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Quality Improvement Project: Compassion Fatigue Prevention

Kelley Schlosshan

Bon Secours Memorial College of Nursing

Quality and Safety in Nursing II

NUR 3207

Jean Digges, MSN, RN, CPNP,CNE

July 19, 2018

Honor Code: I Pledge…


Quality Improvement Project: Compassion Fatigue Prevention

Quality Issue Identified

As a member of the Retention and Recognition (R&R) Council at Memorial Regional

Medical Center (MRMC), one of the main topics discussed is overall nursing turnover. The

departments with the highest turnover rate are the surgical care center, emergency department,

oncology and the interventional cardiac unit. In February 2017, the surgical care center for

nursing turnover was 31.7% and it increased to 42.2% by April 2018. In the emergency

department, the rate was 25.86% and decreased slightly to 22.7%, however it still remains above

the accepted retention rate. The oncology department rate increased from 13.33% to 21.7% and

the interventional cardiac unit, the rate increased from 7.14% to 27.9%. These departments

typically present a greater degree of death and trauma leading to nurses experiencing a higher

level of stress, which can lead to compassion fatigue. Compassion fatigue is defined as the state

of exhaustion by emotional demands of constant exposure to human suffering, regardless of how

satisfying the outcome (Salmond, Ames, Kamienski, Watkins, & Holly, 2017). When nurses

care for traumatized patients, they could re-experience the patient’s traumatic events. It can

cause burnout leading to nurses becoming less empathetic and more irritable with co-workers.

One of the challenges facing many health care systems is nurse retention. Is it possible to

positively impact retention by offering nurses ways to alleviate the impact of emotional, physical

and psychological stress?

Background Information

In addition to the potential for developing compassion fatigue, prolonged exposure to

emotional, physical and psychological stress can eventually lead to secondary traumatic stress

and burnout. According to Fahey and Glasofer (2016), one of the main reason nurses leave the

profession is due to compassion fatigue. It can be precipitated by fear, work related secondary

stress and exposure to people who have experienced an extreme or traumatic stressful event. This

can trigger physical and psychological symptoms such as anxiety, insomnia, complaints, nausea

or depression. Burnout and retention is directly correlated to work environment and job


Nurses attend to their patients at their most vulnerable state. Empathy and compassionate

care are essential to building trust in the nurse to patient relationship (Salmond et al., 2017).

Compassion fatigue can negatively impact patient care and safety, patient satisfaction, job

satisfaction, productivity and absenteeism. In order to lessen the effects of stress and maintain a

positive work-life balance, nurses need to be provided opportunities which allow them to de-

compress, mourn and disconnect from daily stress. Compassion fatigue tends to be more

prevalent in nurses ages 21 to 33 and leads to approximately 30-50 percent of all new registered

nurses choosing to change positions or leave nursing altogether within the first three years

(Salmond et al., 2017). Research suggests there are programs and coping strategies which could

be implemented to alleviate stress, reduce compassion fatigue and focus on nursing retention.

Implementation of QI Project

After reviewing MRMC’s overall nursing turnover data during the time from February

2017 to April 2018, I noticed a trend in several units with consistently high turnover rates. These

units include: Intravenous Therapy Team, Oncology and the Surgical Care Center. During this

same time frame, there are units you would expect to have a higher turnover rate but have a

higher retention rate. These departments with a higher retention rate include the Critical Care

Unit, Neonatal Intensive Care Unit, Recovery Room and Ambulatory Surgery. I would like to

propose a project to the R&R council focusing on identifying the differences between

departments with consistently high turnover rates and those with high retention rates. This could

help us identify and institute programs to prevent the negative effects of compassion fatigue. The

program I would present to the council includes adding additional questions to the annual Gallup

Survey for nurses practicing at MRMC. In developing these questions, we would work closely

with Gallup to devise a series of questions which would help determine overall satisfaction

beyond engagement with your department. These questions could include topics such as work

life balance, mental health, etc.

An additional part of the project, I am proposing we engage in another survey called the

Professional Quality of Life Scales (ProQOL). This thirty question survey is a valid and reliable

tool to measure compassion satisfaction and fatigue (Ames, Salmond, Holly, & Kamienski,

2017). Questions are related to how a person feels and examples of questions are: "Do I get

satisfaction from being able to help people?" or "Do I feel overwhelmed because my work load

seems endless?" The survey incorporates a five point scale with 1 point for never, 2 points for

rarely, 3 points for sometimes, 4 points for often and 5 points for very often. The ProQOL scales

is categorized in three sections according to your score. Specific questions measure compassion

satisfaction, burnout and secondary traumatic stress. When totaling these questions, it will reveal

either a low, average or high level of compassion satisfaction, burnout or secondary traumatic

stress. The survey can also be used without any additional cost directly from their website

(, 2012). This survey is used by many institutions and has been in effect since 1995.

It is hoped that units with a high compassion satisfaction score will correlate with those

units also having a higher retention rate and Gallup score. Conversely units with a higher score

in secondary traumatic stress and burnout would have higher compassion fatigue scores and

lower retention rates. The first year the ProQOL survey is taken will correspond to the baseline

score for MRMC. To ensure anonymity and encourage participation the survey will be

administered by an outside organization. I will work through the R&R council to begin the

approval process, asking them to vote on using the survey as part of the plan to reduce

compassion fatigue. Once the council has approved this research project, I would discuss it with

human resources, nurse managers, nurse educators and administrators for support and approval.

The R&R Council will need to work within current Bon Secours communication

channels to ask nurses to participate in this additional survey. These communications will begin

with a letter mailed to all MRMC nurses, which includes instructions for taking the survey. The

letter will include information on the ProQOL survey and its importance in measuring

compassion fatigue and burnout. Other internal communication channels which will be utilized

will include daily huddles, weekly employee newsletter, IRIS, unit champions and screensavers.

Nursing unit champions will work with their respective nurse manager to encourage

participation. We will utilize some of the same strategies encouraging nurses to take the Gallup

Survey; prizes awarded to departments with the highest participation rates. The plan is to

continue this questionnaire on an annual basis in order to determine if programs implemented to

decrease compassion fatigue are positively impacting the retention rate.

Once the initial data is analyzed, the R&R Council will use the survey results to

incorporate industry wide best practice solutions to alleviate stress and the impact of compassion

fatigue. The nurse educators could develop an annual module in IASPIRE to define compassion

fatigue, ways to recognize it and factors to help prevent it. In order to identify competency, all

nurses must score an 80 or better on the compassion fatigue healthcare module. Additional best

practices we could implement include working with employee wellness to develop quiet rooms

nurses could use immediately following a stressful patient or family event or opportunities to

pray with one of the chaplains or a program developed through the Employee Assistance

Program to combat compassion fatigue. Another important step would be to institute multi-

disciplinary debriefings following adverse patient outcomes. These meetings will incorporate

chaplains, nurses, physicians, educators and quality team members. Debriefing meetings can be

an effective tool to relieve stress after critical incidents and improve patient outcomes, identify

training or process gaps and boost morale (Hammerle, Devendorf, Murray, & McGhee, 2017).

The sessions should include a list of standard and open ended questions allowing participants to

express their personal and professional thoughts regarding strategies to improve patient


Healthcare is commonly compared with other high-risks occupations similar to law

enforcement and military and it is essential to provide staff with the appropriate resources and

support to offset the negative impact of high stress situations. By creating a positive

environment, it can support a culture of accepted realities of compassion fatigue and burnout

syndrome, as this allows staff to participate without the fear of being judged by colleagues (Berg,

Harshbarger, Ahlers-Schmidt, & Lippoldt, 2016). Some helpful tips on creating a positive culture

could include; educating the team on recognizing the symptoms of compassion fatigue in

themselves and ensure social support is a priority in leadership development. Engage in team

discussions during meetings and be aware of staff that do not contribute to the discussion, as

compassion fatigue is directly related with silence (Berg et al., 2016). The ProQOL survey will

be administered annually to ensure the program is reducing compassion fatigue and allowing the

team opportunities to implement changes or adjustments.

Professional Practice Implications


Nurses who are satisfied and engaged are more likely to provide better care for their

patients and themselves. Increasing nurse retention and satisfaction is especially important when

you consider the costs of orienting a specialty nurse is $64,000 and the added expense to hire

replacement personnel is approximately $145,000 (Mason et al., 2014). Implementation of best

practices to increase retention and work-life balance can be very rewarding to both the health

system and its team of caregivers. Evidence theorizes that compassion satisfaction is the primary

reason nurses remain in their job (Al-Majid, Carlson, Kiyohara, Faith, & Rakovski, 2018). As

our healthcare environment changes, it is important that compassion fatigue becomes more

acknowledged to ensure retention of caring, compassionate and tenured nurses.

Outcome Improvement

As a nurse, it is imperative that we allow our voices to be heard. Trauma research

demonstrates that people involved in traumatic events need to tell their story approximately eight

or nine times before defusing the physiological and psychological impact of stress or distress

(Mason et al., 2014). Nurses are the front line for providing care to patients and patient care is

evaluated through quality, safety and engagement results. Evidence suggests that when we

engage with other members of our team it can assist in managing stress and creating an

institutional culture that acknowledges, accepts, and supports staff in preventing and controlling

compassion fatigue and burnout (Berg et al., 2016). To evaluate nurse retention, I would create a

dashboard, seen below, in figure 1.1 and figure 1.2, which identifies each unit for the overall

nursing turnover and results from the yearly ProQOL survey. By the end of the survey, results

will be collected on the dashboard and filed. Review, analyze, and compare data to determine


Figure 1.1
FY18 FY19
Department Gallup ProQOL ProQOL ProQOL Gallup ProQOL ProQOL ProQOL STS
Score Compassion Burnout STS Score Compassion Burnout
Satisfaction Satisfaction
IV Therapy Team
Neurology Telemetry
Mother Infant Unit
Avg MRMC Nursing
Figure 1-2
Feb-17 Mar-17
Department Voluntary # of # Using Voluntary # of # Using Resiliency
Turnover Debriefings Resiliency Room Turnover Debriefings Room

IV Therapy Team
Avg MRMC Nursing
Abbreviations: (STS) Secondary Traumatic Stress


Al-Majid, S., Carlson, N., Kiyohara, M., Faith, M., & Rakovski, C. (2018). Assessing the Degree

of Compassion Satisfaction and Compassion Fatigue Among Critical Care, Oncology,

and Charge Nurses. The Journal of Nursing Administration, 48(6), 310-315.

Ames, M., Salmond, E., Holly, C., & Kamienski, M. (2017). Strategies that reduce compassion

fatigue and increase compassion satisfaction in nurses: a systematic review protocol. JBI

Database of Systematic Reviews and Implementation Reports, 15(7), 1800-1804.

Berg, G. M., Harshbarger, J. L., Ahlers-Schmidt, C. R., & Lippoldt, D. (2016). Exposing

Compassion Fatigue and Burnout Syndrome in a Trauma Team: A Qualitative Study.

Journal of Trauma Nursing, 23(1), 3-10.

Fahey, D. M., & Glasofer, A. (2016). An inverse relationship: Compassion satisfaction,

compassion fatigue, and critical care nurses. Nursing2016CriticalCare, 11(5), 30-35.

Hammerle, A., Devendorf, C., Murray, C., & McGhee, T. (2017). Critical Incidents in the ED.

Nursing Management, 9-11.

Mason, V. M., Leslie, G., Clark, K., Lyons, P., Walke, E., Butler, C., & Griffin, M. (2014).

Compassion Fatigue, Moral Distress, and Work Engagement in Surgical Intensive Care

Unit Trauma Nurses: A Pilot Study. Dimensions of Critical Care Nursing, 33(4), 215-

225. (2012).


Salmond, E., Ames, M., Kamienski, M., Watkins, A. V., & Holly, C. (2017). Experiences of

compassion fatigue in direct care nurses: a qualitative systematic review protocol. JBI

Database of Systematic Reviews and Implementation Reports, 15(7), 1805-1811.