Running head: INTEGRATIVE REVIEW 1

Integrative Review

Maxine Audet

Bon Secours Memorial College of Nursing

Christine Turner, PhD

NUR 4122: Nursing Research

April 22, 2018

“I pledge…”
INTEGRATIVE REVIEW 2

Abstract

Purpose: The purpose of this literature review is to identify the relationship between education

and the development of compassion fatigue (CF) and burnout (BO) in emergency nurses.

Introduction/Background: CF is a decreased ability for caring and is associated with caring for

the traumatized. BO is highly implicated in CF and is associated with feelings of hopelessness

and inability to effectively perform one’s job duties. CF and BO are associated with higher

turnover rates.

Design: This is an integrative review in which research was collected from online databases. The

articles discussed are primarily qualitative studies that were analyzed using a set of specific

criteria. The information in these studies was used to determine the effects of education on the

development of CF and BO.

Results/findings: The evidence compiled for this integrative review demonstrates that there is a

relationship between education, CF, and BO, although this relationship is inconsistent.

Additionally, education can be utilized as a tool to combat and treat CF and BO.

Limitations: Limitations include the researcher’s inexperience with the integrative review

process. Additional delimitations include the criteria used to choose articles as well as limitations

within the article themselves.

Implications and Recommendations: The implementation of educational programs seems to be

an effective way to treat/combat CF and BO as well as making nurse managers aware that

education does play a role in CF and BO. It is recommended that future research be conducted to

determine a clearer relationship between education, CF, and BO.

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Integrative Review

The purpose of this integrated review is to identify the relationship between education

and prevalence of compassion fatigue in emergency nurses. It is widely publicized that there is a

nursing shortage across the United States, and as the baby boomer population continues to age,

that shortage is only going to grow. The U.S. Bureau of Labor Statistics, predicts that by 2022

there will be a need for 1.1 million new registered nurses (American Nurses Association, 2018).

The Emergency Department (ED) is affected by the nursing shortage at a higher rate than any

other nursing specialty, with an overall turnover rate of 20.3% compared to 14.2% for bedside

nurses (Helbing, Teems, & Moultrie, 2017). The ED creates a unique environment, with high

acuity and traumatized patients as well as increased turnover, ED nurses are at higher risk for

developing some of the negative effects of the nursing profession, such as compassion fatigue

(CF) and burnout (BO).

Compassion fatigue is defined as the inability of the nurse to care for their patient and

usually involves emotional, physical, and spiritual exhaustion from witnessing the trauma of

others. Burnout is highly associated with CF but differs as it associated with feelings of

hopelessness and apathy and interferes with the ability of the nurse to effectively perform their

job (Hunsaker, Chen, Maughan, & Heaston, 2015). CF and BO put nurses under undo stress and

make them more likely to leave their current position. Health systems, nurse managers, and

nursing educators need to be aware of the factors that contribute to CF and BO and implement

ways to combat these conditions (Helbing et al., 2017) (Hinderer, et al., 2014) (Hunsaker et al,

2015) (Kelly, Runge, & Spencer, 2015). The aim of this review is to examine and discuss

published data related to the researcher’s PICOT question: Does education influence the

prevalence of CF and BO in emergency nurses?

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Design and Methods

This integrative review is focused on five research articles. The method used by the

researcher began with an initial search using EBSCO’s Nursing Center Reference database and

PubMed. The search words used were compassion fatigue, emergency nursing, burnout, and

education. The results yielded over 1,000 articles. The articles were then filtered by date,

language, peer-review, and relevance to the research question. Articles were limited to the years

2013-2018, and only included those that had been published and were peer-reviewed. This

significantly limited the number of available articles. Additionally, only articles printed in

English and had the full-text available were utilized for this literature review.

These articles were then chosen based on their relevance to the PICOT question. The

researcher was limited to primarily qualitative studies due to nature of CF and BO. Information

on education must have been available in order to be considered for inclusion in this review.

Relevant and qualified authors were prioritized; examples include Doctor of Philosophy (PhD),

Doctor of Nursing Practice (DNP), Master of Science in Nursing (MSN), and Registered Nurse

(RN). The total number of articles chosen after these limitations applied were five, resulting in

one quantitative study (Kelly, et al., 2015) and four qualitative/descriptive studies (Hinderer, et

al., 2014) (Hunsaker, et al., 2015) (Helbing, et al., 2017) (Flarity, Gentry, & Mesnikoff, 2013).

Findings

The results and findings of the articles do not clearly identify a relationship between level

of education and development of CF amongst ED nurses (Helbing, et al. 2017) (Hinderer, et al.,

2014) (Hunsaker, et al., 2015) (Kelly, et al., 2015). A summary of the results of the five articles
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is located at Table 1-Article Evaluation. The following is a brief overview of each articles’

findings.

Helbing et al. (2017) sought to determine the overall level of job satisfaction among ED

nurses. The framework utilized for this study was Herzberg’s Theory of Motivation-Hygiene.

This was a cross-sectional study with a descriptive design and was conducted with a one-time

online anonymous survey. The variables investigated included overall job satisfaction,

demographics, and both intrinsic and extrinsic job characteristics. The sample consisted of 89

RNs who worked in the ED and were primarily employed at a hospital in upstate New York.

Data on job satisfaction was collected using a survey developed by Helbing et al., (2017),

consisting of five demographic questions and seven questions aimed at satisfaction. Univariate

descriptive statistics were performed to determine overall job satisfaction among ED nurses.

Additionally, the data was filtered by demographic information to look at differences in

satisfaction based on “age, gender, years of nursing experience, years of ED experience, and

highest level of education” (Helbing, et al., 2014 p. 105). Findings noted significant differences

in highest level of education and job satisfaction. The sample consisted of Associate, Bachelor’s,

and Master’s prepared nurses. Those nurses who were Associate prepared experienced the

highest level of overall satisfaction, with Bachelor’s prepared nurses reporting the lowest level of

overall satisfaction.

Hinderer et al. (2014) aimed to determine how BO, CF, and compassion satisfaction (CS)

contribute to development of secondary trauma syndrome (STS) in trauma nurses. They also

looked at the relationship between personal and environmental characteristics, coping strategies

and trauma exposure and the development of BO, CF, and CS. A cross-sectional descriptive
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design was used in this study. The sample consisted of 128 staff nurses from a large urban

trauma center in the eastern United States.

Data was collected on demographics, BO, CF, CS, and STS. To collect demographic

information, a demographic/behavioral instrument was developed and used to assess

demographic, personal characteristics, coping strategies, and trauma exposure. To assess BO,

CF, and CS the ProQOL scale was utilized. The Penn Inventory was used to assess STS. Data

was analyzed using SPSS and descriptive statistics were performed on the demographics.

Pearson correlations were performed to determine the relationship between the variables and

trauma exposure, coping strategies, and personal characteristics. In order to look at whether BO,

CF, and CS could predict STS a linear regression was performed. The results of this article

suggest that there is no correlation between level of education and development of BO and CF in

trauma nurses. Although, those nurses who possessed higher levels of education self-reported

lower levels of CS than their less educated counterparts.

Hunsaker et al. (2015) sought to determine the prevalence of CS, CF, and BO amongst

ED nurses throughout the United States. Additionally, they hoped to determine what

demographic and work information impacted the development of these conditions. The design of

this study was nonexperimental, descriptive, and predictive. The sample included 284 ED nurses

across the United States. Participants were recruited via direct mail using a mailing list obtained

from the Emergency Nurses Association.

Data was collected using a demographic questionnaire and ProQOL scale to collect

information on CF, CS, and BO. The data was analyzed using SPSS. First, descriptive statistics

were done for CS, CF, and burnout. Pearson r correlation, t test, and ANOVA were used to

determine the relationship between demographic info, workplace characteristics, and the level of
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CF, CS, and BO. A multiple regression was performed to examine what demographic

information and workplace characteristics contributed to differences in level of CS, CF, and BO.

The results suggest that there is low to average CF and BO across ED nurses as a whole. In

regard to level of education, those nurses with a higher level of education reported higher levels

of CS and lower burnout levels.

Kelly et al. (2015) aimed to look at CF and CS in acute care nurses across multiple

disciplines. The design was a cross-sectional quantitative study that was conducted over a 3-

week period. The sample consisted of 491 acute care nurses in a quaternary facility in the

southwest U.S. All participants needed to be direct-care nurses and needed to be employed on

their unit for a minimum of three months.

Data was collected using an electronic survey that consisted of a demographic survey and

ProQOL scale, as well as some investigator derived questions. Descriptive statistics were run on

the demographics. Differences in ProQOL scores between age generations and nursing specialty

were determined using an ANOVA. A regression analysis was performed to look at differences

in ProQOL scores and nurse characteristics. Finally, univariate analysis was done to look at the

significance of demographic information, satisfaction, and intent to leave, on CS, CF, and BO.

Nearly half of the participants were Bachelor’s prepared nurses and the majority of the

participants reported that they were highly satisfied. The results did not report anything

significant on level of education and incidence of CF. However, the results of the study suggest

that nurses that fall in the millennial generation (age 21-33) were more likely to report higher

levels of BO and lower levels of CS, than the older generations. This is significant as millennials

are entering the nursing workforce at nearly double the rate of ‘baby-boomers’, and more and

more nurses are becoming Bachelor’s prepared (Andrews, 2017).

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In an effort to combat CF in ED nurses, Flarity, et al. (2013) developed an education

program to decrease CF and BO and increase CS. The design of the study was a pre/posttest

design with participants serving as their own control group. The sample consisted of 73 ED

nurses working at a hospital in Colorado. All participants self-selected to participate and were

recruited via packets that were placed in their work mailboxes. All participants self-scheduled to

participate in the CF intervention program.

Data was collected using a pre/posttest of the ProQOL as well as a demographic sheet.

SPSS was utilized for data generated from the ProQOL scores and Microsoft Excel was utilized

for demographic information. The pre- and post-test scores were compared individually for any

differences. Univariate statistics were used to evaluate the normalcy of the distribution. The

results of the study suggest that 59% of ED nurses experience symptoms of BO and 60% of ED

nurses exhibited at least one symptom of CF in the past month. The interventional program

demonstrated the ability to increase CS and decreasing BO symptoms. All participants rated the

program as excellent and many felt that it should be a requirement and would be helpful in

preventing burnout in young nurses. While this study does not address level of education, it does

address an educational intervention as a means to decrease CF and BO amongst ED nurses and

sheds some light on a simple way to combat CF and BO.

Discussion/Implications

The articles selected for review demonstrate an inconsistent relationship between

education and reported levels of CF and BO (Helbing, et al., 2017) (Hinderer, et al., 2014)

(Hunsaker, et al., 2015) (Kelly, et al., 2015). While the majority of the studies used the ProQOL

scale as a means to evaluate CF, CS, and BO each of these studies brought new information to

light. This review is framed according to the following categories: CF and BO, CS, and
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interventions. The following discussion regarding the implications of the articles is organized by

common themes and relevance to the PICOT question.

Compassion Fatigue and Burnout

Each study examined a unique sample of ED nurses all made up with a different

percentage of Associate, Bachelor’s, and Master’s prepared nurses. The studies that found a

relationship between level of education and reported CF and BO found that Bachelor’s prepared

nurses are more likely to report symptoms of CF than their Associate or Master’s prepared

colleagues. (Kelly, et al., 2015). This is important as the nursing profession is shifting to all

nurses either being Bachelor’s prepared prior to hire or requiring them to obtain their Bachelor’s

degree post-hire if they are Associate prepared. Additional research needs to be done to look at

the effect of higher levels of education on development of CF and BO.

Compassion Satisfaction

The results of the research demonstrated that there is a relationship between levels of

education and CS. As previously discussed, CS is a positive side effect of nursing work and like

CF and BO contributes to overall job satisfaction. The results of Helbing, et al. (2014) and

Hinderer, et al. (2014) demonstrate that those with a higher level of education were more likely to

report lower levels and CS and overall lower job satisfaction. On the other hand, Hunsaker, et al.

(2015) found that those with higher levels of education were more likely to report higher levels of

CS. The differences in reported levels of CS between studies may be due to differences in samples

or that CS levels were reported at only one specific point in time, as CS and CF levels may differ

throughout time. Although there are differences in the data, this is still an important relationship
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to highlight as increasing CS levels in nurses across multiple disciplines, regardless of education

level, may play an important role in nursing retention and staff ratios.

Interventions for Nursing Practice

In terms of nursing practice, each of the studies highlighted ways to improve nursing

practice and to help combat CF and BO and improve CS in ED nurses. Flarity et al. (2013)

developed an educational program to help combat and treat CF amongst ED nurses. This is a

simple tool that could be easily incorporated into nursing practice and implanted periodically

into seminars or new hire orientation. Hunsaker et al. (2015) discussed making nurse managers

aware of the role they play in the development of CF and BO amongst ED nurses. It may be

helpful to implement a training program for nurse managers, so they can adequately support

nurses, specifically the Bachelor’s prepared nurse who may be at increased at risk for the

development of CF and BO.

Future Research

Future research should be aimed at finding a more consistent relationship between CF

and level of education. This is extremely important as millennials continue to join the nursing

profession and there is an increased push for all nurses to be Bachelor’s prepared, at a minimum.

As most of the studies reviewed were performed on a small scale, it would be important for

future researchers to reproduce these studies on a larger scale (Helbing, et al., 2017) (Hinderer, et

al., 2014) (Kelly, et al., 2015).

Limitations

While conducting this integrative review, the researcher was met with many limitations.

The largest limiting factor was the researcher’s inexperience and limited knowledge about the
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integrative review process. The researcher has very few qualifications in performing an in-depth

discussion of the subject being discussed, as the researcher is not a registered nurse. The

researcher was only able to provide limited insight into the topic presented by the PICOT

question.

An additional limitation is related to the process of locating articles for review. The

researcher had some difficulty in finding full-text articles as well as articles that examined CF in

ED nurses alone. Additionally, only a limited number of articles discussed the nurse’s level of

education, so the incorporation of educational interventions needed to be included. This was out

of the researcher’s control and significantly impacted the collection process. The filters applied

to the available articles also limited the results of the search criteria. The search was delimited to

five articles with a five-year time frame (2013-2018), this is far from a comprehensive review of

all information available on the topic. The articles themselves had additional limitations such as

sample size and mainly being limited to qualitative study type. Additionally, all data was self-

reported which may decrease the reliability and validity of the data. All these factors decrease the

quality and reliability of the research, which should be considered when discussing further

research.

Conclusions

The evidence compiled in this literature review highlights the need for additional research

regarding education and the development of CF among ED nurses (Helbing, et al., 2017)

(Hinderer, et al., 2014) (Hunsaker, et al., 2015) (Kelly, et al., 2015). While the data related to CF

is inconsistent, there has been a difference in reported levels of CF, BO, and CS between nurses

of varying educational backgrounds. Throughout the studies it was clear that Bachelor’s prepared

nurses were either experiencing lower CS, lower overall job satisfaction, or higher levels of CF
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in comparison to those with either higher or lower levels of education. Regardless of the

inconsistencies in the data, education, whether it be nursing education or educational programs

incorporated into practice, plays some sort of role in the development of CF, BO, and CS. Future

research should be focused on recruiting a larger sample size and nurses across the U.S in a

longitudinal study. Researchers should also focus more heavily on level of education as more of

the nursing workforce obtains a Bachelor’s degree. In regards to the PICOT question being

addressed, there seems to be some relationship between education and CF in ED nurses, however

that relationship remains unclear and needs to be investigated further.

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References

American Nurses Association. (2018). Workforce. Retrieved from:

https://www.nursingworld.org/practice-policy/workforce/

Andrews, M. (2017). Millennials embrace nursing profession- Just in time to replace baby

boomers. Retrieved from: https://khn.org/news/millennials-embrace-nursing-profession-

just-in-time-to-replace-baby-boomers/

Flarity, K., Gentry, J.E., & Mesnikoff, N. (2013). The effectiveness of an educational program

on preventing and treating compassion fatigue in emergency nurses. Advanced

Emergency Nursing Journal, 35, 247-258. doi: 10.1097/tme.0b013e31829b726f

Helbing, E., Teems, M., & Moultrie, D. (2017). An investigation of job satisfaction among

nurses in the Emergency Department. Association of Black Nursing Faculty Journal,

103-108.

Hinderer, K., VonRueden, K.T., Friedmann, E., McQuilan, K.A., Gilmore, R., Kramer, B., &

Murray, M. (2014). Burnout, compassion fatigue, compassion satisfaction, and secondary

trauma stress in trauma nurses. Journal of Trauma Nursing, 21, 160-169. doi:

10.1097/jtn.0000000000000055

Hunsaker, S., Chen, H.C., Maughan, D., & Heaston, S. (2015). Factors that influence the

development of compassion fatigue, burnout, and compassion satisfaction in Emergency

Department nurses. Journal of Nursing Scholarship, 47, 186-194. doi: 10.1111/jnu.12122

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Kelly, L., Runge, J., & Spencer, C. (2015). Predictors of compassion fatigue and compassion

satisfaction in acute care nurses. Journal of Nursing Scholarship, 47, 522-528. doi:

10.1111/jnu.12162
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First Author (Year)/Qualifications
Background/Problem Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if appropriate
Measurement Tool/Data Collection
Method
15
Hinderer, K. (2014) / PhD, RN, CCRN affiliated with Salisbury University, Salisbury, MD
Examine how burnout, compassion fatigue, and compassion satisfaction contribute to the development of secondary
stress syndrome. The study also examined the relationship between burnout, compassion fatigue, and compassion
fatigue and personal/environmental characteristics, coping strategies, and exposure to traumatic events.
Dutton and Rubinstein’s theory of secondary stress syndrome was modified and used as the theoretical basis.
Cross-sectional descriptive design. Participants were asked to answer three surveys which included both multiple
choice and Likert-style items.
A total of 262 nurses who all worked at a large urban trauma center in the eastern U.S. were given the opportunity to
participate in the study. 49% of those nurses responded to and participated in the study. The researchers obtained IRB
approval and all participants were given a letter that described the purpose of the study ad were given a consent form.
There was no identifying information included on any of the forms given to participants. Nurses were able to return
the surveys in anonymous drop boxes that had been placed in each unit.
● Burnout (BO): encompasses emotional exhaustion, patient depersonalization, negative attitudes toward
patients, and diminished feelings of personal and work accomplishments.
● Secondary traumatic stress (STS): development of posttraumatic stress disorder in health care workers and
includes behaviors and emotions experienced as a result of exposure to another person’s trauma.
● Compassion fatigue (CF): a loss of a nurse’s ability to nurture patients
● Compassion satisfaction: feeling a sense of accomplishment and reward as a result of caring for patients.
● Demographic/behavioral instrument which assessed demographics, personal/environmental characteristics,
coping strategies, and exposure to traumatic events. This instrument included both multiple-choice and
Likert-type items.
● Professional Quality of Life Scale (ProQOL): was used to assess BO, CF, and CS. This is a 30-item tool that
uses a Likert scale. The ProQOL has three subscales, one for each of the three variables.
● Penn Inventory was used to measure STS. It is a 26-item multiple choice survery where participants are
asked to choose which statement best matches their feelings towards a particular construct
INTEGRATIVE REVIEW
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
First Author (Year)/Qualifications
Background/Problem Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
16
● Analysis conducted using SPSS
● Descriptive statistics were used to for all variables for normality and missing values
● Demographic variables were assessed using descriptive statistics
● Pearson correlations were performed to assess the relationship between BO, CF, and CS with STS and
exposure to traumatic events, coping strategies, and personal/environmental characteristics
● Linear regression was done to assess whether BO, CF, and CS predicted STS
● Strongest correlation between BO and CF, those with higher BO scores were more likely to have CF
● Trauma nurses report high levels of CS, which is negatively related to BO, CF, and STS
● Those with higher BO scores were more likely to suffer from STS
● BO was related to certain coping strategies such as medicinals and seeking professional help.
● Coworker relationships has a significant impact on BO. Those with more support reported less BO.
● Nurses with higher levels of education had less CS than those with less education (i.e. bachelors degree v.
associates degree)
This highlights the need for staff support systems and the need for there to be strategies put in place to enhance a
healthy and positive work environment as well as education on prevention on the development of BO, CF, and STS.
Further research is needed to explore why BO, CF, and STS develop in some nurses and not in others.
Hunsaker, S. (2015) / MSN, CPEN, CEN and Associate Teaching Professor at Brigham Young University
College of Nursing
The purpose was to ascertain the prevalence of compassion satisfaction, compassion fatigue, and burnout in
emergency nurses and to determine which demographic and work-related components affect the development of
compassion satisfaction, compassion fatigue, and burnout.
Figley’s stress-process framework was developed based on factors that lead to compassion fatigue. Stamm’s Pro-QOL
scale, which is based off of Figley’s framework, was used to create a conceptual framework related to CS, CF, and
burnout which guided the study.
Cross-sectional study that used a nonexperimental, descriptive, and predictive design. Participants were given a
survey packet which consisted of informed consent, a demographic questionnaire, and the ProQOL scale.
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Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if appropriate
Measurement Tool/Data Collection
Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
17
The sample consisted of 284 emergency room nurses from across the United States. The packets were sent out to 1000
possible participants based off of a mailing list from the Emergency Nurses Association. IRB approval was obtained.
The surveys were answered anonymously and all identifying information was removed. All of the data was
numerically coded and was only accessible by the researchers in order to ensure confidentiality.
● Compassion fatigue: emotional, physical, and spiritual exhaustion from witnessing and absorbing the
problems and suffering of others.
● Burnout: feelings of hopelessness and apathy and creates an inability to perform one’s job duties effectively
● Compassion satisfaction
ProQOL 5 scale and demographic questionnaire. Demographics included education level, years in nursing profession,
typical shift length, age, etc. The ProQOL scale is a 30-item self-report survey that includes three subscales, one for
each variable.
All data was analyzed using SPSS. Descriptive statistics were performed for levels of CF, CS, and burnout. A series
of Pearson r correlation, t test, and ANOVA were performed to look at the connection between demographics, work-
related characteristics, and level of CS, CF, and burnout. Multiple regression was done to look at which demographic
and work-related variables contributed to differences in the level of CS, CF, and burnout.
● Results revealed average to low levels of CF and burnout.
● Average to high levels of CS
● Age, educational background, and years in nursing influenced the prevalence of CS, CF, and burnout
● Manager support was a key predictor of CS, CF, and burnout
● Increased awareness of CF and burnout may improve job satisfaction among ED nurses
● Nurses need to address support strategies and solutions to increase higher levels of work satisfaction
Overall, a good study. Highlighted some new factors that contribute to CF and burnout among ED nurses and
introduced some strategies to combat these variables.
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First Author (Year)/Qualifications
Background/Problem Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if appropriate
Measurement Tool/Data Collection
Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
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Helbing, E. (2017)/ MSN, RN
The purpose of this study was to determine the overall job satisfaction among ED nurses. Emergency departments are
affected by higher turnover and nursing shortages than any other specialty area and is something that needs to be
addresses, especially as ED use continues to increase.
Herzberg’s Theory of Motivation-Hygiene Factors was used to guide this study. This framework is helpful in
identifying factors within a work place that lead to satisfaction or dissatisfaction.
Descriptive cross-sectional study. A one-time survey was completed online.
A sample of RNs who worked in the ED was utilized. IRB approval was obtained. Participants were recruited via
social media flyer and completed an anonymous survey on line.
Job satisfaction was the major variable studied. The study also looked at work relationships, education, total years
nursing experience, age, etc.
The McCloskey-Mueller Satisfaction Scale was used to create a Satisfaction Survey which was made up of five
demographic questions and seven satisfaction questions. A pilot study was initially done with 5 nurses in order to
assure the questions were understood and it could be completed in a timely manner. The survey was placed on the
website “Survey Monkey” and was made available for an 8-week period.
89 surveys were returned. Univariate descriptive statistics was done to look at overall satisfaction and satisfaction of
each the job variables. The data was filtered by demographic information to look at differences in satisfaction based
on age, gender, years of nursing experience, years in the ED, and highest level of education.
An overwhelming percentage (72%) of the participants reported that they were satisfied in their current position.
Participants were the most satisfied with the work itself and their work relationships. The areas that participants were
the least satisfied with were current work conditions and achievement/recognition. Those with an Associate’s degree
were more likely to report job satisfaction, followed by Master’s prepared, and then by Bachelor’s prepared nurses.
While there are some serious limitations to this study, such as sample size and only being able to reach nurses via
social media and not being able to verify that the respondents were currently employed as ED nurse, it does highlight
some interesting recommendations for nursing practice, research, and education. Recommendations include
promoting positive work relationships and involving nurses in discussions and decisions regarding company policies.
The researchers suggested that educators be more transparent about specific areas were job satisfaction is low to better
prepare students and future nurses for the actual work environment they will encounter.
INTEGRATIVE REVIEW
First Author (Year)/Qualifications
Background/Problem Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if appropriate
Measurement Tool/Data Collection
Method
Data Analysis
Findings/Discussion
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Kelly, L. (2015) / PhD, RN. Associated with University Medical Center Phoenix, AZ and Assistant Professor,
Arizona State University, Phoenix, AZ
The purpose of this study was to examine compassion fatigue and compassion satisfaction in acute care nurses in the
inpatient setting.
None described.
Cross-sectional, quantitative survey study conducted to assess CF and CS over a 3-week period.
The study was conducted at a large, quaternary care facility in the southwest U.S. In order to be considered for the
study, the nurse must be employed as full-time, part-time, or per-diem in an inpatient setting for at least 3 months.
Additionally, the nurse must work in direct patient care. IRB approval was obtained through the health system. The
survey was distributed electronically through a website address within an email to all direct care nurses. Participation
was voluntary. There was no mention as to how information was coded to maintain confidentiality.
● Compassion fatigue: the combination of burnout and secondary traumatic stress.
● Burnout: composed of three constructs emotional exhaustion, depersonalization, and diminishing one’s
personal accomplishments
● Compassion satisfaction: the pleasure and gratitude that develops from caregiving for patients
An electronic survey was sent to participants which included demographics, the ProQOL scale, and investigator-
derived recognition. Demographics included work status, professional backgrounds, job satisfaction, and intent to
leave current position. Nurses were also asked if they had ever received recognition such as the DAISY award.
Descriptive statistics were performed to describe the sample. ProQOL subscales were reverse scored and averaged,
satisfaction was dichotomized into low and high satisfaction. Ages were broken down into three generational
categories (millennials, generation x, and baby boomers). An ANOVA was performed to assess differences in
ProQOL scores between generations and specialties. Regression analysis was performed on the ProQOL subscale
scored and individual nurse characteristics. Univariate analysis was used to look at the initial significance of
demographics, satisfaction, and intent to leave on burnout, STS, and CS.
Contributes to what is known regarding CF but looks at it across multiple disciplines. The younger generation
(millennials) are experiencing higher levels of burnout and STS compared to older generations. This may contribute to
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Appraisal/Worth to practice
First Author (Year)/Qualifications
Background/Problem Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
\Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if appropriate
Measurement Tool/Data Collection
Method
20
them leaving their positions and/or the nursing profession in general. This study also looked at ways to combat CF,
this included recognition and increasing workplace satisfaction. The researchers make suggestions that health care
organizations should actively work to address CF and CS in order to increase nursing retention rate and increase
patient satisfaction.
Overall, a good study. It highlighted some interesting information and made good recommendations for practice and
future research. It would have been interesting if they had included more information on ProQOL scores based on
nursing specialty.
Flarity,K. (2013) / DNP, PhD, CEN, CFRN, FAEN associated with Memorial Hospital, University of Colorado
Health, Colorado Springs. Also affiliated with the Office of the Surgeon General Headquarter U.S. Air Force,
Washington, District of Columbia
The purpose of this study was to investigate the treatment effectiveness of an education program to decrease CF and
BO symptoms and to increase CS in emergency nurses.
None described.
Pre-/posttest w/ participants serving as their own control. This was a qualitative study. A CF resiliency program was
implemented to determine the effect of the program on both preventing and treating CF.
The sample was a convenience sample consisting of 73 ED nurses at Memorial Hospital in Colorado Springs, CO.
IRB approval was obtained, and all nurses volunteered to participate. Nurses were contacted via research packets in
their work mailboxes. All participants self-scheduled to participant in the educational intervention. There were no
names or personal identifiers used, instead participants were asked to create a fictitious name to use for the
pre/posttest. There was no way to link actual name to fictitious name.
Burnout, CF, and CS were the major variables studied.
A demographics questionnaire was developed. Participants completed the ProQOL scale as the pre/posttest.
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Data Analysis Data was analyzed using SPSS and Microsoft Excel. Scores from the pre/posttests were individually compared for
changes. Univariate statistics were used to examine for normalcy of distribution.

Findings/Discussion Overall, nurses reported that the educational program was excellent and helped to reduce CF and increase reported
levels of CS. The researchers feel that this sample justifies continuing to offer this training for its nurses.

Appraisal/Worth to practice Overall a good study. This should be replicated with a larger study and possibly have nurses reevaluate using the
ProQOL scale at various time periods to see how effective the intervention is in the long run.
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