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Kelley Schlosshan
NUR 3207
Medical Center (MRMC), one of the main topics discussed is overall nursing turnover. The
departments with the highest turnover rate are the surgical care center, emergency department,
oncology and the interventional cardiac unit. In February 2017, the surgical care center for
nursing turnover was 31.7% and it increased to 42.2% by April 2018. In the emergency
department, the rate was 25.86% and decreased slightly to 22.7%, however it still remains above
the accepted retention rate. The oncology department rate increased from 13.33% to 21.7% and
the interventional cardiac unit, the rate increased from 7.14% to 27.9%. These departments
typically present a greater degree of death and trauma leading to nurses experiencing a higher
level of stress, which can lead to compassion fatigue. Compassion fatigue is defined as the state
satisfying the outcome (Salmond, Ames, Kamienski, Watkins, & Holly, 2017). When nurses
care for traumatized patients, they could re-experience the patient’s traumatic events. It can
cause burnout leading to nurses becoming less empathetic and more irritable with co-workers.
One of the challenges facing many health care systems is nurse retention. Is it possible to
positively impact retention by offering nurses ways to alleviate the impact of emotional, physical
Background Information
emotional, physical and psychological stress can eventually lead to secondary traumatic stress
and burnout. According to Fahey and Glasofer (2016), one of the main reason nurses leave the
QUALITY IMPROVEMENT PROJECT: COMPASSION FATIGUE 3
profession is due to compassion fatigue. It can be precipitated by fear, work related secondary
stress and exposure to people who have experienced an extreme or traumatic stressful event. This
can trigger physical and psychological symptoms such as anxiety, insomnia, complaints, nausea
or depression. Burnout and retention is directly correlated to work environment and job
satisfaction.
Nurses attend to their patients at their most vulnerable state. Empathy and compassionate
care are essential to building trust in the nurse to patient relationship (Salmond et al., 2017).
Compassion fatigue can negatively impact patient care and safety, patient satisfaction, job
satisfaction, productivity and absenteeism. In order to lessen the effects of stress and maintain a
positive work-life balance, nurses need to be provided opportunities which allow them to de-
compress, mourn and disconnect from daily stress. Compassion fatigue tends to be more
prevalent in nurses ages 21 to 33 and leads to approximately 30-50 percent of all new registered
nurses choosing to change positions or leave nursing altogether within the first three years
(Salmond et al., 2017). Research suggests there are programs and coping strategies which could
be implemented to alleviate stress, reduce compassion fatigue and focus on nursing retention.
Implementation of QI Project
After reviewing MRMC’s overall nursing turnover data during the time from February
2017 to April 2018, I noticed a trend in several units with consistently high turnover rates. These
units include: Intravenous Therapy Team, Oncology and the Surgical Care Center. During this
same time frame, there are units you would expect to have a higher turnover rate but have a
higher retention rate. These departments with a higher retention rate include the Critical Care
Unit, Neonatal Intensive Care Unit, Recovery Room and Ambulatory Surgery. I would like to
propose a project to the R&R council focusing on identifying the differences between
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departments with consistently high turnover rates and those with high retention rates. This could
help us identify and institute programs to prevent the negative effects of compassion fatigue. The
program I would present to the council includes adding additional questions to the annual Gallup
Survey for nurses practicing at MRMC. In developing these questions, we would work closely
with Gallup to devise a series of questions which would help determine overall satisfaction
beyond engagement with your department. These questions could include topics such as work
An additional part of the project, I am proposing we engage in another survey called the
Professional Quality of Life Scales (ProQOL). This thirty question survey is a valid and reliable
tool to measure compassion satisfaction and fatigue (Ames, Salmond, Holly, & Kamienski,
2017). Questions are related to how a person feels and examples of questions are: "Do I get
satisfaction from being able to help people?" or "Do I feel overwhelmed because my work load
seems endless?" The survey incorporates a five point scale with 1 point for never, 2 points for
rarely, 3 points for sometimes, 4 points for often and 5 points for very often. The ProQOL scales
is categorized in three sections according to your score. Specific questions measure compassion
satisfaction, burnout and secondary traumatic stress. When totaling these questions, it will reveal
either a low, average or high level of compassion satisfaction, burnout or secondary traumatic
stress. The survey can also be used without any additional cost directly from their website
(ProQOL.org, 2012). This survey is used by many institutions and has been in effect since 1995.
It is hoped that units with a high compassion satisfaction score will correlate with those
units also having a higher retention rate and Gallup score. Conversely units with a higher score
in secondary traumatic stress and burnout would have higher compassion fatigue scores and
lower retention rates. The first year the ProQOL survey is taken will correspond to the baseline
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score for MRMC. To ensure anonymity and encourage participation the survey will be
administered by an outside organization. I will work through the R&R council to begin the
approval process, asking them to vote on using the survey as part of the plan to reduce
compassion fatigue. Once the council has approved this research project, I would discuss it with
human resources, nurse managers, nurse educators and administrators for support and approval.
The R&R Council will need to work within current Bon Secours communication
channels to ask nurses to participate in this additional survey. These communications will begin
with a letter mailed to all MRMC nurses, which includes instructions for taking the survey. The
letter will include information on the ProQOL survey and its importance in measuring
compassion fatigue and burnout. Other internal communication channels which will be utilized
will include daily huddles, weekly employee newsletter, IRIS, unit champions and screensavers.
Nursing unit champions will work with their respective nurse manager to encourage
participation. We will utilize some of the same strategies encouraging nurses to take the Gallup
Survey; prizes awarded to departments with the highest participation rates. The plan is to
Once the initial data is analyzed, the R&R Council will use the survey results to
incorporate industry wide best practice solutions to alleviate stress and the impact of compassion
fatigue. The nurse educators could develop an annual module in IASPIRE to define compassion
fatigue, ways to recognize it and factors to help prevent it. In order to identify competency, all
nurses must score an 80 or better on the compassion fatigue healthcare module. Additional best
practices we could implement include working with employee wellness to develop quiet rooms
nurses could use immediately following a stressful patient or family event or opportunities to
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pray with one of the chaplains or a program developed through the Employee Assistance
Program to combat compassion fatigue. Another important step would be to institute multi-
disciplinary debriefings following adverse patient outcomes. These meetings will incorporate
chaplains, nurses, physicians, educators and quality team members. Debriefing meetings can be
an effective tool to relieve stress after critical incidents and improve patient outcomes, identify
training or process gaps and boost morale (Hammerle, Devendorf, Murray, & McGhee, 2017).
The sessions should include a list of standard and open ended questions allowing participants to
express their personal and professional thoughts regarding strategies to improve patient
outcomes.
enforcement and military and it is essential to provide staff with the appropriate resources and
support to offset the negative impact of high stress situations. By creating a positive
environment, it can support a culture of accepted realities of compassion fatigue and burnout
syndrome, as this allows staff to participate without the fear of being judged by colleagues (Berg,
Harshbarger, Ahlers-Schmidt, & Lippoldt, 2016). Some helpful tips on creating a positive culture
could include; educating the team on recognizing the symptoms of compassion fatigue in
themselves and ensure social support is a priority in leadership development. Engage in team
discussions during meetings and be aware of staff that do not contribute to the discussion, as
compassion fatigue is directly related with silence (Berg et al., 2016). The ProQOL survey will
be administered annually to ensure the program is reducing compassion fatigue and allowing the
Nurses who are satisfied and engaged are more likely to provide better care for their
patients and themselves. Increasing nurse retention and satisfaction is especially important when
you consider the costs of orienting a specialty nurse is $64,000 and the added expense to hire
practices to increase retention and work-life balance can be very rewarding to both the health
system and its team of caregivers. Evidence theorizes that compassion satisfaction is the primary
reason nurses remain in their job (Al-Majid, Carlson, Kiyohara, Faith, & Rakovski, 2018). As
our healthcare environment changes, it is important that compassion fatigue becomes more
Outcome Improvement
demonstrates that people involved in traumatic events need to tell their story approximately eight
or nine times before defusing the physiological and psychological impact of stress or distress
(Mason et al., 2014). Nurses are the front line for providing care to patients and patient care is
evaluated through quality, safety and engagement results. Evidence suggests that when we
engage with other members of our team it can assist in managing stress and creating an
institutional culture that acknowledges, accepts, and supports staff in preventing and controlling
compassion fatigue and burnout (Berg et al., 2016). To evaluate nurse retention, I would create a
dashboard, seen below, in figure 1.1 and figure 1.2, which identifies each unit for the overall
nursing turnover and results from the yearly ProQOL survey. By the end of the survey, results
will be collected on the dashboard and filed. Review, analyze, and compare data to determine
improvements.
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Figure 1.1
FY18 FY19
Department Gallup ProQOL ProQOL ProQOL Gallup ProQOL ProQOL ProQOL STS
Score Compassion Burnout STS Score Compassion Burnout
Satisfaction Satisfaction
IV Therapy Team
IVCU
Orthopedics
Oncology
Neurology Telemetry
Mother Infant Unit
Avg MRMC Nursing
Depts.
MRMC Goal
Figure 1-2
Feb-17 Mar-17
Department Voluntary # of # Using Voluntary # of # Using Resiliency
Turnover Debriefings Resiliency Room Turnover Debriefings Room
IV Therapy Team
IVCU
Orthopedics
Oncology
Neurology
Telemetry
Avg MRMC Nursing
Depts.
MRMC Goal
Abbreviations: (STS) Secondary Traumatic Stress
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References
Al-Majid, S., Carlson, N., Kiyohara, M., Faith, M., & Rakovski, C. (2018). Assessing the Degree
https://doi.org/10.1097/NNA.0000000000000620
Ames, M., Salmond, E., Holly, C., & Kamienski, M. (2017). Strategies that reduce compassion
fatigue and increase compassion satisfaction in nurses: a systematic review protocol. JBI
https://doi.org/10.11124/JBISRIR-2016-003142
Berg, G. M., Harshbarger, J. L., Ahlers-Schmidt, C. R., & Lippoldt, D. (2016). Exposing
https://doi.org/10.1097/01.CCN.0000490957.22107.50
Hammerle, A., Devendorf, C., Murray, C., & McGhee, T. (2017). Critical Incidents in the ED.
Mason, V. M., Leslie, G., Clark, K., Lyons, P., Walke, E., Butler, C., & Griffin, M. (2014).
Compassion Fatigue, Moral Distress, and Work Engagement in Surgical Intensive Care
Unit Trauma Nurses: A Pilot Study. Dimensions of Critical Care Nursing, 33(4), 215-
225. https://doi.org/10.1097/DCC.0000000000000056
Salmond, E., Ames, M., Kamienski, M., Watkins, A. V., & Holly, C. (2017). Experiences of
compassion fatigue in direct care nurses: a qualitative systematic review protocol. JBI
https://doi.org/10.11124/JBISRIR-2016-003143