Compassion fatigue in the perioperative environment

This Article is brought to you for free and open access by Journal of Perioperative Nursing. It has been accepted for inclusion in Journal of Perioperative Nursing by an authorized editor of Journal of Perioperative Nursing. Recommended Citation Wakefield, Erin (2018) "Compassion fatigue in the perioperative environment," Journal of Perioperative Nursing: Vol. 31 : Iss. 2 , Article 2. Available at: https://doi.org/10.26550/2209-1092.1027

Compassion fatigue (CF) is an important issue for nursing professionals today because 'caring and compassion, which provide nurses with satisfaction and fulfilment in patient care, can contribute to the exhaustion of those emotions and lead to compassion fatigue' 1 .CF can impact negatively not only on the professional performance of the nurse 2 but in broader terms of workplace stability 3 including staff retention and turnover 4 , absenteeism due to sickness, low morale 4 , psychological injury claims 5 and even patient outcomes 3 .It can impact personally on nurses' quality of life 6 including their health 3 .Left untreated, CF can lead to compromised patient care, as nurses may become desensitised toward future patient suffering 6 .
CF is considered to be the 'cost of caring' 3 , and is defined as 'the convergence of secondary traumatic stress and cumulative burnout; a state of physical and mental exhaustion caused by a depleted ability to cope with one's everyday environment' 5 .The term was originally used by Joinson 1 in a study investigating burnout in emergency nurses who lost 'the ability to nurture' 3 and became tired, depressed, angry, ineffective, apathetic and detached 3 .Charles Figley later adopted the term in his study of psychotherapists who became distressed by caring for clients who had experienced trauma 3 .He claimed CF has the same symptoms as a secondary traumatic stress reaction -a construct of Post-Traumatic Stress Disorder 1 .Today, CF is defined as the cumulative effects of both burnout, and secondary traumatic stress 1,4,5,7 .It is interesting to note that burnout is associated with many professions while CF, although it has many similarities with burnout 8 , is generally agreed to belong to the caring professions 3 .
Burnout is 'a progressively worsening condition whereby one has difficulties performing his or her job effectively due to feelings of hopelessness and a non-supportive environment' 6 .It can also refer to a 'lack of interest in work, exhaustion, and the physical and emotional collapse that evolves over time in response to a period of high workload 3 .Environmental stressors 8 may include a disproportionately great workload 1 , poor workplace culture, or inadequate staffing 1 .Emotional exhaustion 2 is another causative agent, which, in the professional environment may stem from feelings of 'frustration and powerlessness' 1 .Evidence of burnout may include a detached demeanour, more frequent mistakes and cynicism 9 .), where all patients have undergone a surgical trauma.Regardless of the nature of the surgery performed or the causative agent, surgery may bring emotional, physical and psychological distress.It is important to remember that 'exposure to patients experiencing trauma or distress can negatively impact professional's mental and physical health, safety and wellbeing, as well as that of their families, the people they care for, and their employing organisations 5 .

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The risk factors inherent to CF amongst nurses in today's literature are transferrable to the perioperative environment.
Patient-related stressors 3 may include factors such as recurrent exposure to patient distress and trauma 3 , patient death and unexpected outcomes 1 .Cocker and Joss further state 5 that caring for patients where treatment is futile, or who have life-threatening conditions, may trigger CF, as may caring for 'difficult' patients while fulfilling the moral obligations of the nursing role 3 .
Practice related stressors 3 include factors such as intensifying workloads 5 and physically and emotionally draining work 5 , long shifts and inadequate rest time between shifts 5 , inadequate staffing levels 1 , and limited resources and equipment 3 .These stressors may also stem from management -poor support 5 , quality of interpersonal relationships 3 , and a lack of meaningful recognition 5 .
In addition, unique environmental stressors in the perioperative environment exist.These may include 'the need to work quickly, to face higher medical dispute risks, to work uncertain shifts, to handle precision instruments, and to master complex techniques' 10 , as well as instrument processing issues, low morale and staff shortages' 10 .Theatre nurses also have a uniquely potentially hostile environment, and may be exposed to or experience different forms of bullying compared to nonperioperative colleagues 10 .
Perhaps not surprisingly, the ability to use empathy in nursing is considered a risk factor in developing CF 5 .However, this is contentious, as no research has been completed linking nurses who self-describe as 'very compassionate' with increased levels of CF 3 .It is also interesting to note that multiple research cites contradictions in prevalence -some state that nurses with three or fewer years' experience are most at risk 1 as are those who are younger 7 , while other state that as experience grows, so does the likelihood of CF 2 .With the ageing workforce, and the increasing demand for surgery as our population also ages, CF is an issue that must be explored.
The signs and symptoms of CF are many (see Table 1).
Compassion satisfaction (CS) ' is the ability to receive gratification, joy and a sense of purpose derived from providing care' 8 .It is imperative that the positives of CS outweigh the • physical exhaustion and fatigue 3 • impaired ability to care for patients 3 • insomnia 3 • compromised immunity 3 • somatisation 3 • headaches and stomachaches 1,3 • sleep disturbance 1,3 • negative coping behaviours e.g.drug and alcohol abuse 3,5 • increased absenteeism 3,5 • altered personal relationships 3 • avoidance of patients 3 • compromised patient care 8 and diminished performance 3 • anger 5 • irritability 5 • a lessened sense of enjoyment in work 5 • impaired ablity to made decisions 3,5,8 • emotional exhaustion 3 • resentment 3 • diminished professional satisfaction 3 • depression 1 • reduced ability to feel sympathy and empathy 3,5 • moral distress 1,3 • decreased spiritual wellbeing 1,3 • errors in judgement 3 negatives of CF in order to achieve not only good quality professional life for individual nurses, but also for the broader nursing community.Poor quality of professional life (that is, low CS and high CF) 'has strong links to a decline in patient care' 6 .Much research has been done for nonperioperative specialties, some of which translates across all acute care nursing 5 ; however, the exploration carried out by this author has found that there is a dearth of research on the effectiveness of interventions to reduce CF in nurses in generallet alone in the perioperative environment.
Much of the current literature concurs that the risks of occupational exposure are difficult to limit or change 5 .Therefore, one solution to combatting and preventing CF must be based upon strategies to promote resilience in individual nurses, and promote effective coping tactics 5,9 .Much research proves a strong correlation between the burnout aspect of CF, and lack of resilience 9,11 . In

Table 1 :
Signs and symptoms of compassion fatigue