Compassion Fatigue Among Registered Nurses:

COMPASSION FATIGUE AMONG REGISTERED NURSES:

Caring that hurts TOO much to care anymore!

Unpublished Manuscript
Author: Maralon Bevans RN MN
July 28, 2010

Work Healthy, Work SmartSelf-Care Plan

Acknowledgement:
Grateful appreciation to the course facilitators and nursing colleagues of the Athabasca University
Master of Nursing Program for their support, encouragement, and shared expertise to help me
disseminate this important message to the community of Registered Nurses in Canada
Dr. Marg Osborne, Dr. Kim Munich, Dr. Terra Murray, Dr. Marianne McLennan, & Christina Huff RN

Compassion Fatigue Among Registered Nurses:

Abstract
There is an immediate need in health care and the nursing community to understand the
deleterious effects of compassion fatigue (CF) among registered nurses (RNs) in a number of
practice settings. CF being a relatively new term, the purpose of writing this article is to raise
awareness among Canadian RNs and the health care community about CF defining CF, who is
at risk, contributing causes, warning signs, difference between CF and burnout, and effects on
nursing practice. CF is PREVENTABLE! A RN practice experience and a conceptual model
provide additional insights, strategies, and interventions to overcome and prevent CF.
[Words: 100]

Key Words:
Compassion Fatigue (CF), Caring-work, Registered Nurse (RN), Health care, Occupational
Stress.

Word Count: 3247 (includes abstract & references)

Compassion Fatigue Among Registered Nurses:

COMPASSION FATIGUE AMONG REGISTERED NURSES:

Caring that hurts TOO much to care anymore!
Introduction
Nursing can be one of the most rewarding and fulfilling experiences of a lifetime. It can
also read like the Dickens novel - It was the best of times and the worst of times. Along with
the best of times, undeniably, many Registered Nurses (RNs) are experiencing high levels of
occupational stress in a number of practice settings directly related to the care-giving experience.
In health care, there is an immediate need to raise awareness and act upon the inordinate amounts
of physical, emotional, and spiritual fatigue nurses are experiencing leading to compassion
fatigue (CF) and burnout. Canada cannot afford to lose one more excellent nurse to the
deleterious effects of CF. CF being a relatively new term, the purpose of writing this article is to
raise awareness among Canadian RNs and the health care community about CF defining CF,
who is at risk, warning signs, contributing causes, difference between CF and burnout, and the
effects on a RNs life, health, and practice. It is my hope RNs will join the action-oriented
momentum to raise awareness about CF, share the information and resources provided with
colleagues and leaders in health care, and help bring about a greater understanding of supports
needed for nurses involved in caring-work to stay healthy when caring for others.
RN Practice Experience
As a health care professional who cares deeply about the health and wellbeing of others,
I was exposed to many traumatic, heart wrenching, and challenging care situations that spanned
over a period of approximately 15 years. With the onslaught of health care restructuring and
reform of the late 90s, nursing practice supports changed and diminished. The lack of staffing
supports became alarmingly inadequate to match the workload and meet my practice needs. An

Compassion Fatigue Among Registered Nurses:

unhealthy situation developed with challenging levels of physical and moral distress as I tried to
meet and advocate for my patients care needs and maintain professional standards of practice.
Amidst the turmoil, unhealthy work environments culminated from the fiscal and economic
constraints and ongoing staffing cutbacks.
In the lengthy course of my caring-work, I experienced a perplexing phenomenon
Caring that hurts TOO much to care anymore! I desperately wanted to understand why, and
how, this happened to me after thirty years of dedicated nursing practice. I simply could not do
this anymore despite my efforts to give unconditionally to my patients, colleagues, and
workplace. Normally, care-giving activities provided me with much personal joy and
fulfillment - being a part in helping others, making a difference, and the lessons learned in the
process.
I faced a practice situation where I was temporarily incapacitated physically, emotionally,
and spiritually to give any more to others. The occupational stress had become my Goliath. I
was too fatigued and disheartened to fight the fight - inadequate staffing to match heavy
workloads to meet patient care needs, and working in environments that failed to adequately
address my patient care and practice concerns. Under such sustained duress, it literally hurt
TOO much to care anymore! I was scared about what was happening inside of me to feel this
way. I started to question, Why do caring, compassionate, and competent nurses become
disabled from practicing or doing what they so dearly love to do - care for others? How can the
attributes of caring and compassion render a caregiver incapable of being able to safely care for
others? Where is help and support when a caregiver really needs it to help them get through
such a difficult time?
The needs of others became bigger than 'me'. Coupled with a lack of resources and

Compassion Fatigue Among Registered Nurses:

supports to perform my job well and meet patient care needs in a timely manner, produced an
eventual sense of hopelessness. I recall very vividly one such incident where I tried to hide tears.
They began uncontrollably streaming down my cheeks while juggling administering to the needs
of a fearful patient with chest pain, a frail elderly person with breathing difficulties, and another
with acute abdominal pain - all at the same time. Being present with each patient in his or her
time of need was near impossible. My caring ethic and expectations were slowly being eroded
away from feelings of frustration, anger, guilt and pain in practice environments cut to the bone
and ears deaf to practice concerns. In such situations and under such duress, it literally broke
my caring spirit because of the impossibility to timely respond to the pain and distress of others.
In my quest to understand the very nature of caring and compassion and how it relates to
RNs and their practice, I came upon the term Compassion Fatigue which began an insightful
and meaningful research and healing journey that I would like to share with every practicing RN.
What is Compassion Fatigue?
In my search, I learned that CF is a deep physical, emotional, and spiritual exhaustion
associated with acute emotional pain. It can overtake a person and cause pervasive decline in
their energy to feel and care for themselves and others, and happens from long-term involvement
in emotionally demanding caring situations (Pfifferling & Gilley, 2004; McHolm, 2008;
Adkinson, 2005; Figley, 1995). Overlooked or disregarded, CF can escalate to become an
overpowering and pervasive stress that dominates a persons life by interfering with cognition
and decision-making skills. In essence, CF is a term not a pathological disease or disorder in the
sense of a mental illness. Rather, it is a natural behavioral and emotional response resulting from
helping or desiring to help another person suffering trauma or pain (Steven-Guille, 2003;
McHolm, 2006). A sense of hopelessness develops in response to peoples suffering, not from

Compassion Fatigue Among Registered Nurses:

busy work. CF can occur when giving high levels of energy and compassion over an extended
period without experiencing a positive outcome of seeing a patient get better (Figley, 2007).
Compassion Fatigue Model
Figure: 1. Model: Caring Connections & Caring-Work

What is Compassion Fatigue?

Practice Experience insights?
Who is at risk?
What are the signs?
How can it be prevented?
Why is it a concern?
What is needed?
Proposed Action!

Burnout Powerlessness
Associated with nursing
work e.g. time pressures,
complex patient loads,
coordinating care with
other teams or depts,
resources,
Toxic Work

Patient consumer of
Health Services
Individual or family who
accesses services to
assist them maintain
health and wellbeing
and/or assistive care for
a health problem

Nurse (Care-Provider)
Giving high levels of
energy and compassion
over a prolonged period
of time to persons who
are suffering and need
support to cope with life
and/or death situations.

Compassion Fatigue Hopelessness

A deep draining physical
emotional-spiritual
exhaustion. A natural
behavioral & emotional
response to anothers
suffering trauma or pain.

pain.

environments

HC Organization
Entity providing access
& coordination of HC
services for the public
individ. & communities.
Assisting the consumer
to care which supports
health & well-being.

Maralon J.R.Bevans [2008]

A conceptual Model Caring Connections & Caring-Work Compassion Fatigue

(Figure: 1.) evolved as I searched for meaning and understanding of caring and the care-giving
experience. Caring being central to the art of nursing, ironically has variable meaning for each
practitioner, ranging from obligatory to emotional attachment. Caring, as an emotion, evoked by

Compassion Fatigue Among Registered Nurses:

a persons senses, can trigger a natural or learned response prompting an action to help or
respond to anothers need. Whereas compassion; is a deeper emotion and capacity to feel the
pain and suffering of others (Roach, 1997). Understanding these concepts and significance to the
caregiver, helps to understand how CF can develop. The Model triangles connecting nurse,
patient, and agency in the care-giving relationship, creates a visual awareness of the caring-work
dynamics and its various effects. It depicts how demands and control over a RNs practice can
influence and lead to the development of CF and/or burnout, and how it can erode quality of life,
morale, and job satisfaction relative to performing caring-work. With inordinate demands for
support, knowledge, and skills placed upon RNs 24/7 for fulfillment of patient care
needs/demands, coupled with the fulfillment of the organizations work demands/expectations,
the degree of control or autonomy over ones practice can have positive and/or negative effects
on a caregiver. The CF Model helps put into perspective how a RNs practice overburdened and
constrained for enduring periods can significantly increase occupational stress and moral
distress. Unrelieved, such stressors can produce a state of hopelessness and/or powerlessness
with accompanying deleterious effects leading to CF and burnout (Foster, 2009; McHolm, 2008).
Difference between Compassion Fatigue and Burnout
According to McHolm (2008), most assuredly CF is not burnout! Burnout is workorientated, whereas CF is people-orientated. As mentioned, peoples suffering (trauma or
pain), elicits a natural behavioral and emotional response in a caregiver from helping or desiring
to help those who are suffering. The difference between CF and burnout is distinct and often
misunderstood, even unknown to many health care professionals. Burnout produces emotional
withdrawal and diminishes empathy, whereas with CF, a person tries to continue to give
believing that they have failed at their profession (Pfifferling & Gulley, 2000).

Compassion Fatigue Among Registered Nurses:

Who is at Risk? - Risk Factors & Contributing Causes

Health care professionals purported to be more susceptible to developing CF include
professionals working in emergency care, palliative care, public health, social workers,
counselors, mental health, physicians, pastoral care, advocate volunteers, and human and animal
service workers (McHolm, 2008; Mulder & Gregory, 2000; Adkinson, 2005).
Some nurses by virtue of their caring natures and personalities are highly susceptible to
CF and without heightened awareness about CF, it is almost impossible to recognize it
(Adkinson, 2005; Roach, 1997). Some compassionate caregivers, in constrained working
environments, may place excessive and unrealistic demands on self to meet the care needs of
others - often to the detriment of their own health. According to McHolm (2008), work
environments and conditions of employment are large contributors of RN occupational stress
fatigue, leading to CF and burnout.
The caring-work of nursing does expose nurses to many risks in care-giving experiences
with varying degrees of stress from numerous sources co-workers, leadership and management
styles, professional boundary conflicts, organizational restructuring and reform, and emotional
pain experienced from the pain and suffering of their patients. Nurses also interact and cope
with various personality types, generational issues, and work under conditions often less than
ideal - over employment, staffing shortages, and high acuity workloads. Against the odds, nurses
strive to give excellent care in a do more for less or suck it in, chin up environments (Nelson
& Gordon, 2006; CIHI, 2005; Sabo, 2008; Fagerstrom, 2006; McHolm, 2008). Under such
accumulative occupational stress and extreme circumstances, many nurses are saying- I cant do
this anymore!
Warning Signs and Effects on Professional Practice

Compassion Fatigue Among Registered Nurses:

Compassion fatigue onset can be rapid with a sense of hopelessness, shock and
disorientation. Moreover, individuals who develop CF experience episodes of fear, depression,
disorientation, helplessness, hopelessness, feeling out of control, extreme mood swings,
avoidance behaviors, among other signs and symptoms (Figley, 2007; McHolm, 2008; StevenGuille, 2003). Caregivers may exhibit any number of the signs listed in Tables (a) and (b) and in
varying degrees of severity during the course of caring for others. Ignoring the signs or failing to
recognize them and their significance can lead to personal and professional dysfunction namely, rendering a person devoid of emotional fulfillment, physical illness, and poor or
declining performance (Figley, 2007).
.
Table (a): Personal Impact of Secondary Trauma *(Warning signs: classic stress pattern)
Cognitive
-Confusion
-Spaciness
-Forgetfulness
-Trauma imagery
-shorter attention
span
-Rigidity
-Apathy
-Self-doubtdecreased self
esteem.
-Minimization
-Thoughts of selfharm or harm to
others
-Disorientation

Emotional

Behavioral

-Anxiety
-Emotional
rollercoaster
-Anger/rage out of
proportion
-Numbness
-Overwhelmed
-Fear
-Signs of Depression
-Depleted
-Sadness
-Survivors guilt
-Less ability to feel
joy
-decreased sense of
personal
accomplishment

-Clingy
-Moody
-Rigidity
-Nightmares
-Impatient
-Appetite
Changes
-Hypervigilance
-Elevated Startle
Response
-Use of negative
coping
-Sleep disturbances
-Abusing drugs,
alcohol, food or sex

Spiritual
-Loss of purpose
-Anger at God
-Questions
Prior religious
beliefs
-Pervasive
hopelessness
-Believe major
change necessary
-Less ability to feel
joy

Interpersonal
-Withdrawn
-Over protective
-Mistrust
-Decrease in
Intimacy/sex
-Isolation
-Projection of
Anger/Blame
-Intolerance
-Loneliness
-Critical of others
-Depersonalization
of patients

Physical
-Aches /Pains
-headaches
-Dizziness
-Breathing
difficulties
-fatigued
-Somatic
complaints
-Impaired
immune
system
-Rapid Heart
beat
-stomach aches
-sleep
disturbance

Table (b): Effects on Professional Functioning

Performance of Tasks
-Decrease in quality
-Decrease in quantity
-Low motivation
-Medication errors
-Avoidance of job tasks
-Poor documentation
-Setting perfectionist standards

Morale
-Decrease in confidence
-Loss of interest
-Job dissatisfaction
-Low motivation
-Negative attitude
-Lack of appreciation
-Detachment

Interpersonal
-Withdrawn from
colleagues
-Impatience
-Decrease in the quality
of work relationships
-Poor Communicator
-Increase in staff conflicts

Behavioral
-Absenteeism
-Tardiness, chronic
-Exhaustion
-Faulty Judgment
-Overwork/Workaholism-no
time for self
-Frequent job changes

References: (Ingram, 2005; McHolm, 2008; Adkinson, 2005; Stevens-Guille, 2003; Merrill, 2008; Pfifferling & Gilley, 2000; Varner,
2004; Benson & Magraith, 2005; Stanley, 2001). Developer: Maralon Bevans

Compassion Fatigue Among Registered Nurses:

10

Registered Nurses are highly educated, knowledgeable, and skillful practitioners whose
sole intent and purpose is to care for others. When resources and supports are insufficient or
lacking to do the job well (timely and meeting the needs of others pain and suffering), it can
become all consuming due to feelings of hopelessness and powerlessness of the situation. The
pain of others turns inward and the burden becomes TOO painful to carry or bear anymore. In
desperation, and with no place to turn for support, no rescue, RNs either leave the profession
and/or their job or continue to work wounded, and some end their life. In all cases, this is a
preventable tragedy!
Pathway to Healing and Well-Being
Overcoming Compassion Fatigue
The human cost associated with compassion fatigue is far reaching affecting the caregiver,
loved ones, and the health care organization. While the effects of CF are dismal, the chances of
a recovery are not. CF is both preventable and treatable. In constructing a pathway to healing,
several authors (Benoit et al, 2007; Figley, 2007; Steven-Guille, 2003) share points of wisdom:
First, remove yourself from the context of care giving to undertake restorative tasks.
Develop an individual self-care plan to get well and keep a balance between work and
life by setting realistic boundaries to prevent over extending yourself or allowing others
to encroach on them. See Figure: 2. Compassion Fatigue Keys to Recovery.
Keep a healthy care-giving perspective. Reframe or reevaluate your views of what it
means to be helpful. Being helpful is not necessarily about taking away peoples
suffering, for that may be beyond our own capabilities and/or responsibility.
Take a Self-Help Quality of life and Compassion Fatigue Assessment Test to help
evaluate your health and functioning (i.e., Quality of Life Scale: Compassion

Compassion Fatigue Among Registered Nurses:

11

Satisfaction and Subscales Revision IV www.isu.edu/~bhstamm/tests.htm; SelfAssessment for Compassion Fatigue http://www.aafp.org/fpm/20000400/39over.html;
and ACE-Network - Secondary trauma of compassion fatigue in caretaker and helping
professions http://www.ace.network.com/cfspotlight.htm). In selecting an appropriate
self-help test, it is important to consider the design and intended target audience as not all
self-help tests adequately reflect the experiences, language and feelings of nurses (Sabo,
2006).
Check out the Compassion Fatigue Awareness Project (2008) website at
http://www.compassionfatigue.org for useful information, tools and resources to assist
you on your road to recovery.
If self-healing approaches do not effectively restore your health in a timely manner, it is
important to seek additional help to establish a team approach - a supportive caring network (i.e.,
your doctor; a psychologist who specializes in CF; counseling services; employment assistance
program; or a personal health coach; family and friends, pastoral care, etc.). By seeking help and
intervention early increases the chances for recovery and enjoying a full and fulfilling life again.

Compassion Fatigue Among Registered Nurses:

Figure: 2.

Compassion Fatigue
~Keys to Recovery~
.Self-Care PlanYou TOO matter!
Recognize that positive change is difficult. Let me propose then, that you do
not have compassion for the person most important to the patient. That is,
you do not have compassion for yourself. Before Albertans loose one more
excellent nurse, you must care for yourself so that you are able to care for
others.

Understand that the basics such as diet, exercise and sleep are the building

blocks to a balanced life. Balance in your life is the goal. To achieve balance
you may have to work less and therefore earn less.

Believe in yourself as deserving of care from others. Frame the need for
changes in your own family as teaching others how to care for you.

Develop a self-care plan and encourage all in your world to understand that
you are suffering and deserve to stick to your recovery plan. Self-care is not
selfish.

Find yourself. Who am I? How did I come to be the person I am? These are
questions that need to be answered. A mental health professional can help
you understand yourself and show you how to make the changes that you
decide are necessary based on your life, values, beliefs and goals.

Give yourself time. Time alone, in nature or in other places that bring you a
sense of peace and timelessness. Visualize, meditate and learn how to relax
your body as well as your mind.

Re-connect to your family and community by having discussions that are

meaningful once a day. Sharing joy as well as despair is powerful. In order

to talk about our emotions we have to be able to feel them.

Learn to feel and identify emotion other than anger.

Do not make important or life changing decisions before you are well.
Reference: Stevens-Guille, B. (2003). Compassion fatigue: Who cares for the caregivers? The key to recovery. Alberta RN. Vol. 59, 7.
Reproduced with permission of Dr. Betty Stevens-Guille.

12

Compassion Fatigue Among Registered Nurses:

13

Strategies & Intervention to Prevent Compassion Fatigue

1.

Leadership & Human Resource Planning Workshops: The nursing community, health
care leadership, and human resource planning need to understand what CF is and the
deleterious effects it can have on RNs, their practice, and consequences in an
organization (i.e., increasing sick time and benefit use, lowered organizational morale
and job satisfaction, and RN retention and recruitment issues, etc.).

2.

Building Supportive Networks: Supportive workplace environments and culture are

foundational in the treatment and prevention of CF. A collaborative multidisciplinary
organizational wellness team approach in raising awareness about CF is vital and
necessary to help retain, and sustain healthy RNs in the workforce. Keeping a pulse on
the needs of RNs involved in health care delivery, requires monitoring health trends,
attrition rates, and establishing a supportive network (i.e., counseling services, wellness
program, and CF support group to support RNs in work settings exposed to inordinate
caring-work demands and situations).

3.

Nursing Managers:

Front-line managers are first line in helping to prevent the build-up

of CF. Figley (2007) offers the following suggestions:

- Consistently let RNs know that they are valued and appreciated.
-

Celebrate as often as possible all the good staff do for the organization and patients.

Debrief and access appropriate interdisciplinary support after critical incidents.

Ensure staff has someone to talk to, listens, and understands their concerns.

Promote healthy work environments by fostering respectful communication

Create empowering activities and opportunities at work (i.e., directly involve RNs in
the design and decision-making processes that affect their work)

Compassion Fatigue Among Registered Nurses:

4.

14

Proposal: RN Occupational Coalition & Wellness Program: Provincially establish a

multi-stakeholder RN Occupational Wellness Coalition and Wellness Initiative Work
Healthy, Work Smart to advocate, address, educate, and assist RNs in their employment
settings. The RN workforce represents 78% of the total nursing workforce in Canada and
occupational stress in health care is on the increase (CIHI, 2007). The purpose of
establishing a Coalition is to oversee a RN Occupational Wellness Program and function
as an advisory group who collectively advocates and strategizes to monitor RN
occupational stress, trends, and nursing workforce issues across the health care system.
The proposed benefits and outcomes are to raise awareness and address issues relative to
organizational, individual, and collective responsibility and accountability for workplace
wellness; reduce human resource related expenditure; and promote a sense of
organizational community- caring for self and for each other while caring for others.

Conclusion
In my experience, it was through the love and support of my family, caring colleagues,
professional advocates, and a self-healing/renewal plan that helped me to find my way forward,
to rejuvenate and refill my caring capacity to dare to feel and give again. The healing process
of CF takes time, and recovery rate varies from person to person. Understanding CF - cause and
effects, and choosing the right healing pathway, recovery is possible!
May we all reach out with kindness and extend care and support to colleagues within the
nursing community injured in the course of performing caring-work, and commit to make a
positive difference by collectively advocating at the local, regional, provincial, and national
levels to develop and implement strategies to recognize, overcome, and prevent CF.

Compassion Fatigue Among Registered Nurses:

15

References
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Compassion Fatigue Test. Retrieved from: http://www.ace.network.com/cfspotlight.htm
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disaster relief teams. Unpublished masters thesis, Lesley University, Cambridge, MA.
Benoit, L. G., Veach, P. McC., LeRoy, B. (2007). When you care enough to do your very best:
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Benson, J., Magraith, K. (2005). Compassion fatigue and burnout. The role of balint groups.
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Fagerstrom. L. (2006). The dialectic tension between being and not being a good nurse.
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Figley, C. R. (1995). Compassion fatigue: Secondary traumatic stress disorders in those who
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Figley, C. R. (2007). The art and science of caring for others without forgetting self-care. Gift
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Foster, D. (2009). Rethinking compassion fatigue as moral stress. Journal of Ethics in Mental
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Ingram, B. (2005). Compassion Fatigue. Retrieved from:
http://www.calcasa.org/fileadmin/2005_Leadership_Conf/Brenda_Ingram__Slides_.pdf

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McHolm, F. (2008). Rx for compassion fatigue. Journal of Christian Nursing. Vol. 23 No. 4;
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