BM Sabo

International Journal of Nursing Practice 2006; 12: 136–142

✠ R E S E A R C H PA P E R ✠

Compassion fatigue and nursing work:

Can we accurately capture the consequences
of caring work?
Brenda M Sabo RN BA MA PhD-student
Adjunct Professor, School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada

Accepted for publication October 2005

Sabo BM. International Journal of Nursing Practice 2006; 12: 136–142

Compassion fatigue and nursing work: Can we accurately capture the consequences of caring work?

Health outcomes and, in particular, patient health outcomes have become a driving force within health-care delivery. Little
emphasis has been placed on the potential health consequences for nurses providing care and caring within the health-care
system. Compassion fatigue (or secondary traumatic stress) has emerged as a natural consequence of caring for clients who
are in pain, suffering or traumatized. This paper sheds light on how nursing work might impact the health of nurses by
exploring the concept of compassion fatigue. Limitations of current instruments to measure compassion fatigue are high-
lighted, and suggestions for future direction are presented.
Key words: compassion, compassion fatigue, empathy.

INTRODUCTION communication, coordination of care, assessment) and

Changes in accreditation practices during the mid- to
late 1980s, coupled with health-care restructuring,
downsizing and fiscal restraint policies, have resulted in
the re-emergence of outcome-based or evidence-based
nursing practice.1–4 The need for effective instruments to
monitor and evaluate nursing care,5,6 government
requests for health-care accountability,2,7,8 professional
legitimacy4,7,9,10 and policy reform1,2,4,5,8,11,12 has shifted
the focus from primarily pathophysiological or disease-
based to outcomes interconnected with organizational
structure and nursing processes.
Although emphasis has been on the interrelationship
between nursing processes (i.e. nursing interventions,
Correspondence: Brenda M Sabo, 7B-112 CEN, QEII Health Science
Centre, 1278 Tower Road, Halifax, NS, B3H 2Y9, Canada. Email:
brenda.sabo@cdha.nshealth.ca
organizational structures (i.e. staff mix, work load,
work environment) to patient outcomes, it would seem
reasonable to assume that nursing practice and work
environment could be commensurate with health out-
comes for nurses. It is my hypothesis that, in caring
for patients experiencing trauma, pain and suffering,
nurses’ health can be profoundly affected, resulting in a
phenomenon such as compassion fatigue (CF) (second-
ary traumatic stress (STS)). Outcomes research has his-
torically focused on patient and pathology in relation to
the work of health-care providers. Little research has
explored the consequences of ‘caring work’ on the
health of providers such as nurses. The following dis-
cussion will explore the potential benefits and limita-
tions of attempting to quantify compassion and caring
within an outcomes model. In particular, do we run
the risk of pathologizing a quality of nursing that forms
its foundation?

© 2006 The Authors

Journal compilation © 2006 Blackwell Publishing Asia Pty Ltd doi:10.1111/j.1440-172X.2006.00562.x
Compassion fatigue and nursing work
UNDERSTANDING COMPASSION
AND EMPATHY
Blum refers to compassion as the experience of feeling
with another while recognizing that the feelings of one are
not the same as another. Compassion promotes equality as
experiencing compassion suggests an inherent regard and
respect for the other as a fellow human being.13 Compas-
sion is often understood as an emotion. In understanding
compassion as emotion, Oakley refers to the affective
dimension reflected within feeling including a psychic
dimension; it can be understood in terms of ‘the mental
tone which affects us and which characteristically perme-
ates our perceptions, our desires and actions in ways
which we are not always aware of’.14 This psychic quality
suggests that compassion affects our lives over extended
periods of time, not just in the moment, and can exist in
the absence of feeling. For example, ‘the nurse who exhib-
its compassion will therefore not simply respond with
feelings at the time of the patient’s suffering, but will care
for this patient in an ongoing way that might not always be
expressed in terms of feeling’.15 Furthermore, evidence
of compassion includes displays of character such as virtue
leading to concern for the good of others, an awareness of
the other’s suffering and a desire to act to relieve that
suffering.15–19
Central to the relationship between individuals is a
need to understand and be understood; furthermore, it
forms the foundation on which the nursing relationship is
built.20 The most critical element within the therapeutic
or helping relationship is empathy.16,21–24 In the ever
increasing complex, technological world of health care,
‘technical competence is necessary, but must be combined
with interpersonal skills such as empathy, warmth and
respect, before the patient feels health professionals
care’.21
Difficulties lie with ‘the nature of empathy and whether
it is innate or learned, a personality dimension, amenable
to change through experience or an observable skill’.25 It
may be best considered as a multidimensional, multiphase
construct that consistently appears to be interpreted
within a narrow one-dimensional frame. The extent to
which the various elements are interrelated appears to be
a source of much disagreement among theorists.23 In a
review of the literature, Morse and colleagues identified
four components of empathy: moral, emotive, cognitive
and behavioural.26
Definitions of empathy include:
137
Accurate empathy involves more than just the ability of the
therapist to sense the client’s ‘private world’ as if it were his
own. It also involves more than just the ability of the therapist
to know what the client means. Accurate empathy involves the
sensitivity to current feelings and the verbal facility to com-
municate this understanding in a language attuned to the
client’s feelings.27
Truax emphasizes empathy as a way of perceiving and
communicating that is consistent with Morse et al.’s
cognitive-behavioural components.
Similarly, Rogers perceived empathy as an attitude
thus emphasizing communication. Furthermore, he felt
that empathy was a learned skill if one was to communi-
cate warmth and genuineness and achieve the ability to
successfully understand the client’s perspective. Other
theorists have argued that empathy is an interpersonal
concept comprised of a learned set of skills as opposed to
an innate ability reinforcing the cognitive-behavioural
approach.23
Perhaps the most relevant definition of empathy is the
following, which reflects the communication skills of
nurses:
Empathy signifies a central focus and feeling with and in the
client’s world. It involves accurate perception of the client’s
world by the helper, communication of this understanding
to the client, and the client’s perception of the helper’s
understanding.28
This definition includes perceptional and interactional
empathy highlighting empathy as more than ‘a way of
being’29 but a communication tool that validates the world
as perceived by the client.23
Empathy has been conceptualized as a human trait
(innate natural ability), professional state (learned
communicative skill comprised of cognitive-behavioural
components), communication process (exchange where
the professional perceives, expresses understanding and
the client perceives this understanding), caring (compul-
sion to act because of understanding the experience of
the client) and, finally, special relationship (reciprocity
requiring time).22 Empathy requires that the individual
perceive the world as the other, be non-judgmental,
understand the other’s feelings and communicate this
understanding.30
Caring, compassion and empathy might exhort a cost
from practitioners, reducing ‘our capacity or our interest
© 2006 The Authors
Journal compilation © 2006 Blackwell Publishing Asia Pty Ltd
138
in bearing the suffering of others’.31 Compassion fatigue,
also described as secondary victimization,32 STS32–36 and
vicarious traumatization,37,38 has been associated with the
‘cost of caring for others in emotional pain.39 Underlying
the effectiveness of therapy or caring is the ability to
empathize, understand and help the client. Empathy
becomes a double-edged sword for the nurse or clinician:
on the one hand, empathy facilitates caring work; on the
other hand, the act of caring leaves the nurse or clinician
vulnerable to its very act:
We all feel or have felt the distress and the isolation. Ulti-
mately, I believe, there is no solution to the problem. All of us
who attempt to heal the wounds of others will ourselves be
wounded; it is, after all, inherent in the relationship.40
Although research evidence supports the assumption
that empathy is a necessary component of the helping rela-
tionship,22,23,25,26,41–43 little is known about the impact of
the role empathy might play on the health of nurses.
Before that can occur, an operational definition of the con-
cept is required that is relevant to nursing and the helping
professions.
HELPER STRESS OR
COMPASSION FATIGUE
As recognition for traumatology and the need for early
intervention for victims of trauma grew in the late 1970s
and early 1980s, it became apparent that those providing
assistance were themselves experiencing adverse effects
arising out of their work.44 Early conceptualizations of the
phenomenon experienced by health-care professionals
and first responders included a form of burnout or ‘sec-
ondary victimization’,32 later referred to as STS and sec-
ondary traumatic stress disorder.45 Compassion stress and
CF have since emerged as acceptable substitutes for STS
and secondary traumatic stress disorder given the empha-
sis on the ‘cost of caring’ for health-care professionals.46
Health-care professionals find the term to be more reflec-
tive of their lived experiences in working with clients who
are in pain, suffering or traumatized.
Related terms include vicarious traumatization, which
refers to the cumulative effect of the client’s traumatic
material that affects and is affected by the health-care pro-
fessionals’ world view.37 Vicarious traumatization differs
from CF in that the individual undergoes a ‘transforma-
tion’ in their personal and professional belief systems.
Other terms used interchangeably with CF include ‘emo-
© 2006 The Authors
Journal compilation © 2006 Blackwell Publishing Asia Pty Ltd
BM Sabo
tional contagion’,47 an affective process wherein the indi-
vidual’s responses parallel those of actual or anticipated
emotions; counter-transference,48 an unconscious attune-
ment to and absorption of a client’s trauma; and burnout,
a gradual progression or wearing down of the individual
resulting from an imbalance between their expected and
actual outcomes in the workplace.49–53 All involve interac-
tion with another, generally clients in the context of care
and caring, and are considered a natural consequence of
caring. To varying degrees, empathy appears to be an inte-
gral component underlying all of the identified concepts,
probably because of its facilitative nature in developing the
therapeutic relationship.
Compassion fatigue is a relatively recent term, first
used by Joinson in 1992 while studying burnout in nurses
working in emergency departments. The term conveys a
more user-friendly construct and framework than the
more highly pathologized secondary traumatic stress disorder
identified in Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV).54 Compassion
fatigue can be described as:
Natural consequent behaviors and emotions resulting from
knowing about a traumatizing event experienced by a signif-
icant other—the stress resulting from helping or wanting to
help a traumatized or suffering person.34
Compassion fatigue is thought to be a combination of
secondary traumatization and burnout precipitated by the
care delivery that brings health-care professionals into
contact with the suffering.55
Compassion fatigue differs from post-traumatic stress
disorder (PTSD) in that the individual is exposed to the
traumatized or suffering person rather than the traumatic
event itself. Burnout is described as ‘a process in which the
professional’s attitudes and behaviour change in negative
ways in response to job strain’56 arising out of work envi-
ronment triggers such as ‘frustration, powerlessness, and
an inability to achieve work goals’.57 Essentially, a discon-
nect exists between the expectation of the individual
around role performance and the structure of the organi-
zation to support the professional role. Furthermore,
burnout involves a gradual wearing down of the individual
over time whereas CF has an acute onset. Compassion
fatigue results from the ‘natural’ consequence of caring for
people who are suffering rather than a response to the
work environment. The presence of burnout increases the
likelihood of developing CF.34,39
Compassion fatigue and nursing work
MEASURING THE COST OF CARING
Although the body of literature on STS/CF continues to
grow, a paucity of empirical evidence underscores the
need for reliable, validated instruments to accurately mea-
sure the concept. Most of the instruments used to mea-
sure STS were developed to measure symptomatology in
trauma survivors (direct exposure) as opposed to that
arising because of indirect exposure to trauma, pain and
suffering experienced by health-care professionals.58 A
variety of survey methods have been used to gain an
understanding of the demographic indices and levels of
stress inherent in work with the traumatized. These
include: Impact of Event Scale;59 Brief Symptom Inven-
tory;60,61 Penn Inventory of PTSD;62 and Trauma Symptom
Checklist-40.63 These studies focused on response pat-
terns of health-care workers providing information on
levels of stress experienced.
A significant limitation within the STS research is a lack
of psychometrically reliable and valid instruments to mea-
sure STS.64 Motta and colleagues found that many of the
scales used lacked cut-off scores and/or were not amena-
ble to implementation across a wider population and
variety of traumatic experiences (most have been tested
on specific populations such as mental-health workers,
therapists and social workers).64 For example, the Com-
passion Satisfaction-Fatigue (CSF) Test has been used pre-
dominantly with mental-health workers although more
widespread use has emerged.65 The CSF is a self-report
scale comprising three subscales (estimate of compassion,
risk of burnout and CF, and degree of satisfaction derived
from helping others) with a total of 66 items scored using
a Likert scale (0—not at all to 5—very often). The mod-
ification to include compassion satisfaction was deemed
necessary to address inherent shortcomings within the
original CF scale that focused solely on the negative con-
sequences of compassion when working with clients ex-
periencing pain, suffering and trauma. Being exposed to
traumatic stressors does not guarantee that an individual
will manifest symptoms of either CF/STS; nor does tar-
geting the negative aspects and symptomatology provide
answers as to what, why and how it is that some health-
care providers achieve satisfaction from this very work.
Focusing on negative symptoms might create a response
bias that artificially inflates or deflates reports of CF.65
Despite widespread use of the CSF scale, little empir-
ical research has been published.66 More questions need to
be answered before the CSF Test achieves reliability. These
139
include: a comparison of CSF Test with other measures of
traumatic stress such as the Secondary Trauma Scale64,67
and the Secondary Traumatic Stress Scale (STSS);58 is the
test sensitive over time to change (paucity of longitudinal
studies); how do CF/STS, burnout and compassion satis-
faction relate to each other; and can the relationship
between the constructs of CF/STS, burnout and compas-
sion satisfaction be quantified and used to identify poten-
tial risk or protective factors?
More recently, Bride and colleagues have developed the
STSS to measure STS symptoms in social workers and
other health-care professionals working with the trauma-
tized.58 To maintain congruence with the DSM-IV,68 the
STSS did not include characteristic symptoms of PTSD
such as distressing emotions and functional impairment. It
was hypothesized that these characteristic symptoms,
taken together, might correspond with burnout blurring
the ability to clearly distinguish between STS and burn-
out. Secondary traumatic stress was operationalized as
intrusion, avoidance and arousal symptoms.58 The final
version is a 17-item self-report instrument to assess the
frequency of intrusion, avoidance and arousal symptoms
associated with STS. A Likert scoring scale was used (1—
never to 5—very often).
Although the STSS provides a quick and easy assess-
ment of the presence of STS and might serve to guide the
evaluation of intervention strategies to reduce the likeli-
hood of STS occurring, several limitations are apparent.
As with many of the other instruments, the target popu-
lation is a specific subset of health-care providers, social
workers, suggesting a lack of adaptability to accommodate
a variety of STS exposures. Furthermore, the ability to
discriminate between whether the individual is experi-
encing STS, depression, burnout or PTSD has not been
clearly demonstrated. For instance, a subset of the items
also measure symptoms of depression and overlap with
symptoms of PTSD (given that the instrument was based
on PTSD, this is not surprising).58 Further studies are
required before this instrument can be considered a reli-
able and valid tool for the assessment of the presence of
STS in health professionals.
Another instrument that has emerged in an effort to
assess the frequency and presence of STS is the Secondary
Trauma Scale.64 Developed to address criticisms related to
a lack of cut-off scores (degree of STS, or the score above
which we can be sure of STS) and measurement of the
severity of effect of various secondary traumatic experi-
ences across different health professional groups, Second-
© 2006 The Authors
Journal compilation © 2006 Blackwell Publishing Asia Pty Ltd
140
ary Trauma Scale is an 18-item self-report scale using a
Likert scoring scale (1—rarely/never to 5—very often).
It too suffers from a lack of reliability and validity in dis-
criminating between levels of severity of STS, or between
constructs such as STS, dissociation, anxiety and depres-
sion; inability to isolate causal factors; and a lack of gen-
eralizability across various traumatic experiences.
WHERE TO FROM HERE?
In reviewing CF (STS), what becomes apparent is an
attempt to theoretically reflect the pathology (physical
and psychological) arising out of the secondary stress from
working with traumatized individuals.46 Compassion
fatigue emerges suddenly, precipitated by exposure to a
client’s traumatic event with the affected exhibiting sec-
ondary PTSD symptoms. To date, no scientific evidence
exists to support the notion that STS is identical to PTSD;
however, this does not rule out the hypothesis that ongo-
ing, cumulative exposure to individuals who are in pain,
suffering or traumatized might not have effects similar to
PTSD.69 Compassion fatigue focuses largely on negative
symptomatology, rather than exploring contributing fac-
tors leading to its development or onset. Furthermore,
Figley suggests that empathy and emotional energy are the
underlying drivers in the development of CF.31,46 Extend-
ing the concept beyond a one-dimensional approach
would appear to have more relevance, given that little
empirical evidence exists to support empathy or overcar-
ing as a sole causal factor for CF (STS).70–74 Of necessity is
the need to clearly articulate the role burnout plays in the
development of CF.
Empathy has been shown to be a critical component
of the helping relationship. It does not necessarily infer
negative consequences. If, as Figley purports,31,46 empathy
increases the risk for CF, then one might hypothesize that
all health-care professionals should manifest STS or CF
symptomatology to varying degrees. Research has shown
that only 7% of professionals working with traumatized
individuals exhibit ‘emotional reactions typical of the “big
bang” trauma experiences’ (PTSD).69,75
Despite the risk(s) involved in providing care or assis-
tance to individuals who are in pain, suffering or trauma-
tized, certain qualities seem to afford protection such as
resiliency,76,77 hardiness and social support.78 Perhaps the
emphasis within traumatology research should shift from
the pathology to what protects human beings engaged in
caring work with those experiencing pain, suffering and
trauma. Furthermore, empirical evidence is required to
© 2006 The Authors
Journal compilation © 2006 Blackwell Publishing Asia Pty Ltd
BM Sabo
more clearly understand the aetiological process of CF
(STS)—in particular the link between the empathic sen-
sitivity of the health-care professional and their vulnera-
bility to experience secondary trauma. Longitudinal
studies should be undertaken to explore the development
of symptoms in relation to such factors as chronic expo-
sure to traumatized clients, lack of institutional support,
presence of empathy, burnout, type of traumatic expo-
sure, years of experience, level of education and personal
history of traumatic events. Finally, further empirical
studies are required to operationalize instruments such
as the CSF scale; rather than an instrument that focuses on
pathology and symptoms, an instrument that clearly
reflects the concepts of compassion and fatigue, strives to
differentiate causal factors, and draws clear distinctions
between CF and burnout needs development and
validation.
ACKNOWLEDGEMENT
I would like to acknowledge the support and guidance of
Dr Donna Meagher-Stewart, Professor, Dalhousie Uni-
versity School of Nursing whose course, Women’s Health
Outcomes, was instrumental in the development of this
paper. Her patience and guidance have been greatly
appreciated.
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