknowledging pre-understandings and biases as they existed and changed (Annells, 1996). The researcher reviewed her journaled self-reflections and reexamined emerging themes challenging any preconceived understandings or meanings. When understandings were changed, meanings were re-coded in Atlas.ti and themes shifted to reflect the researcher's understanding of the shared meanings. Documented pre-understandings challenged themes and sometimes themes challenged the researcher's pre-understandings. Each sentence or section was then related back to the whole text (Fleming et al., 2003). The researcher's final step was to arrange the themes on a large chart to assist in visually grouping themes while forming the shared meanings. This data analysis approach, based on the hermeneutic philosophy, was essential to gaining understanding of the phenomenon. By incorporating the hermeneutic circle, participants' and the researcher's input validated and clarified the analysis to form shared meaning (Fleming et al., 2003; Gadamer, 2004).

Scientific Rigor

Trustworthiness, credibility, objectivity, confirmability, and auditability were demonstrated by self-reflection, use of direct quotes, record keeping, and participant feedback and clarification (Fleming et al., 2003; Lincoln & Guba, 1985; Sandelowski, 1986). In addition, because biases from one's history form one's consciousness, which makes it impossible to separate one's histories to be objective, the researcher journaled prior to and throughout the simultaneous data collection and data analysis to understand personal feelings, the effect of these feelings on emerging findings, and to incorporate this understanding in the research study findings (Fleming et al., 2003). By journaling and reviewing the journal throughout the data collection and analysis process, the researcher remained open to exploring data that were not originally part of her assumptions.

Results

Participants' ages ranged from the 30s to mid-60s, with 1.5 to 45 years of nursing experience. Nursing was a second career for several participants. Participants (N = 8) were all English-speaking RNs who worked with older adults in a SNF for at least 1 year. Two participants were DONs; one was a nursing supervisor; and the remaining five were staff nurses who worked day and night shifts. All participants were female. Each participant was supplied with a pseudonym (Table 1).

Participant Demographics

Table 1:

Participant Demographics

Four shared meanings emerged: (1) I feel conflicted, which causes my compassion fatigue; (2) I feel physical and emotional manifestations of compassion fatigue; (3) Compassion fatigue is infused in every aspect of my life; and (4) We are trying to cope with compassion fatigue. Participants often used terms such as “resident” when discussing patients, which reflected the SNF environment and philosophy that the SNF was the patients' home. In the following description of shared meanings, participants' direct quotes are included in the narratives to promote rigor.

I Feel Conflicted, Which Causes My Compassion Fatigue

This shared meaning represented how the nature of participants' daily work created emotional conflict. Emotional conflict stemmed from the challenges of caring for residents and their families, the nature of the nurse– resident relationship, the work environment, personal circumstances, and coping with routine resident death. Living with emotional conflict ultimately caused symptoms of compassion fatigue.

Participants described the challenges of caring for residents who were verbally abusive, demanding, combative, and confused. Many participants tearfully described their conflicting feelings of exhaustion and frustration when caring for their most “challenging” residents, but also reported that they experienced significant grief when these same residents died. One participant explained, “…it's the ones that require the most attention or the ones that was [sic] most combative, whatever, that I had to be the most careful of that I cry over the most.” The most difficult residents, who were demanding, cognitively impaired, and most physically in need of nursing care, provoked feelings of fondness and love among participants.

Participants described feeling frustrated by wanting to provide residents with optimal care while lacking the time or resources to provide that care. One participant described caring for residents with dementia. She became tearful and frustrated that she could not spend more time with these residents and did not want to just resort to giving medications to control residents' dementia symptoms. Participants desired to provide excellent care, which was fractured by the imbalance of residents' care needs and nurses' resources, such as staffing and management support.

Participants genuinely cared for residents and were fond of them, which created a “family like” feeling. Participants also formed a connection when they cared for some residents for a long period of time, and frequently the source of sadness was feeling lack of closure when the resident died. Each participant felt energized when she could make a difference, but also felt sad and frustrated because many times she could not make a difference. Her inability to make a difference was related to the resident's inevitable disease progression or work constraints, such as limited staffing ratios and resident care resources, or lack of management support. All participants expressed the paramount need to make a difference in the lives of residents with nursing care and shared that any impediments to this caused emotional conflict. Interactions with residents provoked emotion: “It's energizing in what I can gain from them and I just like people and I get energized when I interact with people. But it's draining when I lose them.”

Because of work constraints, many participants believed they had to “do more with less” and reported feeling too task oriented. All participants reported various work-related stressors and “juggling many roles,” which diverted their time and attention away from resident care and created feelings of hopelessness and frustration. One participant said, “I just think I'm slinging meds like I'm slinging hash. There's just no time…. If I don't have time to do this basic human comfort, something's gotta change.” As a result of work environment challenges, three participants left or planned to leave the SNF care setting.

Physical and Emotional Manifestations of Compassion Fatigue

This shared meaning is identified in the expressed physical and emotional symptoms of compassion fatigue. Several participants described antecedents and symptoms of compassion fatigue but did not initially self-identify with the term compassion fatigue. During the course of the three interviews, two participants self-identified with symptoms of compassion fatigue. After self-identifying with compassion fatigue, these two participants' demeanors changed from tearful to forward-looking.

Participants volunteered experiences with some physical symptoms of compassion fatigue. Reported symptoms were sleep disturbances, weight loss or gain, loss of energy, headaches, and gastrointestinal disturbances. Sleep disturbances was the most commonly reported physical symptom.

Many participants described feelings of frustration, worry, anger, and being drained by constant caregiving. Frustration stemmed from two sources: the work environment and residents themselves. After sharing their frustrations, participants were eager to offer a statement about how deeply they cared for residents. Frequently, their worries were associated with being emotionally drained by “worrying when you're not at work, which makes you tired.” Descriptions included worries about residents' declining status, residents who were without any family, unhappy families, wondering if there were more they could have done for residents, or second-guessing their nursing actions. Some participants associated a feeling of anger when they wished they could do more or missed the signs of a resident's health decline.

Participants reported that continual sadness was just part of their job. Sources of sadness included routinely having residents die, feeling unable to provide safe care for residents, or feeling frustrated and helpless to make positive changes in care. In most cases, the continual sadness was normalized as an inherent part of nursing. Most participants believed that their symptoms of compassion fatigue were a result of recurrent sadness. Some participants reported crying from frustration, feeling helpless, and even experiencing depression. One participant soberly said:

…to have somebody that was part of your shift day in and day out, and you're providing care for them, and then all of a sudden, they're not there. It's just an empty spot. You walk by their room, and the bed's stripped of its linens, and the plastic mattress is there.

Compassion Fatigue Is Infused in Every Aspect of My Life

This shared meaning represented how compassion fatigue impacted overall quality of life at work and at home. All participants recalled a time when they felt close to a resident whose health deteriorated or who died, and even became tearful when discussing death. Frequently, the death of a resident caused participants to actively work to avoid getting emotionally close to another resident, and the emotional distancing served to “protect their heart” from future grief. They also wondered if the emotional distancing equated to a loss of compassion, and then frequently shared feelings of guilt or shame about any perceived loss of compassion. One participant shared her concern about her compassion stating, “I hope it's not being slowly, you know, burned and killed off, never to, you know, have it again.”

Many participants described the mental and physical impact that compassion fatigue symptoms had on their personal lives. Some participants lost interest in engaging in social activities and even isolated themselves from family or friends. Work-related thoughts and worries frequently interfered with usual activities of daily living, such as washing dishes or doing homework with their children. Participants used the term “shutting down” when they described how symptoms of compassion fatigue impacted their home life and when they avoided initiating social encounters. Some participants volunteered that they neglected their self-care by not taking time off from work, exercising, eating properly, or hydrating adequately. Several participants reported being forgetful or scattered and even experiencing memory loss. These symptoms of cognitive dysfunction affected their personal lives and their daily work. One participant described this situation as a “loss of focus, even when I'm not at work. And I thought I was the only one. I'm seeing it in the nurses now.”

Many participants related their challenging work environment to resulting symptoms of compassion fatigue, which ultimately impacted their work performance and desire to stay in the practice setting. Most participants listed the challenges of low staffing; the high level of residents' cognitive, emotional, and physical needs; and lack of management support as inhibitors to their ability to provide safe patient care leading to feelings of compassion fatigue. One participant associated forgetfulness and “being scattered” as symptoms of compassion fatigue and thought this attributed to real and potential patient errors.

We Are Trying to Cope With Compassion Fatigue

This shared meaning represented the way participants coped with compassion fatigue and situations that energized them, in addition to the need for further help to cope. Several participants described coping with use of spirituality, positive self-talk, and prayer. Other methods used to cope with compassion fatigue were “sleeping it away,” music, journaling, massage, meditation, and coloring. Some participants said they gained verbal support from coworkers, family, and spouses. When coping with death, some participants said they shared memories about the resident with coworkers and sometimes expressed their grief with laughter. Another participant reported that she daily rationed out her compassion based on what she felt she had left, stating, “I'm definitely picking and choosing who I am giving my compassion to.”

Each participant stated that she desired help and lacked a formal facility grief support plan and the time to process her grief. Most participants believed they were expected to just manage their grief on their own. Participants said that they relied on their own personal support systems, including coworkers and family, to help grieve. One participant said:

We're providing care for these people, and we get to know them, and they get to know us, and it's sad that things end so abruptly. And it would be nice to have closure. So, I kind of felt sad about not having that closure.

Discussion

As stated above, there were no published studies inclusive of compassion fatigue among RNs working in SNFs in the United States to the authors' knowledge at the time of this research. Although some reported findings align the description of compassion fatigue among SNF nurses within current literature, other findings support nuances in the meaning of compassion fatigue among SNF nurses. Findings in the current study, which are unsupported by existing literature, provide a new perspective that contributes specifically to gerontological nursing literature about SNFs.

Similar to previous research, participants experienced work environment and resident care challenges found to be common in SNFs (Huskamp et al., 2012; Kolthoff & Hickman, 2017; Kubicek et al., 2013; Mooney et al., 2017). These challenges contributed to participants' conflicted feelings of frustration with their most “challenging” residents, but also significant grief when these same residents died. As a result of these conflicted feelings, participants described physical and emotional symptoms of compassion fatigue, such as sleep and gastrointestinal disturbances, sadness, and emotional exhaustion. Existing literature also reports that feelings of compassion fatigue led to loss of compassion, emotional distancing from residents, decreased social interaction, self-care neglect, real and potential patient errors, and decisions to leave the job (Ariapooran, 2014; Hegney et al., 2014; Joinson, 1992; Kubicek et al., 2013; Nolte et al., 2017; Sheppard, 2015, 2016; Sorenson et al., 2016). Participants felt guilt and shame and were reluctant to admit their loss of compassion because compassion is viewed as fundamental to nursing (Sheppard, 2015). Participants reported continual sadness, which they associated with frequent resident deaths as they formed a nurse–resident connection over a prolonged time period becoming emotionally invested (Melvin, 2012; Nolte et al., 2017). As a result of these challenges, three participants left the care setting contributing to the nursing shortage in SNFs (Hawkley et al., 2018; Sheppard, 2016).

In contrast to current literature, the central concern of making a difference in the lives of residents created an energizing feeling, yet participants felt sad when they were unable to make a difference due to the work environment, residents' deteriorating conditions, or resident deaths. When describing their feelings of compassion fatigue, participants reported their use of distancing from residents to “protect their heart” from future grief when being unable to make a difference. Participants' conflicted feelings of energy when providing EOL care yet saddened by death are also not documented in the literature. Participants' experiences of frequent resident deaths without grief support led to continual sadness, which was normalized.

Limitations

There were several limitations in the current study. Nurses elected to participate after they read the recruitment flyer, which contained a limited list of compassion fatigue symptoms. This information may have created bias within participants or deterred others from participating. The researcher's experience within the SNF care setting and understanding of nurses' roles could have been considered a benefit because her experience assisted her in understanding participants' responses in context of their role and directed her to new lines of inquiry. However, her experience may also have influenced her understanding of participants' perspectives (Gadamer, 2004). Journaling pre-understandings assisted the researcher in achieving objectivity, but complete objectivity is not possible (Fleming et al., 2003). Another potential limitation is that all participants were female, and all were drawn from a relatively small geographic area, possibly limiting transferability of findings (Lincoln & Guba, 1985). In addition, three participants were either DONs or supervisors, which may indicate they did not have the same direct care responsibilities as staff nurses; however, because their facilities were not large, they participated in resident care.

Research and Practice Implications

Research Implications

Compassion fatigue occurs regardless of years of experience or other role characteristics. The current study revealed shared meanings so that future qualitative research can be conducted to describe subsets of compassion fatigue with nurses that are influenced by nursing roles or years of experience. Descriptive correlational studies could include an examination of the relationship between years of experience, different nursing roles, and compassion fatigue coping. Future interventional studies would involve implementation of a comprehensive resiliency program, inclusive of organizational and personal interventions, to determine the impact on nurses' professional quality of life. Although nurses may have felt energized when they provided care during the EOL process, they desired formal grief support and time to grieve. Future research may test whether grief preparedness, training, and support interventions could improve the experiences of nurses caring for residents during EOL.

Practice Implications

The current findings describing the short-term outcomes of unresolved compassion fatigue, negative impacts on resident care, decreased professional quality of life, and nurses leaving the care setting provide evidence of the issues SNF management and nurses face and suggest interventions to reduce the risk of compassion fatigue.

When nurses leave the SNF care setting due to compassion fatigue, managers are challenged with replacing the nurse and staff are challenged with filling the increased gap in providing resident care until a replacement is hired. As nurses leave and seek another nursing position, unresolved compassion fatigue symptoms can remain and continue to impact the nurse's professional quality of life and resident care. The loss of compassion can continue to provoke feelings of shame and guilt, whereas unresolved grief may result in continual sadness. Management and nursing staff should be encouraged to determine methods for grieving and closure that fit their needs. One participant described starting the practice of lining the halls with staff to show respect when transporting a deceased resident to the funeral home. In addition, SNF management's commitment to the reduction of compassion fatigue can include: regular shift breaks; permission to take vacation and sick time; assistance with challenging residents; routine compassion fatigue risk assessment; professional boundary and compassion fatigue education specific for challenges experienced by SNF nurses; development of support groups and debriefing after stressful situations; and self-care measures instituted within the facility, such as a relaxation room for nurses to practice stress-reducing activities (Kolthoff & Hickman, 2017; Nolte et al., 2017; Sheppard, 2016). Nurses must claim responsibility for applying learned coping methods and self-care practices that include balancing personal and professional lives, rest and relaxation, proper nutrition, and hydration (Nolte et al., 2017; Sheppard, 2016). A combined comprehensive individual and organizational resiliency program is optimal in reducing the risk of compassion fatigue (Westermann et al., 2014).

Conclusion

Participants described feeling energized when making a difference in the lives of residents, which was of paramount importance; but when they could not make a difference, symptoms of compassion fatigue emerged. A combined comprehensive individual and organizational resiliency program could assist in reducing the risk of compassion fatigue. The current study provides evidence for further research, policy considerations, and education among SNF nurses working with older adults, because compassion fatigue can negatively impact nurses, patients, and organizations.

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Participant Demographics

ID #/PseudonymAge RangeHighest DegreeMarital StatusYears as RNYears in a SNF
1/Alice50sBSNMarried33
2/Jodie50sBSNMarried4.54.5
3/Virginia50sBSNMarried3.53.5
4/Carla50sADNSingle269
5/Noel30sADNMarried6.55.5
6/Nidra30sADNMarried1.51.5
7/Susie60sADNDivorced2045
8/Amy30sADNSingle33
Authors

Dr. Steinheiser is Director of Clinical Education, Infusion Nurses Society, Norwood, Massachusetts; and Dr. Crist is Associate Professor, and Dr. Shea is Clinical Associate Professor, College of Nursing, The University of Arizona, Tucson, Arizona.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This study was supported by research grants from The University of Arizona, College of Nursing and The University of Arizona Foundation–Roie J. Levy Geriatric Nursing Award and Sigma Theta Tau–Phi Pi chapter.

Address correspondence to Marlene M. Steinheiser, PhD, RN, CRNI, Director of Clinical Education, Infusion Nurses Society, One Edgewater Drive, Suite 209, Norwood, MA 02062; email: marlene.steinheiser@ins1.org.

Received: October 26, 2019
Accepted: January 24, 2020
Posted Online: April 13, 2020

10.3928/19404921-20200325-01

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