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Concept Analysis of Burnout and Compassion Fatigue Barbara J. Henry Northern Kentucky University

Running head: BURNOUT AND COMPASSION FATIGUE Purpose The purpose of this paper is to analyze the concepts of burnout and compassion fatigue, particularly as they occur in the oncology nursing populations. According to MacLaughlin Frandsen (2010) burnout occurs in 10 stages: 1. compulsion to prove oneself, 2. working harder, 3. neglecting ones own needs, 4. displacing conflicts by ignoring the root cause of the distress, 5. revision of values in which friends or hobbies are ignored, 6. denial with emergence of cynicism and aggression, 7. withdrawing from social contacts and/or using alcohol or substances to cope, 8. inner emptiness, 9. depression, 10. actual burnout syndrome. Burnout is emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment (Maslach, Schaufeli & Leiter, 2001). Compassion fatigue is often linked to burnout and leads to frustration, loss of control, and low morale (Edmunds, 2010). Compassion fatigue appears suddenly and subsides more quickly than burnout (Figley, 2006). Compassion and fatigue are also two different concepts. Compassion is the therapeutic alliance between the patient and nurse to achieve the desired outcome (Figley, 2006). Compassion fatigue is behaviors and emotions resulting from helping or wanting to help a traumatized or suffering person (Figley, 2006). Compassion fatigue is amenable to intervention; with therapeutic support programs and retreats, nurses may continue to work in their chosen field (Sabo, 2011). Historical Perspective The concept of burnout was first conceptualized by Christina Maslach who developed the Maslach Burnout Inventory tool to measure burnout in healthcare and other professional workers (Maslach & Leiter, 1993). In burnout syndrome, depersonalization occurs when nurses develop negative and cynical attitudes and feelings towards their clients and reduced personal

Running head: BURNOUT AND COMPASSION FATIGUE accomplishments means the nurse has negative perceptions of his or her work (Maslach & Leiter, 1993). Burnout has been studied extensively in occupations other than nursing such as: teaching, social services, mental health, medicine, and law (Pilkington, 2009). The use of psychological terminology and theory development has not been as applicable to exploring burnout in nursing (Pilkington, 2009). Compassion fatigue was first introduced by Joinson in 1992 during an investigation of burnout in emergency department. The author noticed that nurses appeared to have lost the ability to nurture (Joinson, 1992). Joinson never formally defined compassion fatigue and, in 1995, it was adopted by psychologist Charles Figley as a term for secondary traumatic stress disorder (Figley, 1995). Figley also developed the Compassion Fatigue Scale (Figley, 1995). Since the 90s, the phenomenon of nursing burnout has been a focus for research (Knobloch Coutzee & Koppler, 2005). Nursing burnout was never explored, described, or explained in a way that nurses could identify compassion fatigue and combat its effect in clinical practice (Knobloch Coutzee & Koppler.) Nurses have a higher than average proportion of burnout caused by prolonged stress with extreme physical and psychological job demands (MacLaughlin Frandsen, 2010). Current Literature and Related Concepts There has been a great deal published about the prevalence of burnout and compassion fatigue in nursing, but less on interventions to decrease the problems. Burnout and compassion fatigue have been topics of interest in nursing literature, particularly in the past five years (Knobloch Coutzee & Klopper, 2005). The concept of lateral violence has emerged in the literature as both an antecedent and consequence of burnout and compassion fatigue (SheridanLeos, 2008). Other concepts related to burnout and compassion fatigue are: mental exhaustion

Running head: BURNOUT AND COMPASSION FATIGUE low morale secondary traumatic stress vicarious traumatization post-traumatic stress disorder traumatic countertransference lateral violence self-care for nurses (Figley, 2995 & Bush, 2009) Kash, Holland, Breitbart, Berensen, Dougherty, Ouellette-Kobasa, and Lesko identified the concept of a hardy personality, social support, and relaxation methods as moderating variables that may decrease burnout and compassion fatigue (2000). Three attributes of a hardy personality were found to be buffers against stress are commitment to self and work, a sense of being able to control or influence events, and a sense of challenge in the face of a changing environment (Kash, et al., 2000). Yoder and others utilized the Professional Quality of Life (ProQOL) Scale to measure compassion fatigue, compassion satisfaction, and burnout in hospital and home care nurses (2008). Yoders 2010 study found that 15% of participants had ProQOL scores indicating risk for compassion fatigue though estimates of compassion fatigue in oncology nurses is much higher (Najjar, Davis, Beck-Coon, & Carney Doebbeling, 2009). In a study of burnout in Australian nurses, emotional exhaustion and reduced personal accomplishment were experienced more often than depersonalization (Patrick & Lavery, 2007). The level of burnout increased with working more hours per week, however; increased age of nurses was not a factor in burnout (Patrick & Lavery, 2007). In a quasi-experimental study among staff of 29 hospital oncology units in the Netherlands, Le Blanc, Hox, Schaufeli, Taris & Peeters evaluated the effects of a team-based burnout intervention program combining a staff support group with a participatory action research approach. Nine oncology units were randomly selected to participate (2007). Before the Take Care program started (Time 1), directly after the program ended (Time 2), and 6 months later (Time 3), participants filled out a questionnaire

Running head: BURNOUT AND COMPASSION FATIGUE on their work situation and well-being (LeBlanc, et al., 2007). Staff who participated in the program experienced significantly less emotional exhaustion at both Time 2 and Time 3 and less depersonalization at Time 2, compared with staff who did not participate in the program (LeBlanc, et al, 2007). The authors showed that a team-based, participatory approach to burnout intervention may have a stabilizing effect on burnout (LeBlanc, et al., 2007) Medland, Howard-Rubin and Whitaker (2004) identified psychosocial wellness and the avoidance of burnout as key to retention of oncology nurses, and described a program to enhance oncology nurse coping skills. The findings of Medland, et al. (2004) and Knobloch Coutzee & Klopper (2010) can be used to educate nursing students about risk factors and causes of the progressive compassion fatigue process. Further research is needed to develop a theory of compassion fatigue for nursing practice (Knobloch Coutzee & Klopper, 2010). Additional research may determine factors that contribute to the progression from compassion discomfort to compassion stress, and compassion fatigue, and determine time line involved in this process (Knobloch Coutzee & Klopper, 2010). More studies are needed that evaluate interventions for preventing and reducing nursing burnout compassion fatigue as well (Coutzee & Klopper, 2010). Defining Attributes Oncology nurses with burnout and compassion fatigue reach an emotional state with negative physical and psychological consequences that emanate from acute or prolonged caregiving of people struck by intense trauma, suffering, or misfortune (Bush, 2009). When emotional boundaries are blurred and the nurse absorbs distress, anxiety, fears, and trauma of the patient, (a concept called countertransference in psychiatry), compassion fatigue occurs (Bush, 2009). The cumulative effect of untreated compassion fatigue may lead to a negative effect on

Running head: BURNOUT AND COMPASSION FATIGUE personal and professional psychological, physical, social, and work-related health (Bush, 2009). Compassion fatigue has been interchangeably described as burnout, vicarious traumatization, secondary traumatic stress and empathy fatigue (Bush, 2009). Refer to Appendix A for a visual representation of the trajectory of burnout and compassion fatigue. Model Case of Burnout Kathleen was an oncology nurse for thirty years. She started her education in a hospital school of nursing and continued on over the years to complete her Masters degree in nursing. Kathleen was known as a by the book nurse who had little room for flexibili ty with coworkers, reporting any violation of policy or procedure. She was knowledgeable in educating patients and providing appropriate care, but not flexible with colleagues. She worked on the same oncology unit for ten years followed by twenty years in the same outpatient oncology clinic. Colleagues noticed that she was resistant to change and seemed jealous of more progressive colleagues. Though she was always professional with patients, she was judgmental about patient lifestyles, and even more judgmental about colleagues. She often complained to the clinic manager about perceived shortcomings of other nurses. She worked late hours and weekends and reported peer tardiness. She was not married and criticized nurses who had to take sick time to care for their children. She boasted about the amount of vacation time she built up rarely taking off work. Her anger about all of these issues permeated social and professional meetings she attended making it unpleasant to be in her company. Model Case of Burnout and Compassion Fatigue Model cases clearly illustrate critical attributes. Melanie was an experienced oncology nurse who worked on a bone marrow transplant unit for 12 years. Because of her clinical expertise and compassion, she was often assigned patients in critical condition due to

Running head: BURNOUT AND COMPASSION FATIGUE complications from their disease or treatment. Melanie was skilled in comforting families when their loved ones were dying or critically ill. She attended dozens of patient funerals each year and experienced a great deal of personal loss as well. Physicians relied on her expertise to help rally the sickest patients when a rally was possible. She worked extra shifts and felt guilty when a patient died and she was not present. She became very ill herself, eventually having to take a medical leave to tend to her own health issues. Related Case of Burnout and Compassion Fatigue Related cases do not have all the critical attributes illustrated in the model case above. Gail was a float pool nurse who was often assigned to work on a medical oncology floor. She had trouble sleeping after working shifts on this floor because the patients reminded her of friends and family members who had died from cancer. She had nightmares about not being able to save patients, friends and family members from death. She worried about her own health because she was a smoker who didnt exercise or eat healthy meals. Gail also found the oncology nurses to be very cliquish, which made her feel like an outsider. She noticed that she was assigned older and dying patients rather than those who were doing well after treatments. When she asked questions about cancer and chemotherapy, many oncology nurses were impatient with her. After a year, she asked to no longer be assigned to the oncology floor. Borderline Case of Burnout and Compassion Fatigue Some attributes are provided in borderline cases. Sally was a young energetic nurse and mother before she began working on an inpatient oncology unit. After five years of helping cancer patients and families feel better, she began feeling worse herself. Because she was an energetic nurse with many ideas for practice improvement, some of the senior nurses gossiped about how she sucked up to the nursing manager. Sally was frustrated that the on cologists on

Running head: BURNOUT AND COMPASSION FATIGUE her unit did not listen to floor nurses, only the advanced practice nurses who assisted them. She became less confident in her skills and more anxious about coming to work. She developed insomnia and would hit the snooze button dozens of times before finally getting up for work. She was disciplined for taking too many sick days and because she dreaded going to work, had second thoughts about whether she was capable of being a good nurse. Contrary Case to Burnout and Compassion Fatigue A contrary case is the opposite of a model case and gives an example of what the concept is not (Walker &Avant, 2005). In Coutzee & Kloppers concept analysis, compassion satisfaction was defined as the opposite extreme of compassion fatigue (2010). Donna was a nurse who worked eight years in an oncology clinic. She had worked on psychiatric and obstetrics floors prior to working with cancer patients. Her patients and families noticed her calm demeanor and felt comfortable with her care and conversations. She got close to patients and families, but never allowed herself to think of them outside work. Her way of coping with patient death was to cut out obituaries and save them in a drawer. She did not look at the obituaries often, but saving them was a way to honor the patients and thank them for allowing her to share a crucial time in their life. Donna liked to get up 20 minutes early before work to do a Yoga routine. On her way home from work she always listened to upbeat music singing along and observing nature on the drive and in her garden when home. She enjoyed attending her sons sporting events and took a painting class to pursue her own creativity and non -work interest. She enjoyed meeting new friends and neighbors, reading fiction, and travel. Donna was not suffering from burnout or compassion fatigue because she utilized self-care as well as compassion balanced with appropriate professional boundaries.

Running head: BURNOUT AND COMPASSION FATIGUE Antecedents Antecedents come before burnout or compassion fatigue and may include the following: Exposure to traumatic care of cancer patients Vulnerable individual personality traits or lack of coping skills Lateral violence from others Excessive worries Compulsive sensitivity Disabled resiliency Emotional contagion Empathetic distress and strain Physical and mental fatigue Work and emotional overload Existential suffering Final availability (end of life care) Exposure to indirect trauma Secondary victimization Soul pain Vicarious trauma Functioning as wounded healer (Boyle, 2011). Difficulty balancing work and life outside work is also an antecedent to burnout and compassion fatigue. Consequences Oncology nurses may commit lateral violence as a consequence of their burnout and compassion fatigue. The concept of lateral violence (LV) also is known as horizontal violence, bullying, or aggression (Griffin, 2004). Other terms in the literature relating to this concept are horizontal hostility, verbal abuse, or nurses eating their young. Collins reports the consequence of compassion fatigue and burnout is unresolved emotional pain that caregivers store away (2003 p.18). There are many possible consequences of burnout and compassion fatigue. Consequences and symptoms may include: hypervigilance, substance abuse, flashbacks, re-experiencing the trauma, depression, anxiety, insomnia, mood swings, anger, apathy, cynicism, desensitization, discouragement, bad dreams, preoccupation with patient experiences, feelings of being overwhelmed, hopelessness, irritability, lessened enthusiasm, sarcasm, intellectual boredom, concentration impairment, disorderliness,


Running head: BURNOUT AND COMPASSION FATIGUE weakened attention to detail, increased somatic complaints, lack of energy, loss of endurance, loss of strength, proneness to accidents, weariness, fatigue, exhaustion, callousness, feelings of alienation, isolation, inability to share in or alleviate suffering, indifference, loss of interest in activities once enjoyed, unresponsiveness, withdrawal from family or friends, lack of spiritual awareness, poor judgment, absenteeism, avoidance of intense patient situations, desire to quit, diminished performance ability (i.e., medication errors, decreased documentation accuracy/record-keeping), stereotypical/impersonal communications and tardiness (Aycock & Boyle, 2009; Coetzee & Klopper, 2010; Showalter, 2010). In summary, these consequences can cause oncology nurses to leave the nursing profession or change specialties causing a shortage of oncology nurses. Many competent oncology nurses suffer with burnout and compassion fatigue and continue to work in oncology. The nurse, patient, and quality of care may suffer; costs related to tardiness, absenteeism, and poor patient outcomes may be incurred by oncology care facilities. Theoretical Definition Pilkington and others suggest positing a conceptualization of burnout from the perspective of the Neuman systems model (2008). Neumans nursing theory contains stressors of both the patient and the nurse (Current Nursing, 2012a). Jean Watsons seven assumptions of nurse caring provide the theoretical underpinnings of potential for burnout and compassion fatigue (Current Nursing, 2012b). Maslach and colleagues provide the most definitive theoretical definition of burnout arising from difficult patient situations causing staff to become angry, lack empathy, or depersonalize (Maslach & Schaufeli, (1993). Other oncology patients may become special to nurses leading to over-involvement (LeBlanc, et al., 2007). Competent


Running head: BURNOUT AND COMPASSION FATIGUE oncology nurses learn to establish appropriate boundaries that are more semi-permeable than other clinical specialties. Often in the formal training of oncology nurses, there is no solid basis of psychosocial awareness, knowledge, and skills to facilitate coping (LeBlanc, et al., 2007). As a result of high emotional demands in interpersonal relationships with patients, noses may feel emotionally exhausted, that is, emotionally overextended and drained by their interactions with other people (Maslach & Schaufeli, 1993). Emphasis on changing individuals though employee assistance and other programs are helpful. The vast bulk of the research has found that social and organizational factors play a much larger role in the development of burnout than do individual factors (Maslach, Schaufeli & Leiter, 2001). Organizations must support nurses financially and emotionally by providing resources to deal with burnout and compassion fatigue. These organizations include oncology clinics, hospital units, home care, and hospice care. Operational Definitions According to Knoblach Coutzee & Klopper, (2010), compassion fatigue is the final result of a progressive and cumulative process that evolves from compassion stress after a period of unrelieved compassion discomfort caused by prolonged, continuous, and intense contact with patients, use of self, and exposure to stress. Signs of compassion fatigue are: physical, emotional, and spiritual effects of burnout: absence of energy accident proneness, apathy a desire to quit work unresponsiveness callousness indifference towards patients poor judgment disinterest in introspection, and disorderliness (Indiana State Nurses Association, (ISNA), 2011). The ISNA defines several stages of compassion fatigue leading to burnout: 1. Lack of enthusiasm, 2. Stagnation, 3. Frustration and 4. Apathy (2011). The ISNA (2011) also described the difference between burnout and compassion fatigue:


Running head: BURNOUT AND COMPASSION FATIGUE Table 1: The difference between burnout and compassion fatigue BURNOUT COMPASSION FATIGUE Anyone who works in a difficult Healthcare workers who regularly observe or environment is at risk. listen to experiences of fear, pain, & suffering are at risk. Adapt to exhaustion by becoming less Continue to give but cant maintain a healthy empathetic & more withdrawn. balance between empathy & objectivity. Reduced personal achievement. Response to work situation. Response to people. Personally identify with patient & personally absorb patients trauma & pain. Results from being busy. Results from giving high levels of energy & compassion over a long period of time. Evolves gradually when the differences between the expectation of the individual & the organization are in conflict. Note: table adapted from ISNA, 2011 and used with permission. The concept of self-care as a means to prevent or correct burnout and compassion fatigue is illustrated previously in the contrary case presentation. Risk factors for burnout are: stress, use of self and contact with patients who are suffering. Prolonged, continuous, and intense risk factors lead to compassion discomfort that can escalate to compassion discomfort and finally compassion fatigue. Empirical indicators of compassion stress, discomfort, and fatigue are physical, emotional, social, spiritual, and intellectual effects on the nurse. These indicators lead to burnout just as burnout can lead to compassion fatigue. Both compassion fatigue and burnout can lead to low morale, poor patient outcomes, high financial costs, and difficulty recruiting and retaining happy, healthy, quality oncology nurses. These operational definitions are illustrated in Appendix A: Burnout & Compassion Fatigue Concept Map. Conclusions Although oncology nurses are passionate about their work, oncology nurses are faced with a host of psychosocial problems in their daily routine (Boyle, 2011). Nurses observe cancer patients confronting a life-threatening disease, treatment, and severe physical side effects,


Running head: BURNOUT AND COMPASSION FATIGUE causing nurses to experience feelings of uncertainty, a diminished self-image, and changes in social relationships as well as psychological issues (Boyle, 2011). These and other patient reactions to cancer (e.g., regressive behavior, numbness and inappropriate denial, panic and grief, disappointment and anger) are difficult for nurses to handle with professional demeanor (LeBlanc, et al., 2007). Klobach Coutzee & Klopper (2010) believed that the increase in knowledge of compassion fatigue and its manifestations may enable nurses to become aware of others who might be suffering and facilitate the development of a peer support network, making it possible for nurses to seek assistance in dealing with the detrimental effects of compassion fatigue. An employee assistance program should be established in every health-care institution, with free counseling and life skills education services offered to every nurse allowing nurses to seek assistance in dealing with the emotional burden of their work (Coutzee & Klopper, 2010). Burnout and compassion fatigue are commonplace in healthcare today (Showalter, 2010). For nurses, compassion fatigue stems from therapeutic connectedness with patients and families in need (Potter et al., 2010; Sabo, 2008). Fatigue, stress, sadness, decrease in morale, and poor work performance, are all influenced by psychosocial factors that have often been ignored by nurses and healthcare administration (Boyle, 2012). Burnout and compassion fatigue impact retention of staff and may influence patient satisfaction and patient safety (Potter et al., 2005). Encouraging self-care strategies and offering interventions within and outside the workplace address a key distinction of nursing practice, namely that of holistic care (Boyle, 2011).


Running head: BURNOUT AND COMPASSION FATIGUE References Aycock, N. & Boyle, D. (2010). Interventions to manage compassion fatigue. Clinical Journal of Oncology Nursing, 13(2), 183-191. Boyle, D. (2011). (2011). Countering compassion fatigue: A requisite nursing agenda. Online Journal of Issues in Nursing, 13(1). Bush, N.J. (2009). Compassion fatigue: Are you at risk? Oncology Nursing Forum, 36(1), 24-28. Collins, S. & Long, A. (2003) Too tired to care? The psychological effects of working with trauma. Journal of Psychiatric and Mental Health Nursing, 10, 17-27. Current Nursing. (2012a). Application of Betty Neumans System Model. Retrieved from:'s_model.html Current Nursing. (2012b). Jean Watsons Philosophy of Nursing. Retrieved from: Edmonds, M.W. (2010). Caring too much: Compassion fatigue in nursing. Applied Nursing Research. 23, 191-197. Figley, C. (2006). Compassion fatigue: An introduction.,html. Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. Journal of Continuing Education in Nursing, 35(6), 257263. Indiana State Nurses Association. (2011). Ive fallen and I cant get up: Compassion fatigue in nurses and non-professional caregivers. ISNA Bulletin. May, June, July. 1-12. Joinson, C. (1992). Coping with compassion fatigue. Nursing, 22(4), 116, 118-120. Kash, K.M., Holland, J.C., Breitbart, W., Berenson, S., Dougherty, J., Ouellette-Kobasa, S., & Lesko, L. (2000). Stress and burnout in oncology. Oncology, 14(11), 1-12.


Running head: BURNOUT AND COMPASSION FATIGUE Knobloch Coetzee S.K., & Klopper, H.C. (2009). Compassion fatigue within nursing practice: A concept analysis. Nursing and Health Sciences, 12, 235-243. MacLauglin Frandsen, B. (2010). Burnout or compassion fatigue? Long Term Living Magazine, 50-51. Maslach, C., & Schaufeli, W. B. (1993). Historical and conceptual development of burnout. In W. B. Schaufeli, C. Maslach, & T. Marek (Eds.), Professional burnout: Recent developments in theory and research (pp. 116). Washington, DC: Taylor & Francis. Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Burnout. Annual Review of Psychology, 52, 397422. Medland, J., Howard-Ruben, J., & Whitaker, E (2004). Fostering psychosocial wellness in oncology nurses: Addressing burnout and social support in the workplace. Oncology Nursing Forum, 31(1), 47-54. Najjar, N., Davis, L.W., Beck-Coon, K., & Doebbeling, C.C. (2009). Compassion fatigue: A review of the research to date and relevance to cancer-care providers. Journal of Health Psychology, 14(2), 267-277. Patrick, K., & Lavery, J. (2007). Burnout in nursing. Australian Journal of Advanced Nursing, 24(3), 43-48. Pilkington, F.B. (2009). Theorizing the concept of burnout in nursing. Nursing Science Quarterly, 22, 199. Potter, P., Deshields, T., Divanbeigi, J., Berger, J., Cipriano, D., Norris, L., & Olsen, S. (2010). Compassion fatigue and burnout: Prevalence among oncology nurses. Clinical Journal of Oncology Nursing, 14(5), E56-E62.


Running head: BURNOUT AND COMPASSION FATIGUE Sabo, B.M. (2011). Reflecting on the concept of compassion fatigue. , Online Journal of Issues in Nursing Online, 16(1), 1-19. Sheridan-Leos, N. (2008). Understanding lateral violence in nursing. Clinical Journal of Oncology Nursing, 12(3), 399-403. Showalter, S.E. (2010). Compassion fatigue: What is it? Why does it matter? Recognizing the symptoms, acknowledging the impact, developing the tools to prevent compassion fatigue and strengthen the professional already suffering from the effects. American Journal of Hospice & Palliative Medicine, 27(4), 239-242. Yoder, E.A. (2010). Compassion fatigue in nurses. Applied Nursing Research, 23(4), 191-197.



leads to

leads to


lead to

low morale poor patient outcomes higher costs difficulty recruiting & retaining happy healthy quality oncology nurses

Appendix A: Burnout & Compassion Fatigue Concept Map

*Compassion Fatigue Map used with permission, Klobach Coutzee & Klopper, 2010.