1

BEST PRACTICE RECOMMENDATIONS TO PREVENT AND MITIGATE

COMPASSION FATIGUE IN ONCOLOGY NURSING

By

JOANNA RAE TOMAS

____________________

A Thesis Submitted to The Honors College

In Partial Fulfillment of the Bachelors degree

With Honors in

Nursing

THE UNIVERSITY OF ARIZONA

MAY 2019

Approved by:

____________________________

Dr. Wanda Larson

College of Nursing
Running head: PREVENT AND MITIGATE COMPASSION FATIGUE 2

Abstract

This paper examines the research on the knowledge and effects of and interventions for

compassion fatigue in oncology nursing. Though no clear statistics were found on the

prevalence of compassion fatigue in oncology nursing, two different studies found that

compassion fatigue can occur at any point during one’s nursing career (Hooper, Craig, Janvrin,

Wetsel, & Reimels, 2010; Potter et al., 2010). Interventions available to nurses experiencing

compassion fatigue are also scarce, leaving oncology nurses vulnerable to the adverse effects of

grief and compassion fatigue (Aycock & Boyle, 2008). The articles included in the literature

review explore the knowledge and attitudes oncology nurses have toward compassion fatigue,

contributing factors that increase the risk for compassion fatigue, negative effects and

consequences of inadequate or no intervention for an oncology nurse experiencing compassion

fatigue, and availability and efficacy of interventions at the organizational, unit, and individual

levels. Apart from the review of current literature, this thesis will also discuss best-practice

recommendations to combat and mitigate compassion fatigue and propose a theoretical

implementation and evaluation plan for wellness workshops in an oncology unit.

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CHAPTER 1

Introduction

Statement of Purpose

The purpose of this thesis is to establish best-practice recommendations to prevent and

mitigate compassion fatigue in oncology nurses. The recommendations will be set forth after

collecting evidence-based research that discusses precipitating factors for compassion fatigue

and interventions that can alleviate the burden of grief from oncology nurses. The background

and significance of this issue to nursing will be discussed, followed by a review of the literature

available that pertains to compassion fatigue, burnout and resilience. After reviewing the

evidence-based research, best-practice recommendations will be proposed to increase awareness

about burnout and compassion fatigue in oncology nurses and decrease its incidence in the

hospital setting.

Background

Oncology nursing is often a source of significant emotional and physical stress due to the

extensive suffering that cancer brings upon its patients. The amount of stress that the oncology

nursing profession brings can affect nurses negatively, especially if the coping mechanism that

he or she utilizes is ineffective when dealing with stressors. Thus, it is important to understand

how an individual progresses through the coping process when encountering stressful situations

in order to analyze if the individual’s method of coping contributes to positive outcomes in the

long run. According to the Stress and Coping Theory, cognitive appraisal and coping are two

different mediators of stressful situations and their outcomes (Folkman, Lazarus, Dunkel-

Schetter, DeLongis, & Gruen, 1986). Cognitive appraisal occurs when the individual evaluates

the stressor and its significance to his or her well-being. In primary appraisal, the individual
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analyzes the potential benefits and consequences of the stressful encounter and labels it as

irrelevant or stressful. The individual then proceeds to secondary appraisal, which assesses

whether or not something can be done prevent harm or increase beneficial outcomes. After

primary and secondary appraisal, the individual perceives whether the stressful encounter is a

challenge, which has the possibility of overcoming the stressor and reaping benefit, or a threat,

which has the possibility of harm or loss (Folkman et al., 1986). Coping, on the other hand, is

defined as an individual’s way of managing internal and/or external demands that are appraised

as burdensome (as cited in Folkman et al., 1986, p. 993). Coping functions as a way to deal with

the stressor, called problem-focused coping, and as a way to regulate emotion, called emotion-

focused coping (Folkman et al., 1986). Folkman et al. (1986) also determined eight coping

scales that individuals use to deal with stressful encounters. These include confrontive coping,

distancing, self-control, seeking social support, accepting responsibility, escape-avoidance,

planful problem-solving, and positive reappraisal (Folkman et al., 1986). Depending on the

appraisal of the stressor, individuals use certain ways of coping. For instance, Folkman et al.

(1986) found that when threat to self-esteem was increased, coping mechanisms such as

confrontive coping, self-control coping, and escape-avoidance coping were used. Since coping

is a factor in psychological health, understanding the process of cognitive appraisal and the

varying methods individuals cope lays the foundation in creating interventions targeted toward

stressors that can ultimately lead to compassion fatigue.

Traditionally, the term burnout has been used to describe the cumulative, overbearing

stress that affects individuals. However, compassion fatigue has recently replaced burnout in

describing the long-term stress and despair that nurses and other caregivers undergo (Aycock &

Boyle, 2008). According to Stamm’s theory, compassion fatigue is comprised of two parts. The
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first part consists of the emotions typically related to burnout, such as exhaustion and frustration.

Secondary Traumatic Stress is the second component, which is directed by fear and work trauma

(Stamm, 2010). It is considered a natural consequence of caring for suffering people, with

emotional symptoms of anxiety, guilt, depression, anger, and powerlessness (as cited in Perry et

al., 2011, p. 92). Compassion satisfaction, on the other hand, is defined as the sense of

fulfillment and satisfaction that nurses feel as a result of caring for patients during a vulnerable

point in their lives (Sacco & Copel, 2018). Oncology nurses are at high risk for compassion

fatigue due to the atmosphere of ongoing losses, understaffed units, and stressful environment

(as cited in Zadeh, Gamba, Hudson, and Weiner, 2012, p. 294). The attachment that oncology

nurses form with their patients and family members while providing care can lead to feelings of

intense loss when their patient dies. Grief in this context is defined as “mental distress or

suffering associated with a perceived loss” (W. Larson, personal communication, December 7,

2018). In fact, several studies have shown that nurses are more likely to internalize grief and

suffer from extended mental anguish after patient death (as cited in Zadeh et al., 2012, p. 295).

Despite the literature on nurses’ vulnerable states during and after grief, the education nurses

receive about coping with grief and loss in the workplace is very limited. Earlier studies have

found that maintaining physical well-being and self-care, supportive colleague relationships, and

talking to others about their grief experience reduce the effects of compassion fatigue (as cited in

Zadeh et al., 2012, p. 295). However, nursing staff have cited lack of time as the reason why

they have trouble incorporating these strategies into their professional and personal lives (as

cited in Zadeh et al., 2012, p. 295). Thus, protective measures and interventions against

compassion fatigue need to be integrated into the workplace agenda in order to reduce the

incidence of compassion fatigue at an early stage of grief.

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Significance of the Problem

Limited research is available on the prevalence of compassion fatigue in oncology nurses

due to the difficulty in identifying its existence in care providers. According to one study,

oncology nurses are at a higher risk for compassion fatigue than emergency department or

intensive care unit nurses (Hooper et al., 2010). No clear percentages or numbers, however,

were found on the prevalence of compassion fatigue in oncology nurses. One constant finding

throughout literature is the difference between compassion satisfaction and compassion fatigue

between male and female nurses: male nurses consistently had significantly higher compassion

satisfaction and lower compassion fatigue incidence than female nurses (Hooper et al., 2010;

Mooney et al., 2017). On the other hand, inconsistencies were found about the relationship

between years of nursing experience and compassion fatigue. Mooney et al. (2017) found that

years of nursing experience did not impact levels of compassion satisfaction, but a negative

association existed between nursing experience and compassion fatigue. In contrast, Potter et al.

(2010) and Hooper et al. (2010) both concluded that no significant relationship was present

between compassion fatigue and number of years of nursing experience. Despite the differing

results in literature, knowing that compassion fatigue can exist at any point during an

individual’s nursing career should be recognized, as more experienced nurses suffering from

compassion fatigue may be ignored or overlooked.

In terms of intervention availability, healthcare institutions vary widely in the type and

number of resources that are available for their staff. A survey conducted by Aycock and Boyle

(2008) found that the availability of resources for oncology nurses ranged from 0% to 60%, with

45% having no education addressing workplace coping. Even in institutions with substantial

support available, only 47% claimed to take advantage of the resources (Mooney et al., 2017).
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Although the reason for the low support-seeking rate is unclear, more research must be done to

develop interventions that are feasible and effective in combating compassion fatigue, as well as

ways to encourage nurses to seek help before the overwhelming effects of compassion fatigue

occur.

Lastly, compassion fatigue is an important topic to discuss and address because of its

effects on nursing turnover rates and nurses leaving the profession altogether. A study done on

283 nurses in four different hospitals found that compassion fatigue was one of the most

important factors influencing nurses’ turnover intention (Young Hee & Jong Kyung, 2016).

Nursing turnover costs are also expensive to the institution. A 2016 National Healthcare

Retention and RN Staffing Report found that the average cost of one nurse turnover is $37,700 to

$58,400 (Nursing Solutions, 2016). Thus, the effects of compassion fatigue are detrimental to

both the institution and the nurse, and interventions must address both levels in order to be

effective.

Summary

The increased risk oncology nurses have to develop compassion fatigue makes it an

important topic to recognize and mitigate. Nurses suffering from compassion fatigue may

consider leaving the practice or start questioning the value of care they provide (Perry et al.,

2011). The viability of oncology nurses depends on the evidence-based interventions that

alleviate the overpowering consequences of compassion fatigue. Therefore, this thesis will

explore the literature on compassion fatigue in order to design best-practice recommendations

with the intended purpose of mitigating stressors and maximizing the effectiveness of

interventions for oncology nurses.

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CHAPTER 2

Review of Literature

This chapter is focused on a review of literature on compassion fatigue among oncology

nurses. The research articles utilized for this thesis were found through the databases CINAHL

and PubMed. The search was filtered for work published between 2008 and 2018 using the

keywords “compassion fatigue” and subheadings of “oncology nursing” and “burnout.” Twelve

articles involving this topic were chosen based on the type of study conducted, the strength of the

findings, and the recommended interventions. The findings of these twelve articles will be

translated into a best practice proposal about methods to reduce compassion fatigue in oncology

nurses.

Contributing and Protective Factors for Compassion Fatigue in Oncology Nursing

Ko and Kiser-Larson’s (2016) descriptive cross-sectional study aimed to identify stress

levels and stressful factors of oncology nurses working in outpatient units and explore coping

behaviors for work-related stress in oncology nursing. The participants (n = 40) were recruited

from monthly unit meetings or by mail and included registered nurses and licensed practical

nurses. The Nursing Stress Scale (NSS) was utilized to measure levels of stress frequency and

stressful factors, and these results classified the participants into no stress/light stress, moderate

stress, or high stress. Three open-ended questions about ways the participants cope with stress,

resources that the workplace made available to help manage stress, and methods to improve

managing work stress were also completed, along with a demographic questionnaire. The

participants’ average stress score was 71.35, or moderate (Ko & Kiser-Larson, 2016). Workload

and patient death and dying were the highest sources of stress, while the most common coping

behaviors were verbalizing, exercising/relaxing, and taking time for oneself. This study also
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found that younger and less experienced participants had lower average stress scores than those

who were older and more experienced (Ko & Kiser-Larson, 2016). In terms of strengths and

limitations, the high reliability and internal consistency of the NSS make the results more

trustworthy, while the open-ended questions helped with understanding the participants’

viewpoint in a qualitative way. A limitation, though, is the researchers did not measure the

intensity of stress—only frequency and sources of stress. Since the intensity of stress varies

among individuals, this can affect the type of intervention that an oncology nurse needs.

In contrast, Wahlberg, Nirenberg, and Capezuti’s 2016 study included the intensity of

stress that oncology nurses experience while examining the relationship between nurse distress

and coping self-efficacy and identifying the factors that contribute to nurse distress, as well as

coping strategies. The researchers used a cross sectional survey design in order to address their

objectives (Wahlberg et al., 2016). Flyers were distributed in Oncology Nursing Society (ONS)

meetings in New York, New York and Hunter College. Facebook posts on the ONS page was

also utilized to recruit participants. In total, 163 participants responded to an adapted version of

the Distress Thermometer and the Occupational Coping Self Efficacy Questionnaire for Nurses

surveys, which measure nursing distress and coping self-efficacy, respectively. The

Occupational Coping Self Efficacy Questionnaire for Nurses survey included five open-ended

questions at the end in order to gain a qualitative perspective of distress and coping (Wahlberg et

al., 2016). The researchers found that participants with greater coping self-efficacy scores

reported less distress, with a Pearson coefficient of -0.371. Furthermore, the mean level of

distress was 8.06, which was classified as intense based on the Distress Thermometer. Common

themes in the responses to the open-ended questions included difficulty coping with job demand,

unsupportive or insufficient organizations, and the death, dying, and suffering of patients. In
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order to cope with these stressors, participants reported “getting away,” organization, and

cultivating strength as coping strategies (Wahlberg et al., 2016). The use of self-report data may

have affected the findings of the study and decreased the generalizability of the findings.

Moreover, the adapted Distress Thermometer was not used before this study, which brings into

question its reliability and validity. However, one strength of this study is its use of open ended

questions. Integrating a qualitative perspective to capture accurate coping strategies adds to the

credibility of the findings as both quantitative and qualitative methods were used.

Since stress levels and compassion fatigue can vary by nursing specialties, Zajac, Moran,

and Groh (2017) used a mixed method design to determine if levels of compassion fatigue in

oncology nurses differed from nurses in medical-surgical units. They also sought to develop

bereavement support after patient deaths to decrease the staff’s compassion fatigue and increase

patient satisfaction. In order to measure compassion fatigue, the Professional Quality of Life

Scale was used, while patient satisfaction was measured using the Press Ganey survey.

Compassion fatigue was measured before and after the intervention, with the postintervention

survey incorporating a qualitative component by asking a question about the intervention. The

91 participants were recruited via flyers in two medical and two blended medical-surgical units

in a comprehensive cancer center in Midwestern US. The intervention began after each patient

death and lasted for three months—chaplain and nursing supervisors who were trained by a

project director facilitated debriefings, with at least one supervisor present on site at all times to

support the staff. Sessions occurred before the end of the shift or at shift change and consisted of

three questions related to patient care, colleague support, and the impact of patient death.

Participation was contingent upon completion of the surveys and attendance of the session.

During the second quarter of 2015, sixteen deaths occurred, and fifteen sessions were
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implemented. The sessions lasted an average of 9.87 minutes with an average participant

number of 4.53 (Zajac et al., 2017). Compassion fatigue decreased overall in both medical and

medical-surgical unit nurses, but no significant difference was present in burnout or secondary

traumatic stress for those who did or did not participate in debriefings. The participants rated the

debriefings an average of 3.73 out of 5, which translated to “somewhat helpful.” In terms of

patient satisfaction, the only significantly higher item between the Press Ganey scores from

2012-2015 was skill of the nurse. The results also found that nurses 40 and younger and those

with less than ten years of nursing experience had lower compassion satisfaction and higher

burnout (Zajac et al., 2017). The results of this study are supported by the high reliability of both

the survey and questionnaire, but limited by the variable number of deaths, which affected the

amount of sessions held. Furthermore, the seven facilitators could have varying ways of

delivering the presentation, potentially affecting the participants’ experience of the session.

Another way oncology nurses can vary in experiencing compassion fatigue and initiating

coping strategies is through nationality or cultural differences. A descriptive qualitative study

done by Perry, Toffner, Merrick, and Dalton (2011) sought to explore how Canadian oncology

nurses experienced compassion fatigue. Nineteen participants were recruited through

advertisements in the Canadian Oncology Nursing Journal. Inclusion criteria included

employment as an oncology nurse, experience with compassion fatigue, ability to communicate

in English or French, and Internet access. The participants completed a questionnaire and wrote

a narrative about their experiences with compassion fatigue online, which were reviewed by a

research assistance and principal investigator independently and anonymously. Through the

questionnaire and narrative, the researchers found that the participants had a limited knowledge

of compassion fatigue, including the factors that can lead to compassion fatigue. The nurses
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attributed the lack of support, knowledge about compassion fatigue, and time to provide high

quality care to patients were the main causes of compassion fatigue. Aggravating factors noted

were being unable to ease suffering, excessive emotional attachment to the patient, and co-

existing physical and emotional stress. The outcomes of compassion fatigue included

considering leaving the oncology unit, mind and body fatigue, and adverse effects on personal

relationships. However, the participants highlighted that compassion fatigue was reduced by the

support of coworkers, work and life balance, maturity and longer work experience, connecting

with others, and acknowledgement of compassion fatigue. Possible interventions that the

researchers suggested were to increase compassion fatigue education, promote support from

colleagues, foster the belief that more can be done for the patient, and to examine nurses’

emotional attachment to patients (Perry et al., 2011). This study had several strengths:

comments from the participants were presented verbatim in the article, increasing its credibility

and validity; an audit trail was present, increasing the confirmability of the study; and the sample

size was diverse. Despite this, the very small sample size limits the generalizability of the

findings.

Similarly, a descriptive, nonexperimental study by Wu, Singh-Carlson, Odell, Reynolds,

and Su (2015) aimed to examine the differences between compassion fatigue, burnout, and

compassion satisfaction in American and Canadian oncology nurses. The researchers also

wanted to find the characteristics that lead to compassion fatigue and burnout (Wu et al, 2015).

The participants were recruited through convenience sampling via email invitations using the

mailing list of the Oncology Nursing Society (ONS) and Canadian Association of Nurses in

Oncology (CANO). The modified Abendroth Demographic Questionnaire and the Professional

Quality of Life scale (ProQOL 5) were the surveys used to collect data. A total of 549 responses
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were recorded, with 63 from the Canadian participants and 486 from the American participants

(Wu et al., 2015). The researchers found that the only significant difference between the two

groups was years of experience, as most of the American nurses had 2-5 years of experience

compared to mainly 21-25 years of experience in the Canadian group. Both groups experienced

high levels of compassion satisfaction and low levels of burnout and compassion fatigue, with

younger nurses at a higher risk for compassion fatigue. Participants who sacrificed their own

psychological and personal needs in order to care for the patient also had an increased risk for

compassion fatigue. Moreover, in the United States group specifically, nurses with depression or

PTSD episodes were more likely to experience burnout and compassion fatigue. In contrast,

more educated nurses experienced higher compassion satisfaction. Perhaps most notably, team

cohesiveness in the workplace was an important factor in decreasing compassion fatigue and

burnout (Wu et al., 2015). A small response rate from the Canadian group, lack of male

participants, and inclusion of advance practice nurses were all weaknesses of the study. The

finding that more educated nurses experience higher compassion satisfaction differs from

previous studies and may be due to the advance practice participants working in an inpatient

setting instead of an outpatient setting like they usually do. The use of the ProQol scale was a

strength since it had high reliability in compassion fatigue, burnout, and compassion satisfaction

(Wu et al., 2015).

In terms of cultural and ethnic differences, one study about Chinese oncology nurses

presented a unique viewpoint regarding an Asian perspective of compassion fatigue.

Researchers Yu, Jiang, and Shen (2016) implemented a cross sectional study to explore the

prevalence of compassion fatigue, burnout, and compassion satisfaction among Chinese

oncology nurses. The researchers were particularly interested in this population because China is
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currently facing difficulties in caring for oncology patients due to the scarce amount of oncology

nurses available. Furthermore, the high turnover rate of Chinese oncology nurses and the lack of

death education these nurses receive precipitates the challenges of managing patient death.

Thus, the researchers explored the predictors of compassion fatigue, compassion satisfaction, and

burnout in ten tertiary hospitals and five secondary hospitals in Shanghai. The only inclusion

criterium was over one year of oncology nursing experience. Eligible participants were selected

using convenience and cluster sampling; in total, 650 nurses participated in the study. The

participants completed several questionnaires: a demographic and work-related questionnaire

that asked about training on death-related grief, psychological care of the patients and

psychological adjustment of the nurses; the Chinese version of the Professional Quality of Life

Scale for Nurses; Jefferson Scales of Empathy; Simplified Coping Styles Questionnaire;

Perceived Social Support Scale; and the Chinese Big Five Personality Inventory (brief version).

All these questionnaires had a Cronbach’s alpha of at least 0.75 (Yu et al., 2016). The study

found that a higher prevalence of compassion fatigue and burnout occurred among nurses with

more years of experience who worked in secondary hospitals and had passive coping styles.

Furthermore, nurses who exhibited neuroticism had a negative association with compassion

satisfaction because they were more likely to feel angry and depressed due to a greater inability

to control emotions. In contrast, nurses with openness and conscientiousness as traits had a

positive association with compassion satisfaction. Cognitive empathy, training, and support

from organizations were also predictors of compassion satisfaction, with perspective taking

being the strongest predictor. Interestingly, no relationship was found between social support

and compassion fatigue. The researchers speculated that this may be due to Chinese nurses’

tendency to self-adjust, rather than seek social support in times of emotional stress (Yu et al.,
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2016). The findings of this study implicate that nursing educators should provide on-duty

training to teach about cognitive empathy, as well as interventions that promote active coping

strategies for nurses who exhibit neuroticism and passive coping. Several limitations include the

limited generalizability because of the cluster and convenience sampling method, and the self-

report questionnaires affecting the reliability of the data due to bias.

Resilience and Coping

In order to evaluate the effects of burnout and compassion fatigue in oncology nurses, the

concept of resilience must also be assessed to gauge nurses’ capacity to recover from hardship.

Thus, researchers Zander, Hutton, and King (2013) wanted to understand the process of the

development of resilience, how resilience affects the work of nurses, and how to develop

strategies to support resilience development in the workplace. This qualitative study was set in

an outpatient pediatric hematology-oncology unit in Australia. The researchers defined their

inclusion criteria as a nurse working in the oncology unit with more than 12 months of post-

registration nursing experience. Potential participants were sent an information sheet and five

participants volunteered to be in the study. The five participants were interviewed for

approximately one hour in an office location of their choice. Questions asked pertained to the

participant’s definition and understanding of resilience, their coping strategies, and their

experiences in the pediatric oncology ward. The transcript of the interview was sent to the

participant before analyzing the results to verify that the statements were correct. Inductive

analysis was used to generate codes, which were grouped into seven themes (Zander et al.,

2013). The “seven major aspects of forming resilience” are the themes that encapsulate the

participants’ perceptions of resilience and its effects on their work. The individual

conceptualization of resilience describes how the participants saw resilience as either a learned
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concept or an innate ability to cope; nonetheless, all saw it as a life-long skill. The issues and

challenges faced theme focused on how the participants’ resilience was influenced by the issues

and challenges they encountered in their professional and personal lives. Actions and strategies

exemplified how strategies to develop resilience are individualized to each person, whether it be

personal rituals or talking, for instance. Under the need for support theme, participants

acknowledged that they needed a support system as well as awareness of the support available to

them. The insight theme exhibited how a clear perception of oneself and their circumstances

helped to manage the and accept the lessons related to working in pediatric oncology. The sixth

theme, processing situations through reflection, showed that thinking, learning, and reflecting

over time contributes to resilience. Lastly, personal and professional experience, when

combined with the sixth theme, is the most important factor in developing resilience—learning

from one’s experience helped the participants gain a better understanding of their personal and

professional experience (Zander et al., 2013). There are several weaknesses that limited this

study: the sample size was very small, there was limited participant feedback on the final seven

themes, and due to the setting of the study in Australia, different challenges may be faced by

nurses in other parts of the world. Despite this, the researchers validated their data with the

participants before analyzing the results and integrated direct quotes into the findings section,

which strengthened the study.

Another perspective of resilience and its relationship to burnout was examined by

Kutluturkan et al., (2016). The researchers wanted to identify the factors that influence burnout

and resilience and hypothesized that the presence of resilience is associated with a lower rate of

burnout. To test their hypothesis, a descriptive study with 140 participants was done. The

participants were recruited from an oncology-hematology clinic and the only inclusion criteria
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were experience in the oncology-hematology clinics and willingness to participate in the study;

thus, the sample was not randomized. Data collection was carried out using a sociodemographic

attributes form, Maslach’s Burnout Inventory, and Resilience Scale for Adults. Maslach’s

Burnout Inventory measured emotional exhaustion, depersonalization, and personal

accomplishment. The Resilience Scale for Adults measured six subscales: self-perception,

perception of the future, structured style, social competence, family cohesion, and social

resources (Kutluturkan et al., 2016). No statistically significant differences were found between

the demographics of the participants. From Masclach’s Burnout Inventory, median scores were

24.00, 9.00, and 16.00 for emotional exhaustion, depersonalization, and personal

accomplishment, respectively. Emotional exhaustion was the only factor that had moderate

levels, while both depersonalization and personal accomplishment were categorized as low

levels. The Resilience Scale for Adults displayed that nurses between 36 and 44 years old had

higher median structured style and self-perception, while having children was associated with

higher self-perception. Furthermore, there was a negative correlation between emotional

exhaustion and perception of future; depersonalization and structured style and self-perception;

and personal accomplishment and structured style, perception of future, and self-perception

(Kutluturkan et al., 2016). Because this study is descriptive, its evidence level is VI. Some

weaknesses of this study include its small sample size and that it only evaluated burnout and

resilience one time. However, the data collection tools used had high internal reliability, with

Maslach’s Burnout Inventory having a Cronbach’s alpha of 0.78 and the Resilience Scale for

Adults having a Cronbach’s alpha of 0.73 (Kutluturkan et al., 2016).

In order to assess the effectiveness of interventions that foster resilience and decrease

compassion fatigue, the resources available to nurses must be first evaluated. Aycock and Boyle
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(2009) implemented a study aimed at identifying resources and interventions available for

compassion fatigue in oncology nursing. Participants were encouraged to join the study by

sending 231 chapter presidents of the Oncology Nursing Society a letter describing the purpose

of the study and the questionnaire. The questionnaire addressed accessibility to on-site

resources, educational programs, and retreat availability. Before the questionnaire was sent out,

five oncology nurses in diverse roles participated in a pilot survey and feedback was given. Of

the 103 participants, only 22% stated that they had access to a counselor or psychologist on-site,

but the time between the request and appointment made it difficult and unideal to use. In terms

of educational programs, 45% did not receive knowledge and skill development in coping,

adaptation, and emotional self-care. Perhaps most significant is that 0% had employer education

about the care of the dying. Retreats were also minimal, as only 10% had voluntary retreats

available to them, and many said insufficient attendance usually discontinued the retreats. Based

on these results, the researchers recommended to integrate self-care practices into daily life;

organizational support and adequate staffing; individualized interventions based on coping style;

and education and training in communication skills conflict resolution, ethical issues, and self-

care. Furthermore, the researchers proposed the discussion of emotional expression as part of the

meeting agenda, as well as pastoral care services and proper communication of resources

available to the nurses. Many of the participants also expressed interest in retreats, which can

help oncology nurses focus on the personal aspect of the profession through storytelling and

team-building. Lastly, peer support and active listening can decrease the sense of isolation

nurses may feel when dealing with compassion fatigue (Aycock & Boyle, 2009). This study’s

use of both quantitative and qualitative methods to obtain data is a strength, as the researchers

were able to quantify statistical data while also having personal accounts from the participants.
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However, the response rate was only 27%, and the researchers did not describe what kind of

questions the survey asked in order to gather data quantitatively and qualitatively.

Aycock and Boyle’s finding that peer support is an effective way to decrease compassion

fatigue relates to the mixed methods study conducted by Rice, Bennett, and Billingsley (2014),

which strove to identify how oncology nurses express and process grief surrounding their

patients’ deaths using peer storytelling through Second Life. The researchers also wanted to

assess the benefits of peer storytelling when dealing with grief. Participants were recruited

through a purposive method—participants who met the inclusion criteria (at least 12 months of

registered nurse experience, feelings of sadness or grief after a patient death within the last six

months, and confidence in computer skills) were solicited to participate in the study. A total of

nine participants divided into three groups of three were in the study. A 12-item survey was used

at the beginning of the study to measure demographics and professional loss. Each group had

five one-hour sessions of peer storytelling, which was driven by Second Life, a 3-D multiuser

virtual environment. The Bereavement Task Model was used to guide the questions in the

sessions, which was facilitated by a group moderator with grief management experience. The

sessions were recorded, and the participants completed a 20-item survey to measure support

during the sessions and to evaluate the effectiveness of peer storytelling using Second Life (Rice

et al., 2014). At the beginning of the study, participants had an average of 4.33 on a 1 to 10 scale

of grief, while an average of 3.22 rating of grief was recorded after the storytelling sessions. The

researchers compiled the sessions and analyzed the transcriptions using thematic analysis. The

first central theme was cognitive readiness to learn about death. The participants discussed how

cohesiveness, support, and reliance on each other were important to their job satisfaction. They

also remarked about how education about preparing for death and grief was minimal. The
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second central theme, death really takes death experience, explored the spiritual shift that plays

an important role in the growth of emotional resilience. Through vulnerability, the participants

became open and more aware of their emotions and limitations when managing patient death.

Lastly, all participants demonstrated the central theme of emotional resilience through the

management of discordant families, intense emotions, and unresolved conflicts. The participants

explained that remembering and reflecting is the most important factor in developing resilience;

gaining a new perspective on the lives and deaths of their patients helped them cope with the

pain and become stronger. The participants also gave a mean rating of 8.8 on a 1 to 10 scale for

the effectiveness of peer storytelling in making sense of their grief experience (Rice et al., 2014).

Limitations of this study include no randomization, a very small sample size (which limits the

study’s generalizability), and the use of only one facility (which restricts the transferability of the

findings). However, having a mixed method can also be classified as a strength of the study

since both quantitative and qualitative measures were used to gather results.

Aside from emotional wellness, social wellness must also be considered when creating

recommendations to combat compassion fatigue. Zadeh, Gamba, Hudson, and Wiener (2012)

developed a ten-session wellness program for inpatient and outpatient pediatric oncology nurses

in order to promote self-care, education, and team-building. The researchers also wanted to

develop strategies to enhance staff wellness and provide a forum for staff to discuss patient-staff

interactions. The wellness program was conducted at a National Institutes of Health (NIH)

Clinical Center pediatric inpatient unit, outpatient day hospital, and outpatient clinic. The

sessions were offered on two occasions for both inpatient and outpatient nursing staff, with the

first series held both day and night and the second series held once in inpatient and once in

outpatient. The sessions were developed based on the nurses’ requests on a form and an
 21
PREVENT AND MITIGATE COMPASSION FATIGUE
anonymous suggestion box and included topics such as resiliency, communication, teambuilding,

and stress reduction. After gathering the topics and planning the sessions, experts from the NIH

and research team were then chosen to lead individual sessions. The session began with verbal

education on the topic, followed by a hands-on activity or interactive discussion, reading

materials, time for questions, and a formal evaluation at the end. A total of 126 evaluations were

completed. The majority of participants found the sessions effective in providing new

information that would enhance their work skills, and 75% reported that the sessions would

change the way they performed their job. Moreover, the majority of the comments were positive

feedback on the quality of information and format of the session, with some negative comments

about inadequate discussion on some of the topics (Zadeh et al., 2012). Strengths of this study

include the detailed descriptions of each series’ objectives and activities, as well as direct quotes

from the participants’ feedback. Despite the overall positive evaluation of the sessions, however,

the results of this study were minimal and limited only to qualitative data based on the

participants’ feedback.

Lastly, in line with the technological advancements that have developed over the past two

decades, Jakel et al. (2016) examined if usage of the Provider Resilience mobile application

(PRMA) would decrease oncology nurses’ compassion fatigue. The researchers hypothesized an

inverse relationship between the pre- and post-test scores for compassion fatigue. To test their

hypothesis, the researchers implemented a quasiexperimental, longitudinal design in an oncology

unit in California. Participants were recruited through convenience sampling via advertisements.

The inclusion criteria included being 18 years old or older, fluency in English, full-time

employment as an oncology nurse, and possession of a smartphone. Participants were non-

randomly assigned to an intervention or control group (16 participants in the intervention group
 22
PREVENT AND MITIGATE COMPASSION FATIGUE
and nine in control). PRMA use was tracked in the intervention group for six weeks. The

PRMA is a tool developed by the Department of Defense to help ease compassion fatigue among

professions who treat military service members. The application provides education about the

risks of compassion fatigue and burnout, evaluates burnout and compassion fatigue by tracking

symptoms, and gives reminders to engage in self-care and increase resilience. Both groups also

completed the ProQOL 5 as a pre- and post-test to measure compassion fatigue and burnout

(Jakel et al., 2016). At pre-test, 14 participants had average compassion fatigue, 17 had high

compassion satisfaction, and 15 had low burnout. At post-test, eight participants reported low

compassion fatigue, 14 had high compassion satisfaction, and 12 had low burnout. There were

also no statistically significant differences between the two groups from baseline to six weeks

and between the mean scores for compassion satisfaction and burnout (Jakel et al., 2016).

Several limitations may have led to these findings. First, the sample size was small, and

participants were not assigned randomly to their respective groups, which limits the

generalizability of the findings. Furthermore, the tracking software only provided the amount of

time that participants spent on the application, which varied widely. The unit also had a no cell

phone policy, which limited the amount of time the intervention group could use the PRMA.

Though the researchers’ hypothesis was disproven, a strength of the study was its use of a

control and intervention group to test their hypothesis. In addition, since this was a pilot study,

the researchers paved the way for more research to be done on the PRMA in more ideal

conditions.

Conclusion

The results of this literature review exemplified the factors that can aggravate and prevent

compassion fatigue in oncology nurses, as well as potential interventions that can alleviate
 23
PREVENT AND MITIGATE COMPASSION FATIGUE
compassion fatigue and foster resilience. The twelve articles reviewed mainly ranged from a

qualitative analysis to mixed-methods design with relatively small sample sizes. Common

factors that several studies found put oncology nurses in a higher risk of compassion fatigue

were lack of social support, passive coping style, and little to no education about compassion

fatigue. However, discrepancies between the articles were found in the relationship between

years of experience, age and compassion fatigue. Wu et al. (2015) and Zajac et al. (2017) both

had findings that showed younger nurses were at a higher risk for compassion fatigue, while Ko

and Kiser-Larson’s results (2016) displayed that younger nurses with less experience had lower

average stress levels. Overall, most of the studies concluded that colleague support and adequate

staffing, education about patient death and dying, and supportive debriefings were helpful

methods to manage compassion fatigue and burnout. The participants who received debriefing

interventions, which allowed a space for them to speak about their experiences, particularly

responded well to these sessions by helping them acknowledge their grief and make sense of

their experience in the comfort of their colleagues.

More research is needed, however, in identifying the risk factors of compassion fatigue

for male nurses and nurses from other cultural backgrounds. For instance, Yu et al.’s 2016 study

on compassion fatigue among Chinese nurses found no relationship between social support and

compassion fatigue, which is possibly due to the Chinese belief of self-adjusting during

emotional stress. Such a result also calls for more studies on individualized interventions for

nurses. Zander et al. (2013) implemented strategies to support resilience development that were

different for each participant, which successfully enhanced the participants’ resilience. Most of

the studies included in this literature review focused on group debriefing, rather than

individualized interventions for different personalities and coping styles. Thus, the current
 24
PREVENT AND MITIGATE COMPASSION FATIGUE
literature suggests that best-practice recommendations to combat compassion fatigue are

imperative for the viability and emotional well-being of oncology nurses.

 25
PREVENT AND MITIGATE COMPASSION FATIGUE
CHAPTER 3

Best Practice Recommendations: Combating Compassion Fatigue in Oncology Nursing

This thesis sought to create best practice recommendations to combat and alleviate

oncology nurses’ experiences with compassion fatigue. Table 1 presents the best practice

recommendations intended to aid in decreasing the prevalence and harmful effects of compassion

fatigue.

The literature review in Chapter 2 described the experiences of oncology nurses with

compassion fatigue, individual and environmental risk factors that can exacerbate those

experiences, and the negative effects compassion fatigue has on the nurses and their provision of

care. The majority of the research that investigated interventions being implemented to

counteract compassion fatigue found that workplace environment, deficient knowledge, and

inadequate work-life balance are the most significant factors that must be addressed to foster

healthy coping and resilience. For instance, Wu et al. (2016) found that workplace cohesiveness,

such as teamwork and mentorship, buffered the negativity of burnout and compassion fatigue

and even increased compassion satisfaction. Furthermore, nurses expressed that educational and

supportive services provided by their institution were either inadequate or inconvenient (Aycock

& Boyle, 2009), and they wished more resources in the form of debriefing, support groups, and

counseling were available (Wahlberg et al., 2016). Outside of the clinical setting, oncology

nurses found that a fulfilling life outside of work aided in keeping perspective when stressful and

overwhelming situations emerged (Perry et al., 2011).

 26
PREVENT AND MITIGATE COMPASSION FATIGUE
Table 1

Best Practice Recommendations for Preventing and Mitigating Compassion Fatigue in Oncology

Nurses

Recommendation Rationale References Level of

Evidence
More social  American nurses  Wu, S., Singh- Level VI
support and with depression or Carlson, S., Odell, A.,
resources for PTSD episodes are Reynolds, G., & Su,
nurses with a more likely to Y. (2016).
history of experience Compassion fatigue,
depression or secondary traumatic burnout, and
PTSD stress compassion
satisfaction among
oncology nurses in the
United States and
Canada. Oncology
Nursing Forum, 43(4),
161-169. doi:
10.1188/16.ONF.E161
-E169

Develop a culture  A perception of team  Wu, S., Singh- Level VI

of team training cohesiveness at
and enhance team work is a valuable
cohesiveness and factor when
the work decreasing
environment compassion fatigue
and burnout
 Can be done through
adequate staffing,
supervisor support,
and breaks
 Ko, W., & Kiser-
Carlson, S., Odell, A.,
Reynolds, G., & Su,
Y. (2016).
Compassion fatigue,
burnout, and
compassion
satisfaction among
oncology nurses in the
United States and
Canada. Oncology
Nursing Forum, 43(4),
161-169. doi:
10.1188/16.ONF.E161
-E169
Level IV
Larson, N. (2016).
Stress levels of nurses
in oncology outpatient
units. Clinical Journal
of Oncology Nursing,
20(2), 158-164. doi:
 27
PREVENT AND MITIGATE COMPASSION FATIGUE
10.1188/16.CJON.158
-164

Individualized  Oncology nurses  Aycock, N., & Boyle, Level VI

training and with greater coping D. (2009).
education on self-efficacy Interventions to
compassion reported less distress manage compassion
fatigue, fostering  Oncology nurses fatigue in oncology
coping self- view resilience as a nursing. Clinical
efficacy, and life-long skill Journal of Oncology
resilience  Cognitive empathy, Nursing, 13(2), 183-
training, and support 191. doi:
from the workplace 10.1188/09.CJON.183
are protective factors -191
against compassion  Wahlberg, L., Level VI
fatigue Nirenberg, A., &
Capetuzi, E. (2016).
Distress and self-
efficacy in inpatient
oncology nurses.
Oncology Nursing
Forum, 43(6), 738-
746. doi:
10.1188/16.ONF.738-
746
 Yu, H., Jiang, A., & Level IV
Shen, J. (2016).
Prevalence and
predictors of
compassion fatigue,
burnout and
compassion
satisfaction among
oncology nurses: A
cross-sectional survey.
International Journal
of Nursing Studies, 57,
28-38. doi:
10.1016/j.ijnurstu.201
6.01.012

Peer  Peer storytelling is  Aycock, N., & Boyle, Level VI

support/reflecting helpful for oncology D. (2009).
on the grief nurses to make sense Interventions to
experience of their grief manage compassion
experience fatigue in oncology
 28
PREVENT AND MITIGATE COMPASSION FATIGUE
 Compassion fatigue nursing. Clinical
is reduced by Journal of Oncology
colleague support Nursing, 13(2), 183-
and connecting with 191.
others doi:10.1188/09.CJON. Level VI
183-191
 Perry, B., Toffner, G.,
Merrick, T., & Dalton,
J. (2011). An
exploration of the
experience of
compassion fatigue in
clinical oncology
nurses. Canadian
Oncology Nursing
Journal, 21(2), 91-
105. doi:
10.5737/1181912x212
9197
 Rice, K. L., Bennett, Level VI
M. J., & Billingsley,
L. (2014). Using
second life to facilitate
peer storytelling for
grieving oncology
nurses. The Ochsner
Journal, 14(4), 551-
562.
http://www.ochsnerjou
rnal.org/doi/pdf/10.10
43/1524-5012-
14.4.551

Integrating self-  Verbalizing,  Ko, W., & Kiser- Level VI

care practices exercising, relaxing, Larson, N. (2016).
outside of the and taking time for Stress levels of nurses
professional oneself are nurses’ in oncology outpatient
setting most common units. Clinical Journal
coping behaviors of Oncology Nursing,
20(2), 158-164. doi:
10.1188/16.CJON.158
-164
 29
PREVENT AND MITIGATE COMPASSION FATIGUE
Summary of Best Practice Recommendations

In the previous chapter, potential interventions to combat compassion fatigue in oncology

nurses were discussed through a literature review. A quality improvement intervention done on

oncology nurses found that only a few of the participants knew about compassion fatigue, which

implicates that more education about compassion fatigue must be implemented to address its

incidence (Zajac et al., 2017). Similarly, Aycock and Boyle (2009) determined that education

and training in communication skills, especially in care of the dying, should be required for

oncology nurses. Education about and training on coping self-efficacy and active coping skills

are also important, as low self-efficacy was found to be a predictor of distress and active coping

skills were predictors of compassion satisfaction (Yu et al., 2016; Wahlberg et al., 2016). In

addition to education, peer support and reflecting on the grief experience is a key factor in

mitigating the effects of compassion fatigue. Aycock and Boyle (2009) found that only 5% of

participants in their study had access to support groups. Limited perceived support was found to

be a precursor to compassion fatigue, and long-term lack of support exacerbates the experience

of compassion fatigue (Potter et al., 2010). Moreover, programs that allow reflection and

emotional expression, such as peer storytelling, benefits oncology nurses by helping them

understand their grief experience (Rice et al., 2014). Oncology nurses with a history of PTSD

and depression also need more peer support and resources, as they were found to have high

levels of compassion fatigue and burnout. Depression and PTSD can also manifest as

consequences of compassion fatigue and burnout, so additional resources for this population is

necessary (Wu et al., 2016). Furthermore, creating a cohesive and healthy work environment for

the nursing staff can help prevent compassion fatigue and burnout at the institutional level. Wu

et al. (2016) found that both American and Canadian participants who sacrificed personal and
 30
PREVENT AND MITIGATE COMPASSION FATIGUE
psychological needs in order to provide care to their patients had higher levels of compassion

fatigue and burnout. Similarly, Ko and Kiser-Larson (2016) found workload and patient death to

be the two most stressful factors for oncology nurses. Thus, adequate staffing, supervisor

support, and a perception of team cohesiveness can aid in decreasing stress and the incidence of

compassion fatigue and burnout. Lastly, encouraging oncology nurses to participate in self-care

practices at home can enhance coping and decrease work-related stress. Common self-care

behaviors can include verbalizing, exercising or relaxing, and taking time for oneself (Ko &

Kiser-Larson, 2016).
 31
PREVENT AND MITIGATE COMPASSION FATIGUE
CHAPTER 4

Implementation and Evaluation

The first section of this chapter focuses on implementing in-service wellness workshops

with topics on education on compassion fatigue, teambuilding, peer support, and self-care. This

proposed intervention will include evidence-based information on the definition and signs and

symptoms of compassion fatigue, barriers and successful strategies for teambuilding, seeking out

peer support and providing support for colleagues, and self-care strategies for oncology nurses at

a local hospital. The theoretical workshops that will be implemented are based on the best-

practice recommendations in the previous chapter and Zadeh et al.’s (2012) series of wellness

workshops. There will be a total of five workshops, with the last topic being the nurses’ choice.

The workshops will be offered yearly with the hopes that nurses will utilize the tools they

learned to combat compassion fatigue with their colleagues and within themselves.

The framework guiding the implementation and evaluation process is the Plan-Do-Study-

Act (PDSA) cycle, which is an evidence-based approach that tests changes in the work setting

(Institute for Healthcare Improvement, 2017). The PDSA cycle first tests the change in a small

scale, improves and refines the change as necessary, and then tests the change in a broader scale

(Institute for Healthcare Improvement, 2017). The implementation section of this chapter

explains the Plan and Do stages of the cycle, while the latter section discusses the evaluation

process, as well as the Study and Act stages. Lastly, this chapter will evaluate the strengths and

limitations of implementing best-practice wellness workshops at a local oncology unit, as well as

further research related to compassion fatigue in oncology nursing.

Implementation

Implementing an Effective Wellness Workshop

 32
PREVENT AND MITIGATE COMPASSION FATIGUE
A systematic review on teaching evidence-based healthcare found that workshops

improved knowledge, skills, and behavior among post-graduates (Young, Rohwer, Wolmink, &

Clark, 2014). Implementing workshops at the institution itself can help increase participation and

make it more accessible for the nursing staff to attend. The workshops will be theoretically

implemented using the PDSA model for improvement in an oncology unit at a local hospital.

After multiple cycles of PDSA, the workshops can be implemented at other local hospitals.

Plan. Plan is the first step of the PDSA cycle and is focused on identifying objectives,

researching wellness workshops, and brainstorming plans to evaluate the change (Institute for

Healthcare Improvement, 2017). The objective of the wellness workshops is to tackle the major

factors that contribute to compassion fatigue: lack of knowledge, team cohesiveness, peer

support, and self-care. It is important to integrate these four topics into a whole session in order

to address the core problems related to compassion fatigue. Nursing managers and charge nurses

will introduce this objective to the oncology nurses during staff meetings. An additional topic to

cover will be decided based on nurses’ suggestions indicating a topic of their interest related to

compassion fatigue. Charge nurses will collect suggestions three months prior to the start of the

workshops, and the topic will be selected and designed one month before the start date.

When researching wellness workshops, the number of oncology nurses on the unit, cost,

and time are important factors to consider. Depending on the number of oncology nurses on the

unit, one day and one night workshop will be held for each topic to accommodate both shifts.

Varying teaching modes will be used in each workshop, including lectures, discussions, and

hands-on activities. Cost must take into consideration the amount of extra pay the nurses will

receive after completing workshops, since each workshop is one hour long, totaling to five

workshops. Making the workshops on the clock can help facilitate participation and engagement
 33
PREVENT AND MITIGATE COMPASSION FATIGUE
but can be costly depending on the number of staff. Moreover, the cost of implementing the

workshop must address the cost of paying the workshop facilitator and experts who will create

the curriculum, as well as materials, such as handouts. The information in the workshop also

needs to follow up-to-date evidence-based research and be specific to oncology nursing. In order

to do so, experts on compassion fatigue, such as researchers, nursing educators, and nurses

themselves, will develop the content. Preferably, the workshop facilitator will also be one of the

experts curating the content.

Lastly, evaluation of the wellness program will consist of three parts. First, participants

will complete the ProQOL 5, which measures compassion satisfaction and compassion fatigue,

before and after the workshop series (ProQOL, 2012). Second, participants will fill out a

questionnaire consisting of four questions asking about the effectiveness and quality of the

workshops, as well as changes in behavior and knowledge after the workshops. A feedback

section will be included in the questionnaire in order for participants to evaluate the usefulness of

the workshops and suggestions to improve its effectiveness. Thirdly, the annual unit nurse

turnover rates will be tracked one year prior and one year after the intervention in order to

evaluate the workshops’ effect on nurse retention. Once the objectives, cost, content and

materials, and evaluation methods are determined, the Do stage of the PDSA cycle can begin

(Institute for Healthcare Improvement, 2017).

Do. According to the Institute for Healthcare Improvement (2017), the Do stage includes

testing the workshop in a small scale, documenting problems and observations, and analysis of

the data. The wellness workshops will be created by compassion fatigue researchers, nurse

educators, and nurses who have experienced compassion fatigue firsthand. The broad topics

covered by the workshops include education about the signs and symptoms of compassion
 34
PREVENT AND MITIGATE COMPASSION FATIGUE
fatigue, tips to increase team cohesiveness, how to seek out peer support and be an effective peer

supporter, and ways to integrate self-care in and out of the workplace. The last topic will be

determined by the suggestions of the nursing staff. The best-practice recommendations that will

be addressed by the workshops include enhancing team cohesiveness and work environment,

training and education on compassion fatigue, fostering self-efficacy, and resilience, peer support

and reflecting on the grief experience, and integrating self-care practices outside of the

professional setting. Each workshop topic will be one hour long, and participants can sign up for

one of the times the topic is available two weeks in advance. Each workshop will be available

twice a week, with day and night times available to accommodate both shifts. Charge nurses will

have a summary of the content two weeks beforehand, which they will need to discuss with the

nurses during huddles. Content will be in the form of presentations, discussions, and interactive

activities. During the first ten minutes of the first workshop, participants will be given the

ProQOL 5 to complete in order to gather baseline data on compassion satisfaction and

compassion fatigue. Furthermore, the behaviors and reception of the staff to the workshops will

be documented, along with problems encountered. In order to evaluate the strength of the

workshops, the ProQOL 5 will again be administered at the last workshop, as well as a four-part

questionnaire and feedback regarding the content and efficacy of the workshops.

Summary

The implementation process utilizes the effectiveness of workshops with the research-

based PDSA cycle for executing best practice recommendation to combat compassion fatigue in

oncology nurses. Creating content that targets the factors closely related to compassion fatigue

through the use of workshops ensures that oncology nurses are receiving the most relevant and

pertinent information for this topic. Moreover, using the PDSA cycle allows for action-oriented
 35
PREVENT AND MITIGATE COMPASSION FATIGUE
learning based on the scientific method (Institute for Healthcare Improvement, 2017). In the

following section, the Study and Act stages and the evaluation process of the wellness

workshops will be delineated.

Evaluation

The final two stages of the PDSA cycle are Study and Act. These two stages are focused

on analysis of the data and refinement of the change that was implemented (Institute for

Healthcare Improvement, 2017). Evaluation of the wellness workshops will also be discussed

for the integration of best-practice recommendations into oncology nursing units.

Study. The Study stage consists of a complete analysis of data, comparison of the data to

predictions, and reflection on the lessons learned (Institute for Healthcare Improvement, 2017).

It is during this stage that nurse managers would analyze the effectiveness of the workshops on

decreasing compassion fatigue in the unit. This data will come from the ProQOL 5 results

before and after the workshops were conducted and the questionnaire that includes feedback for

the workshops. Furthermore, the outcome of the workshops would correspond with the

prediction that attending all five workshops will decrease the incidence of compassion fatigue on

oncology nurses on the unit. Lastly, nursing managers, workshop facilitators, and experts who

developed the content will summarize and reflect on the strengths, weaknesses, and lessons

learned throughout the implementation of the workshops and report data on annual turnover

rates.

Act. The last stage of the PDSA cycle, Act, is comprised of determining changes that need to be

made and planning the next PDSA cycle that will be implemented based on these changes

(Institute for Healthcare Improvement, 2017). During this stage, refinements are made to the

content and delivery of workshops based on observations and the feedback provided by the
 36
PREVENT AND MITIGATE COMPASSION FATIGUE
participants. Refinements may include shorter or longer workshops, more options for topics to

be covered, or added time slots to attend the workshops. Finally, a plan for the next PDSA test

will be developed based on the outcomes and refinements of this cycle.

 37
PREVENT AND MITIGATE COMPASSION FATIGUE
Strengths and Limitations of Thesis Project

One of the strengths of this best practice recommendation is the amount of compassion

fatigue issues that are being addressed simultaneously through the workshops. Education about

compassion fatigue and its signs and symptoms, enhancing team cohesiveness through

teambuilding, increasing peer support, and teaching strategies for proper self-care are all

common themes found from the literature review that were suggested by researchers or nurses

themselves. In addition, the thorough literature review itself is a strength because compassion

fatigue and interventions for it have recently been brought to the forefront of nursing research, so

the evidence is current and crucial. Furthermore, the content of the workshops can be easily

implemented to other oncology units and nursing specialty units, such as the emergency room

and intensive care unit. The workshops also use a variety of teaching methods, from lectures to

discussions to activities, which accommodates the different learning styles of the participants.

Time is a major limitation of this project. Because of the unconventional schedules of

nurses, not all nurses on the unit may be able to attend the workshops even if they are offered

both day and night. Moreover, the cost of paying the nurses overtime for attending the

workshops and the experts and facilitators for creating and conducting the workshops may be

more costly than if the training was done online. Further research needs to be done to compare

the efficacy of implementing similar workshops in inpatient units compared to online modules

completed at home.
 38
PREVENT AND MITIGATE COMPASSION FATIGUE
Summary

The purpose of this thesis was to establish best-practice recommendations to combat

compassion fatigue in oncology nurses. The literature review in Chapter 2 showed multiple

negative effects of compassion fatigue on an organizational and individual level, from nurse

turnover to secondary traumatic stress. Several of the articles discussed earlier found that nurses

considered leaving oncology and nursing altogether because of compassion fatigue. The effects

of this are detrimental to the current nursing shortage and longevity of experienced and new

graduate nurses. Thus, the topics chosen for the workshops were based on the best-practice

recommendations in Chapter 3. The wellness workshops focus on increasing knowledge,

resources, and support for oncology nurses so that grief and compassion fatigue can be prevented

and mitigated before it manifests into physical and emotional damage. In addition, the

evaluation portion of the PDSA cycle allows participants of the workshops to provide their

feedback and input for future workshops. Doing so recognizes the participants’ opinions of and

personal reflections on the workshops and their own experiences of compassion fatigue.

Hopefully, by integrating routine wellness workshops for oncology nurses into the workplace,

the concept of caring for healthcare professionals will be perceived to be just as important as

caring for the patients that are under their care.

 39
PREVENT AND MITIGATE COMPASSION FATIGUE
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