431311

2011

PMJ27210.1177/0269216311431311Slocum-Gori et al.Palliative Medicine

PALLIATIVE
MEDICINE

Original Article

Understanding Compassion
Satisfaction, Compassion Fatigue
and Burnout: A survey of the
hospice palliative care workforce
Suzanne Slocum-Gori

Palliative Medicine
27(2) 172178
The Author(s) 2011
Reprints and permission:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0269216311431311
pmj.sagepub.com

University of British Columbia, School of Population and Public Health,

Faculty of Medicine, Vancouver, Canada

David Hemsworth
Winnie WY Chan

University of Nipissing, School of Business, North Bay, Canada

University of British Columbia, School of Population and Public Health,

Faculty of Medicine, Vancouver, Canada

Anna Carson

University of British Columbia, School of Population and Public Health,

Faculty of Medicine, Vancouver, Canada

Arminee Kazanjian

University of British Columbia, School of Population and Public Health,

Faculty of Medicine, Vancouver, Canada

Abstract
Background: Despite the increasingly crucial role of the healthcare workforce and volunteers working in hospice and palliative care
(HPC), very little is known about factors that promote or limit the positive outcomes associated with practicing compassion.
Aim: The purpose of this study was to: 1) understand the complex relationships among Compassion Satisfaction, Compassion Fatigue
and Burnout within the hospice and palliative care workforce and 2) explore how key practice characteristics practice status, professional
affiliation, and principal institution interact with the measured constructs of Compassion Satisfaction, Compassion Fatigue and Burnout.
Design: Self-reported measures of Compassion Satisfaction, Compassion Fatigue and Burnout, using validated scales, as well as questions
to describe socio-demographic profiles and key practice characteristics were obtained.
Setting/participants: A national survey of HPC workers, comprising clinical, administrative, allied health workers and volunteers,
was completed. Respondents from hospital, community-based and care homes informed the results of our study (n = 630).
Results: Our results indicate a significant negative correlation between Compassion Satisfaction and Burnout (r = -0.531, p < 0.001)
and between Compassion Satisfaction and Compassion Fatigue (r = -0.208, p < 0.001), and a significant positive correlation between
Burnout and Compassion Fatigue (r = 0.532, p < 0.001). Variations in self-reported levels of the above constructs were noted by key
practice characteristics. Levels of all three constructs are significantly, but differentially, affected by type of service provided, principal
institution, practice status and professional affiliation. Results indicate that health care systems could increase the prevalence of
Compassion Satisfaction through both policy and institutional level programs to support HPC professionals in their jurisdictions.
Keywords
Allied health personnel, burnout, empathy, health personnel, palliative care, professional, supportive cancer care

Introduction
Very little is known about in the hospice and palliative care
(HPC) workforce in Canada, whose daily practice includes
the regular exercise of empathy. Our study intended to establish national baseline information on this workforce and their
work. All factors that may impact professionals work life
were included; however, those factors that foster a positive

response in the face of constant exposure to grief and bereavement were of specific interest in this nationally administered
survey study.
HPC workers empathize with the losses their patients are
experiencing in the dying process and often feel a sense of
personal failure that they cannot help their patients; working

Corresponding author:
Dr Armine Kazanjian, Professor, School of Population and Public Health, Faculty of Medicine, University of British Columbia, 2206 East Mall,
Vancouver, BC, Canada, V6T1Z3.
Email: arminee.kazanjian@ubc.ca.

173

Slocum-Gori et al.
on the edge between life and death cultivates an acute
awareness of the fragility of life.1 Research has identified
various stressors to HPC workers: constant exposure to death,
inadequate time with dying patients, growing workload,
inadequate coping with their own emotional response to the
dying, increasing number of deaths, communication difficulties with dying patients and families, and feelings of grief,
depression and guilt.2
Previous research has described the relationship between
stress and Burnout among HPC staff.2-6 Burnout is measured
by Maslachs Burnout Inventory.7 Mixed findings of levels
of occupational stress observed in HPC relative to workers
in other health care sectors remain unexplained. Where stress
causes Burnout it is ascribed, in large measure, to organizational factors.4 More direct delineation of the relationship
between secondary traumatic stress and Burnout in palliative medicine and implications for Compassion Fatigue are
described by Figley.8,9
Compassion Fatigue has often been referred to as the emotional cost of caring for others and has led professionals to
abandon their work with traumatized victims in their care.8
It is portrayed as a stress response that emerges suddenly and
without warning and includes a sense of helplessness, isolation and confusion.9 If not attended to, Compassion Fatigue
may lead to depression and stress-related illnesses.8,9
An important distinction between Burnout and Compassion
Fatigue is that clinicians with Compassion Fatigue can still
care and be involved with their patients, albeit in a compromised way.10 Stamm suggests that Burnout is too broad a
term in its application, as it can relate to a stress response in
any profession, and is not linked directly to practicing compassion.11 Compassion Fatigue is unique to the helping professions, and a highly applicable concept within the HPC
workforce.
A demonstration of compassion in the long term does not
always lead to negative emotional states or outcomes.
Compassion Satisfaction stems from the emotional rewards
of caring for others in a health care context; clinicians feel a
sense of return or incentive by seeing a change for the better
in patients and families.11,12 Stamm identified Compassion
Satisfaction as a possible factor that counterbalances the risks
of Compassion Fatigue and suggested that this may account
for the resiliency of the human spirit (p.110).13
The overlaps and differences between concepts related to
secondary traumatization were empirically studied, including
Compassion Fatigue, and Burnout.14 We elected to examine
Compassion Fatigue as distinct from Burnout. Compassion
Satisfaction was selected to better understand the intricacies
of the HPC workforce context. We posited that the experience
of Compassion Satisfaction is measurable in this sector, in addition to various degrees of Compassion Fatigue and/or Burnout.
Unfortunately, no comprehensive conceptual framework
exists that examines the dynamics among Compassion
Satisfaction, Compassion Fatigue and Burnout. Understanding

the dynamic relationship among these three constructs could

provide health system managers with a foundation for programs to support the HPC workforce, that is, reducing the
types of stresses that lead to Compassion Fatigue and fostering best practices that increase levels of Compassion
Satisfaction. The purpose of this study is to provide a better
understanding of the levels of Compassion Satisfaction,
Compassion Fatigue and Burnout in the Canadian HPC workforce and to examine key practice characteristics associated
with each.

Measures
Stamm the Professional Quality of Life
Scale (ProQOL)
We selected Stamms approach to operationalizing Compassion
Satisfaction, Compassion Fatigue and Burnout because all
three of the concepts were examined within one primary
tool pertinent to HPC. The Professional Quality of Life Scale
(ProQOL) has been shown in various contexts to be a reliable
and valid tool.11 Although the ProQOL was originally developed for emergency personnel and trauma counselors, the
scale has been utilized internationally and has been psychometrically validated in various target populations.13,15 The
ProQOL had not been used in a large study of health care
professionals within HPC prior to the launch of our study
(but see Alkema et al.12).
Each of the ProQOLs three scales is psychometrically
unique and cannot be combined with the other scores.11 It
contains 30 items in total (with five-point Likert measures)
and was included in our survey. Higher Compassion
Satisfaction scores represent a greater satisfaction related
to the ability to be an effective caregiver in ones job; higher
scores on the Compassion Fatigue scale indicate that health
professionals may want to examine how they feel about their
work and work environment; higher scores on the Burnout
scale indicate a higher risk for Burnout.11
Each scale has a maximum of 50 points, with the following mid-point scores and alpha reliabilities: Compassion
Satisfaction mid-point score = 37 ( = 0.87), Compassion
Fatigue mid-point score = 13 ( = 0.80) and Burnout midpoint score = 22 ( = 0.72).11 For ease of analysis, the
resulting scores are divided by 10 yielding a score between
0 and 5, as presented in this paper (labeled Index in the
tables).

Socio-demographic and practice characteristics

Demographic variables in the questionnaire included year
of birth, sex, marital status and highest education attained.
Practice characteristics included practice status, professional
affiliation, principal institution and type of palliative services
provided.

174

Methods
Identification of the target population
Health professionals whose primary area of responsibility is
HPC and unpaid volunteers were included in the target population. The two-stage approach utilized to identify this multidisciplinary workforce was used in previous research.16 The
guidelines laid out by Kelley et al. for survey research were
followed.17 The Canadian Hospice Palliative Care Association
(CHPCA) provided their membership mail-out for contacting
managers and administrators of HPC organizations.
Organizations were approached by the research team to inform
them of our study and request lists of the HPC workers in their
employ. HPC associations from each province were also contacted for this purpose. A list of individual HPC workers was
thus compiled where no provincial or national register existed.

Survey of HPC workforce

Once pilot-tested in British Columbia, the survey was conducted across Canada. A web-based questionnaire was developed and email was used to contact HPC workers, with an
option for paper copy if requested. A cover letter explaining
the purpose of the study and a secure web link to the questionnaire (or the paper version with a courier envelope) was sent
to all workers identified by their employers. Letters encouraging non-responding organizations and later individual HPC
providers to participate in the research were sent to follow-up.
Since the survey was national in scope, the questionnaire and
all correspondence were available in both official languages,
French and English. The questionnaire was translated into
French and examined for face validity by three translators.
After continuous follow-ups, the usable number of responses
reached 630 in January 2010.

Face validity and pilot testing

A focus group was conducted to establish the face validity
of the ProQOL11 within the context of HPC and to pilot the
entire questionnaire. Purposeful sampling was used to recruit
13 participants who worked or volunteered with palliative
patients and families in hospital and hospice settings. The
constructs resonated for all of the participants and reflected
their experiences. Revisions were made to the questionnaire
after the pilot testing.

Hypotheses
The philosophy of HPC involves the practice of empathy,
minimization of pain and other symptoms, and the provision
of effective medicine.18 At its essence, it aims to relieve suffering and improve the quality of both life and the process of
death.19 After careful consideration of the gaps in the literature,
the following hypotheses were identified:

Palliative Medicine 27(2)

1. The type of palliative services provided significantly impacts the level of Compassion Satisfaction,
Compassion Fatigue and Burnout.
2. Practice status significantly impacts the level of
Compassion Satisfaction, Compassion Fatigue and
Burnout
3. Professional affiliation significantly impacts the level
of Compassion Satisfaction, Compassion Fatigue and
Burnout
4. Principal institution significantly impacts the level
of Compassion Satisfaction, Compassion Fatigue and
Burnout.

Statistical analysis
The Compassion Satisfaction, Compassion Fatigue and
Burnout scales were scored using the prescribed recoding in
the ProQOL manual.11 A missing value analysis was performed
in SPSS version 18. Surveys that were missing more than
10% of responses were removed from the analyses, yielding
503 surveys. The MCAR analysis of the remaining data was
non-significant (p = 0.303) indicating that the remaining missing values are completely random. Unless otherwise stated,
all analyses of the data are statistically significant at p < 0.05
and all statistical tests were conducted using SPSS version 18.
Pearson correlation tests were performed to describe the
correlations between each of the three ProQOL constructs.
Three HPC services were reported by the majority of respondents. Individual t-tests were carried out for each of the three
services to compare the levels of each ProQOL construct
among HPC workers who indicated that they provided each
of these services to those workers who indicated that they did
not, and to determine whether there was a significant difference between these two groups for each measured construct.
Pearson chi-square tests were performed to understand the
effect that practice status, professional affiliation and principal institution have on Compassion Satisfaction, Compassion
Fatigue and Burnout. Finally, differences between full-time
and part-time workers were tested with independent t-tests.

Results
Demographic synopsis
The average age was 52.34 years (55.01 for male and 51.75
for female). Most (82.4%) of the respondents were female and
well over half were married or lived with a partner (67.2%).

Association between Compassion

Satisfaction, Compassion Fatigue and
Burnout
Our results support and quantify the underlying assumptions
postulated in the literature about how these three constructs

175

Slocum-Gori et al.
Table 1. Correlations among Compassion Satisfaction, Burnout
and Compassion Fatigue.
Compassion Compassion Burnout
Satisfaction Fatigue
CS Pearson correlation 1
CF Pearson correlation -0.208*
BO Pearson correlation -0.531*

1
0.532*

N = 503
CS: Compassion Satisfaction, CF: Compassion Fatigue, BO: Burnout
*Correlation is significant at the 0.01 level (two-tailed).

are interrelated. Namely, Compassion Satisfaction is negatively correlated with both Compassion Fatigue and Burnout,
and there is a positive association between Burnout and
Compassion Fatigue. Correlations among the three scales
were calculated as shown in Table 1. We found:
a) negative correlation between Compassion Satisfaction
and Burnout (r = -0.531, p < 0.001);
b) negative correlation between Compassion Satisfaction
and Compassion Fatigue (r = -0.208, p < 0.001);
c) positive correlation between Compassion Fatigue and
Burnout (r = 0.532, p < 0.001).
Given these correlations, we then examined the relationship
of practice characteristics on Compassion Satisfaction,
Compassion Fatigue and Burnout.
Respondents (n = 503) were asked to indicate which HPC
services they usually provide. Table 2 shows the three services that the highest number of respondents reported providing in their work. Assistance with provision of relief from
physical, emotional and/or spiritual pain or distress was the
service most often provided (n = 371/503). When the respondents who provide this service were compared with those who
do not, the former reported a significantly higher level of
Compassion Fatigue (p = 0.025) and Burnout (p < 0.001),
but no statistically significant difference in Compassion
Satisfaction. Similarly, those that provide psychosocial support to patients and/or families (n = 367/503) had significantly higher levels of Compassion Fatigue (p < 0.001) and
Burnout (p < 0.001) and no significant differences in level
of Compassion Satisfaction. Finally, with respect to providing

Table 2. Correlations of palliative services and Compassion

Satisfaction, Compassion Fatigue and Burnout.
N

Index

Significance

t-value

1) Assistance with provision of relief from physical, emotional,

and/or spiritual pain or distress
Compassion Chosen
371 4.39
0.994
0.008
Satisfaction
Not chosen 132 4.39

Compassion Chosen
371 1.89
0.025*
2.24
Fatigue
Not chosen 132 1.79

Burnout
Chosen
371 2.13
0.000*
4.29
Not chosen 132 1.94

2) Psychosocial support to patients and/or families

Compassion Chosen
367 4.41
0.131
1.51
Satisfaction
Not chosen 136 4.34

Compassion Chosen
367 1.91
0.000*
3.99
Fatigue
Not chosen 136 1.72

Burnout
Chosen
367 2.14
0.000*
4.86
Not chosen 136 1.93

3) Emotional support to other team members

Compassion Chosen
317 4.42
0.080
1.76
Satisfaction
Not chosen 186 4.34

Compassion Chosen
317 1.92
0.000*
4.25
Fatigue
Not chosen 186 1.74

Burnout
Chosen
317 2.16
0.000*
5.61
Not chosen 186 1.94

*Correlation is significant at the 0.05 level (two-tailed).

emotional support to other team members (n = 317/503)

respondents who provide this type of care reported higher
levels of Compassion Fatigue (p < 0.001) and Burnout (p <
0.001) and again showed no significant difference in levels
of Compassion Satisfaction. Thus, there is support for
Hypothesis 1 with respect to Compassion Fatigue and
Burnout, but not with Compassion Satisfaction.

Practice status, professional affiliation and

principal institution
The analysis presented in Table 3 indicates that levels of the
three constructs are significantly different across practice
statuses and by professional affiliation. Practice status and
professional affiliation denote the intensity and frequency of
exposure to secondary stress, and may be considered as a

Table 3. Key practice characteristics: practice status, professional affiliation and principal institution and the impact on Compassion
Satisfaction, Compassion Fatigue and Burnout.
Variable

Compassion Satisfaction

Compassion Fatigue

Burnout

Practice status

2 (3, n = 496) = 11.54,

p = 0.009
2 (23, n = 495) = 40.9,
p = 0.012
Non-significant,
2 (8, n = 479) = 6.59,
p = 0.581

2 (3, n = 496) = 27.87,

p < 0.001
2 (23, n = 495) = 63.49,
p < 0.001
2 (8, n = 479) = 18.87,
p = 0.016

2 (3, n = 496) = 107.87,

p < 0.001
2 = (23, n = 495) 115.1,
p < 0.001
2 (8, n = 479) = 37.45,
p < 0.001

Professional affiliation
Principal institution

176

Palliative Medicine 27(2)

Table 4. Mean levels of Compassion Satisfaction, Compassion Fatigue and Burnout categorized by practice status and professional affiliation.
Score (Index [M])

Practice status
Full time (n = 333)
Part time (n = 128)
Casual (n = 3)
On leave (n = 32)
Total (n = 496)
Professional affiliation
Administration (n = 38)
Allied health (n = 77)
Medicine (n = 33)
Nursing (n = 203)
Integrative medicine (n = 8)
Volunteers (n = 121)
Total (n = 480)
Comparative scoring11
Bottom quartile
Mid-point
Top quartile

Compassion Satisfaction

Compassion Fatigue

Burnout

43.7
45
41.3
42
43.9

(4.37)
(4.50)
(4.13)
(4.20)
(4.39)

19.1
16.9
24.7
19.3
18.6

(1.91)
(1.69)
(2.47)
(1.93)
(1.86)

21.8
17.6
26.7
22.6
20.8

42.1
44.1
44.6
43.4
48.1
44.9
43.9

(4.21)
(4.41)
(4.46)
(4.34)
(4.81)
(4.49)
(4.39)

16.7
18.8
17.6
20.1
17.3
16.9
18.6

(1.67)
(1.88)
(1.76)
(2.01)
(1.73)
(1.69)
(1.86)

21
21.4
22.4
22.3
17.5
17.7
20.8

33
37
42

dose-response measure. In addition, the impact of principal

institution of practice was discernible on levels of Compassion
Fatigue and Burnout but not on Compassion Satisfaction.
Table 4 provides interesting details regarding the mean
scores of the ProQOL questionnaire for both practice status
and professional affiliation. Part time workers had higher
Compassion Satisfaction levels (M = 4.50) and differences
with full time workers (M = 4.37) were statistically significant
(t(459) = 2.66, p = 0.008). Also, part-time workers had lower
levels (M = 1.69) of Compassion Fatigue than the full time
ones (M = 1.91) (t(459) = 4.74, p < 0.001) . Finally, Table 4
shows that part-time workers had significantly (t(459) = 10.35,
p < 0.001) lower levels (M = 1.76) of Burnout than the fulltime ones (M = 2.18).
The six different categories of professional affiliations
reported are presented in Table 4 as well as mean scores for
levels of Compassion Satisfaction, Compassion Fatigue and
Burnout. Administration had the lowest level (M = 4.21) and
integrative medicine had the highest level (M = 4.81) of
Compassion Satisfaction. From Table 4, nursing reported
the highest level (M = 2.01) and administration reported the
lowest level (M = 1.67) of Compassion Fatigue; medicine and
nursing had the highest levels (M = 2.24 and 2.23, respectively)
and integrative medicine had the lowest level (M = 1.75)
of Burnout. There were no statistically significant differences
by principal institution.

Discussion and conclusion

As shown in the above results, our four hypotheses are mostly
confirmed. 1) The type of regularly delivered HPC services
significantly impacts the level of Compassion Fatigue and

8
13
17

18
22
27

(2.18)
(1.76)
(2.67)
(2.26)
(2.08)

(2.10)
(2.14)
(2.24)
(2.23)
(1.75)
(1.77)
(2.08)

Burnout. Compared with the averages in the existing literature which utilize the ProQOL, the respondents in this study
had high levels of Compassion Satisfaction (43.9 vs. topquartile = 42), slightly elevated levels of Compassion Fatigue
(18.6 vs. top-quartile = 17), and average levels of Burnout
(20.8 vs. mid-point = 22).18 Interestingly, the type of service
delivered did not have an impact on the level of Compassion
Satisfaction, reflecting, perhaps, HPCs unifying central
tenet of empathy. 2) Part-time practitioners experienced a
higher level of Compassion Satisfaction, and lower levels
of Compassion Fatigue and Burnout than full-time ones.
3) Professional affiliation also impacts the level of Compassion
Satisfaction (integrative medicine highest), Compassion
Fatigue (nursing highest), and Burnout (integrative medicine
lowest). 4) The principal institution significantly impacts
the level of Compassion Fatigue and Burnout. Although
Compassion Satisfaction was hypothesized to be impacted
by principal institution, it was not statistically significant,
likely reflecting the same phenomenon (HPCs central tenet
of empathy) as in Hypothesis 1. The difference in the strength
of the correlation between Compassion Satisfaction and each
of Compassion Fatigue (-0.208) and Burnout (-0.531) support
the nascent literature in differentiating between these two
constructs.11,12 It is likely that these are non-random results;
the experiences of the HPC workforce are somewhat different from other helping professions. This finding warrants
further analysis to understand the causal pathways resulting
in Compassion Fatigue versus Burnout.
There are two possible levels of implications of these
research findings. The first level pertains to funding policies
and ensuring specific standards of care. Resources and decisions will need to be directed towards developing education

177

Slocum-Gori et al.
and training programs for HPC workers to maximize
Compassion Satisfaction and minimize Compassion Fatigue
and Burnout. Training could be implemented at the basic
entry-to-practice education level. Alternatively, education
could be integrated into post-basic curriculum programs,
such as continuing professional development through the
various professional regulatory bodies. Despite awareness
of the stress on oncologists and oncology nurses, training
programs are lacking the curriculum elements to teach physicians and nurses how to cope with HPC, including the
psycho-social needs of the dying patients and their families.20
The second level of implications is at the institutional level.
The development of local programs to support the HPC workforce on-the-job, such as targeting psychological, spiritual and
informational needs, requires careful planning and resources.
A US review of interventions to manage Compassion
Fatigue within the oncology nursing workforce highlighted
that HPC workers and their employers have a responsibility
(to the patients and their families) to recognize the presence
of Compassion Fatigue and implement interventions to mitigate the symptoms.21
Research has pointed to self-care interventions as a resolution to reducing levels of Compassion Fatigue and increasing Compassion Satisfaction.12 Mindfulness, meditation and
creative writing were (statistically) significant in a RCT
study.22 A review categorized prevention and treatment programs in cancer care personnel into three groups: personalized, professional and organizational.23 However, the literature
is mixed on which interventions work and what are appropriate measures of success.24-26

Strengths and limitations

A major strength of this study was the large sample size,
drawn from across Canada. The inclusion of a range of both
practice statuses and professional affiliations reflects the multidisciplinary contexts in which HPC is provided in Canada.
The use of a previously validated questionnaire (ProQOL)
for this survey, as well as the piloting of the entire questionnaire prior to the national survey, is also a fundamental
strength. The CHPCA provided their membership list.
However, we do not know whether this membership list captures the entire HPC workforce within Canada. HPC is multidisciplinary and multi-professional; to fully define and
capture its breadth of scope will require further research. In
addition, Stamms ProQOL11 has not been validated within
an HPC workforce population; or within Canada. Therefore,
the health system context and structure could potentially yield
score differences that are due to system factors. However, the
magnitude of the score differences observed in our study
indicates that this is not the case. The use of a widely validated
assessment tool within a new population of healthcare workers on a national scale adds valuable knowledge to this field.
Although Burnout as a construct has been widely researched
within various professions, this assessment of both Compassion

Satisfaction and Compassion Fatigue in a large, national

survey makes an appreciable additional contribution.

Future research
Study replication in similar systems would be desirable.
A recent smaller study has demonstrated that these complex
constructs are measurable in the HPC workforce.12 Our study
provides a clearer understanding, based on our sample size,
of the levels of Compassion Satisfaction, Compassion Fatigue
and Burnout as well as the magnitude of these scores. A high
level of Compassion Satisfaction in the Canadian HPC workforce was measured in this study. Comparative national-level
studies using the same constructs may provide a better focus
for understanding effective practices that increase Compassion
Satisfaction in the HPC sector.
Future research examining ethnicity and varying levels of
Compassion Fatigue, Compassion Satisfaction and Burnout is
warranted.27 The current research study examined aspects of
culture; individual, professional and organizational culture in
the Canadian HPC workforce are being examined in a separate
paper. In addition, how program development may need to
change to meet the individual and organizational cultural needs
of the HPC workforce warrants further investigation.

Conclusion
While Burnout has been highly researched in a variety of helping professions, including HPC, this is the first large study of
the HPC workforce to focus specifically on the positive aspects
of practicing empathy, measured by the construct of Compassion
Satisfaction, while still describing Compassion Fatigue.
Acknowledgements
We would like to thank Mr Lars Apland, Mr Harvey Bosma,
Dr Patricia Boston, Dr Susan Cadell and Ms Julie A Lachance for
their contributions to the launch of this project.

Funding
This work was supported by the Canadian Institutes of Health
Research (CIHR) [MOP - 81292]

Conflict of interest
The authors declare that there are no conflicts of interest.

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