Compassion fatigue, burnout, and compassion satisfaction
Introduction
Provide a brief description of the research article to be discussed.
Wu, S., Singh-Carlson, S., Odell, A., Reynolds, G., & Yuhua, S. (2016). Compassion fatigue, burnout, and compassion satisfaction among oncology nurses in the United States and Canada. Oncology Nursing Forum, 43(4), E161-E169. doi:10.1188/16.ONF.E161-E169
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Paragraph 2
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ONCOLOGY NURSING FORUM • VOL. 43, NO. 4, JULY 2016 E161
Compassion Fatigue, Burnout, and Compassion
Satisfaction Among Oncology Nurses
in the United States and Canada
Stacey Wu, MSN, FNP, Savitri Singh-Carlson, PhD, APHN-BC, Annie Odell, PhD, FNP-BC,
Grace Reynolds, PhD, and Yuhua Su, PhD
ONLINE EXCLUSIVE ARTICLE
Purpose/Objectives: To examine the experiences of compassion fatigue, burnout, and
compassion satisfaction among oncology nurses in the United States and Canada.
Design: Quantitative, descriptive, nonexperimental.
Setting: Online survey with members from the Canadian Association of Nursing Oncology
and the Oncology Nursing Society.
Sample: 486 American and 63 Canadian practicing oncology nurses.
Methods: The Professional Quality of Life (ProQOL) scale, version 5, and modified Abendroth
Demographic Questionnaire were administered through FluidSurveys™, an online data collection
instrument. Chi-square tests of independence were used to investigate associations
between demographic characteristics, health, personal stressors, and work-related characteristics
to experiences of compassion fatigue, burnout, and compassion satisfaction. Compassion
fatigue was measured using the subscales of secondary traumatic stress and burnout.
Main Research Variables: Compassion fatigue, burnout, and compassion satisfaction.
Findings: Demographic characteristics were similar in American and Canadian participants,
and both cohorts reported comparable levels of compassion fatigue, burnout, and
compassion satisfaction. Perception of team cohesiveness within the workplace environment
was found to be significant for both groups, as indicated by significant relationships
in all three subscales of secondary traumatic stress, burnout, and compassion satisfaction
in the ProQOL.
Conclusions: Healthy and supportive work environments are imperative to nurses’ health,
well-being, and satisfaction. Improvements in the workplace can help prevent negative
sequelae, as well as improve health outcomes for patients and nurses, decrease nurse
turnover, and reduce healthcare expenditures.
Implications for Nursing: Findings can be used to implement institutional changes, such
as creating policies and guidelines for the development of preventive interventions and
psychosocial support for nurses.
Wu is a student, Singh-Carlson is a professor
and department chair, and Odell is an
assistant professor, all in the School of
Nursing, and Reynolds is an associate professor
in the Department of Health Care
Administration, all at California State University,
Long Beach; and Su is the owner of
Dr. Su Statistics in Kaunakakai, HI.
No financial relationships to disclose.
Wu and Singh-Carlson contributed to the
conceptualization and design. Wu completed
the data collection. Reynolds provided
the statistical support. Su provided the
analysis. Wu, Singh-Carlson, Odell, and
Reynolds contributed to the manuscript
preparation.
Wu can be reached at
stacey.wu1@gmail.com, with copy to
editor at ONFEditor@ons.org.
Submitted May 2015. Accepted for publication
September 17, 2015.
Key words: nursing; oncology; cancer;
compassion fatigue; burnout; compassion
satisfaction
ONF, 43(4), E161–E169.
doi: 10.1188/16.ONF.E161-E169
Nursing care involves an innate recognition and responsibility to alleviate
pain and suffering, which implies that kindness, compassion,
and competency (Straughair, 2012) are integral parts of the process.
Generally, those who enter the nursing profession are motivated by
the desire to provide quality compassionate care (Baughan & Smith,
2008) regardless of the specialty area; however, oncology nursing has special
challenges because of the nature of cancer.
Evidence indicates that oncology nurses are particularly vulnerable to occupational
stress (Aycock & Boyle, 2009) because of the conditions under
which they provide care. Research has demonstrated that two of the most
commonly reported work-related consequences for nurses are compassion
E162 VOL. 43, NO. 4, JULY 2016 • ONCOLOGY NURSING FORUM
fatigue and burnout (Sabo, 2011). Several studies
report that oncology nurses naturally develop rapport
with patients and family members, subjecting
them to greater likelihood of immense emotional
burden, grief, and distress. This is particularly true
after nurses are involved in traumatic events, such
as death or when the patient and the patient’s family
receive an unexpected prognosis of terminal
illness (Aycock & Boyle, 2009; Potter et al., 2010;
Wenzel, Shaha, Klimmek, & Krumm, 2011). In the
current state of health care, institutional and political
constraints, such as limited resources, lack
of management support, increased workloads, and
staffing shortages, in combination with increasing
patient acuity, put oncology nurses at risk for the
inability to provide compassionate care (Coetzee
& Klopper, 2010; Hooper, Craig, Janvrin, Wetsel, &
Reimels, 2010; Neville & Cole, 2013). As a result of
routine and chronic exposure to human suffering
(Coetzee & Klopper, 2010) amalgamated with pressures
to provide quality care, oncology nurses are in
a prime position for developing compassion fatigue
and burnout.
Compassion fatigue is comprised of two parts:
burnout, characterized as “exhaustion, frustration,
anger and depression” (Stamm, 2010, p. 12), and secondary
traumatic stress, described as the negative
consequences secondary to fear and work-related
trauma. Compassion satisfaction is the positive
feelings derived from helping others, whether it be
from direct contribution or for the betterment of
society (Stamm, 2009). Although compassion fatigue
is often used synonymously with burnout, the two
concepts are derived from two separate failed survival
strategies. Compassion fatigue arises from a
rescue-caretaking response, and burnout arises from
an assertiveness-goal achievement response (Valent,
2002). Compassion fatigue occurs when the caretaker
cannot shield or save the individual from harm and,
therefore, results in feelings of guilt and distress, and
burnout is when one cannot achieve an anticipated
goal, resulting in frustration and perceived loss of
control (Valent, 2002). Compassion fatigue is caused
by a natural and intrinsic response to alleviate pain
and suffering. Burnout is environmentally driven (e.g.,
time and resource constraints, increased workload)
(Perry, Toffner, Merrick, & Dalton, 2011), and the onset
and resolution period between compassion fatigue
and burnout are different. Compassion fatigue has an
acute and insidious onset, resulting in long-term consequences
that are not easily reversible. Conversely,
burnout has a rapid onset and resolution, suggesting
that removal of stressor source may be effective
(Sabo, 2011). Despite these differences, researchers
must investigate compassion fatigue and burnout
concurrently because of their intimate relationship,
particularly in relationships between healthcare professionals
and patients.
Differing healthcare delivery systems between the
two countries under study, a nonuniversal healthcare
system in the United States and a universal healthcare
system in Canada, may contribute to perceptional
differences of nursing, patient care, and workplace
environment. These differences in healthcare delivery
systems can result in differing models of cancer care
delivery (e.g., private or public clinical settings with
their own healthcare policies and protocols, culture
of interdisciplinary teamwork, financing of health
care for patients) that may dictate various levels of
treatments available for patients. The Patient Protection
and Affordable Care Act in the United States
articulates patients’ healthcare insurance coverage
and may indirectly affect patients’ and healthcare
professionals’ perceptions of cancer care (Kumar &
Moy, 2013). Given these various contextual factors,
recognizing how nurses’ perceptions and experiences
of varying levels of supportive work environment may
differ because of the political, personal, institutional,
or geographic setting of cancer care is important.
The purposes of this study were to (a) examine
oncology nurses’ experiences of compassion fatigue,
burnout, and compassion satisfaction and (b) identify
any differences in experiences of compassion fatigue,
burnout, and compassion satisfaction between oncology
nurses in the United States and Canada. The
study addressed the following research questions:
• What demographic, personal, health, and workrelated
characteristics contribute to the risk for compassion
fatigue and burnout among oncology nurses
in the United States compared to those in Canada?
• What is the relationship between compassion
fatigue, burnout, and compassion satisfaction among
oncology nurses in the United States compared to
nurses in Canada, given the differing healthcare systems
and organization of healthcare delivery?
Methods
This descriptive, nonexperimental study adhered to
a quantitative methodology, an approach that suited
the use of surveys to collect data that would inform
the concepts identified for this study (Denzin & Lincoln,
2011). Maslow’s Hierarchy of Needs (Burtson &
Stichler, 2010), which postulates that motivations are
dependent on meeting certain needs in a particular
order, and Watson’s Theory of Human Caring (Sourial,
1996), which emphasizes the relationship between
the transaction of care between patient and nurse,
was appropriate for this study. The ethics research
committee at the California State University, Long
ONCOLOGY NURSING FORUM • VOL. 43, NO. 4, JULY 2016 E163
Beach gave ethics approval. The modified Abendroth
Demographic Questionnaire (Abendroth & Flannery,
2006) and the Professional Quality of Life (ProQOL)
scale, version 5 (Yang & Kim, 2012), were used as
data collection tools. This study was conducted with
practicing oncology nurses employed in Canada and
the United States. All participants were members
of the Canadian Association of Nurses in Oncology
(CANO) and the Oncology Nursing Society (ONS). Included
nurses were RNs (including advanced practice
nurses) with active CANO or ONS membership who
worked in an oncology setting and were currently in
a role of direct patient care.
Instruments
The modified Abendroth Demographic Questionnaire
is a data collection tool developed for the study
of compassion fatigue among hospice nurses. The
form was created using concepts from disciplines
of “nursing, medicine, and the social sciences”
(Abendroth & Flannery, 2006, p. 349). The questions
are designed to gather information related to participants’
demographic characteristics, health, and
work-related roles and environment.
The ProQOL scale is one of the most common instruments
used in the study of compassion fatigue
(Yang & Kim, 2012). The instrument consists of three
subscales used to measure secondary traumatic
stress, burnout, and compassion satisfaction. Compassion
fatigue is a combined measure of secondary
traumatic stress and burnout, and compassion satisfaction
is an independent measure. The ProQOL scale
is a 30-item instrument using a five-point Likert-type
scale from 1 (never) to 5 (very often) that yields composite
scores for the three psychometrically unique
phenomena. The instrument has been tested extensively
with reliability alphas of 0.88 for compassion
satisfaction, 0.75 for burnout, and 0.81 for secondary
traumatic stress, and it is a valid measure of each
individual phenomenon (Stamm, 2009). Cutoff and
average scores were established as indicators of potential
risk of the different concepts, using a quartile
system with about 25% at high risk, 25% at low risk,
and 50% at moderate risk.
Recruitment and Data Collection
Permission for email access to CANO and ONS members
was sought and given for a student thesis by the
research officers from these organizations. From June
to August 2014, convenience samples of CANO and
ONS members were invited to participate in an online
survey study. FluidSurveys™, a web-based survey tool
for data collection, was used to conduct the survey. Canadian
participants were recruited directly by CANO,
with email invitations sent to every member, inviting
them to participate in the research study. Recruitment
in the United States was conducted by leasing an ONS
mailing list of 5,000 randomly selected members for
the purpose of this study. ONS also emailed the participants
directly. Every member on the ONS list met
the inclusion criteria based on previously provided demographic
data. Participants in both cohorts received
an email invitation from their respective professional
organization, notifying them of the study. Members
interested in participating were provided with a link
to the survey and consent form, as well as electronic
versions of the modified Abendroth Demographic
Questionnaire and ProQOL scale. All questions were
mandatory and included a “decline to answer” option
in the event that the respondent did not wish to
provide a response. The study remained active for six
weeks for both cohorts. An email reminder was sent
one week prior to the closing of the study.
Statistical Analysis
Responses were coded and entered into SPSS®,
version 22.0. Data analysis employed inferential and
descriptive analysis. The chi-square test of independence
was used to investigate whether demographic,
personal stressors, health, and work-related characteristics
were associated with the risk for and experience
of compassion fatigue, burnout, and compassion
satisfaction. The study used a p value of 0.05 for significance.
Analysis using chi-square tests for each of the
questions on demographic data (age, gender, ethnicity,
marital status, highest level of nursing education, professional
nursing licensure, number of years in nursing,
and number of years in oncology nursing), personal
stressors (number of children at home, whether they
were caring for an elderly or disabled parent or loved
one at home, experience of a recent personal death,
and if maintaining financial budget was a source of
stress), health questions (headaches, smoking, diagnosis
of hypertension, depression, and post-traumatic
stress disorder [PTSD]), and work-related variables
(workplace setting, nursing role, hours worked per
week, self-sacrificing behaviors, and exposure to patient
death and traumatic death) to the compassion
fatigue subscales (secondary traumatic stress and
burnout) and to compassion satisfaction to determine
if significant relationships existed.
Results
This study yielded a total of 63 responses from
Canadian participants and 486 responses from
American participants for a combined sample of 549
participants. Demographic representations were quite
similar between the cohorts (see Table 1). The majority
of respondents in both cohorts were Caucasian
E164 VOL. 43, NO. 4, JULY 2016 • ONCOLOGY NURSING FORUM
non-Hispanic, female (no male participants from
Canada), aged 51–60 years, and married. Participants
in the United States and Canada were predominately
educated at the bachelor’s degree level, were RNs,
and had a substantial amount of nursing experience.
The only notable difference between the cohorts was
years of oncology nursing experience. The majority
of nurses in the United States had 2–5 years of experience,
compared to 21–25 years of experience in the
Canadian cohort.
Descriptive statistics yielded no statistical differences
between the two countries when mean scores
and standard deviation for secondary traumatic
stress, burnout, and compassion satisfaction were
compared (see Table 2). Both cohorts of oncology
nurses experienced high levels (as indicated by high
risk) for compassion satisfaction and low levels of
burnout and compassion fatigue (as indicated by a
combination of low risks for burnout and secondary
traumatic stress) (see Table 3).
Several significant associations were found between
demographic variables and secondary traumatic
stress (a component of compassion fatigue) and compassion
satisfaction in the American participants
(see Table 4). Younger nurses (categorized as aged
40 years or younger) were more likely to experience
moderate to high levels of secondary traumatic stress
(c2[2, N = 484] = 8.094, p = 0.017) when compared to
older nurses (categorized as aged 41 years or older).
Because younger nurses were not found to have experienced
burnout, this finding indicates that they are at
risk for compassion fatigue but does not point to having
experienced compassion fatigue. This finding was
further supported when more experienced nurses
(experience of 26 years or greater) were found to have
the lowest levels of secondary traumatic stress (c2[2,
N = 485] = 6.117, p = 0.047), which suggests that older
and more experienced nurses are least at risk of compassion
fatigue. The samples did not reveal significant
differences between years of oncology experience to
any of the other subscales. Education was associated
with levels of compassion satisfaction. Higher levels
of education (those holding master’s or doctoral
degrees) were most likely to experience high levels
of compassion satisfaction (c2[2, N = 477] = 6.871, p =
0.032). There were no significant findings between
demographic characteristics of Canadian nurses to
levels of secondary traumatic stress, burnout, and
compassion satisfaction.
Health-related characteristics were examined in relation
to the subscales, and American nurses who had
depression or PTSD and episodes of headache were
more likely to experience moderate to high levels of
secondary traumatic stress (c2[1, N = 485] = 9.969, p =
0.002) and high levels of burnout (c2[1, N = 485] =
TABLE 1. Demographic Characteristics by Country
United States
(N = 486)
Canada
(N = 63)
Characteristic n % n %
Age (years)
21–30 64 13 3 5
31–40 111 23 10 16
41–50 112 23 22 35
51–60 153 31 25 40
61 or older 44 9 3 5
Decline to answer 2 < 1 – –
Gender
Male 27 6 – –
Female 459 94 63 100
Ethnicity
Caucasian (non-Hispanic) 330 68 37 59
Caucasian 86 18 16 25
Hispanic 23 5 – –
Asian 18 4 5 8
African American 9 2 – –
Southeast Asian 7 1 – –
Native American 1 < 1 – –
Other 5 1 3 5
Decline to answer 7 1 2 3
Marital status
Single 85 18 9 14
Married 334 69 44 70
Separated 7 1 1 2
Divorced 46 10 5 8
Widowed 8 2 2 3
Decline to answer 6 1 2 3
Highest level of
nursing education
Diploma program 78 16 9 14
Associate degree 51 10 12 19
Bachelor’s degree 233 48 25 40
Master’s or doctorate 115 24 15 24
Other 6 1 1 2
Decline to answer 3 < 1 1 2
Nursing licensure
RN 432 89 59 94
APRN 44 9 1 2
Other 9 2 3 5
Decline to answer 1 < 1 – –
Years in nursing
profession
1 or less 4 1 2 3
2–5 77 16 3 5
6–10 94 19 6 10
11–15 43 9 13 21
16–20 42 9 8 13
21–25 55 11 3 5
26 or greater 170 35 28 44
Decline to answer 1 < 1 – –
Years in oncology nursing
1 or less 3 < 1 7 11
2–5 122 25 10 16
6–10 118 24 3 5
11–15 68 14 12 19
16–20 48 10 10 16
21–25 61 13 13 21
26 or greater 66 14 8 13
Note. Because of rounding, percentages may not total 100.
ONCOLOGY NURSING FORUM • VOL. 43, NO. 4, JULY 2016 E165
13.659, p = 0.000). The combined
high levels on these two subscales
are an indicator that nurses with
these health conditions are significantly
more likely to experience
compassion fatigue. Likewise,
results from the Canadian nurses
suggest that episodes of headaches
were also linked to high levels of
secondary traumatic stress and
burnout. However, unlike the American
nurses, elevated conditions of
depression and PTSD conditions
were not associated with secondary
traumatic stress or burnout in
the Canadian cohort.
American and Canadian nurses
expressed that stressors related
to personal finances were linked
to high levels of secondary traumatic
stress (Americans: c2[1, N =
479] = 38.198, p = 0.000; Canadians: c2[1, N = 63] =
13.542, p = 0.000) and burnout (Americans: c2[1, N =
479] = 27.334, p = 0.000; Canadians: c2[1, N = 63] =
8.646, p = 0.003). Elevations in both subscales have
indicated high levels of compassion fatigue. No statistically
significant findings were found when other
personal stress factors were compared.
Of note, work-related characteristics were addressed
relating to experiences of secondary traumatic
stress, burnout, and compassion satisfaction, with
a number of significant findings within the American
cohort. Experience of compassion fatigue was significant
if there had been a nurse-encountered traumatic
death (secondary traumatic stress: c2[1, N = 485] =
3.887, p = 0.049; burnout: c2[1, N = 485] = 7.894, p =
0.005) and when nurses felt a need to sacrifice their
own personal and psychological needs to satisfy their
patients’ (secondary traumatic stress: c2[1, N = 484] =
45.276, p = 0.000; burnout: c2[1, N = 484] = 31.541, p =
0.000). However, these negative experiences could
be buffered when nurses felt that their workplace
encompassed a cohesive teamwork environment at
all times. They were not only least likely to experience
compassion fatigue and burnout, but also were able to
derive more compassion satisfaction from it (secondary
traumatic stress: c2[2, N = 486] = 10.546, p = 0.005;
burnout: c2[2, N = 486] = 12.928, p = 0.002; compassion
satisfaction: c2[2, N = 486] = 10.51, p = 0.005). Nurses
who worked more hours and encountered a greater
number of patient deaths (three or greater) experienced
high levels of compassion satisfaction (c2[3, N =
486] = 8.042, p = 0.045).
Although the Canadian cohort did not yield as many
significant findings in comparison to the American
cohort, one common finding between the two groups
was the increased risk for compassion fatigue when
tendencies of sacrificing personal and psychological
needs to care for their patients existed (United
States: secondary traumatic stress: c2[1, N = 484] =
45.276, p = 0.000; burnout: c2[1, N = 484] = 31.541, p =
0.000; Canada: secondary traumatic stress: c2[1, N =
63] = 9.27, p = 0.002; burnout: c2[1, N = 63] = 15.047,
p = 0.000]).
Discussion
Perhaps the most significant finding is nurses’
perceptions of team cohesiveness within the workplace
environment and the relationship with their
experiences of compassion fatigue, burnout, and
compassion satisfaction. Oncology nurses in this
study reported that a healthy work environment
was valuable in decreasing compassion fatigue and
burnout. In both cohorts, nurses who felt that their
workplace functioned cohesively experienced low levels
of compassion fatigue and burnout and high levels
of compassion satisfaction. The culture of teamwork
has been linked to considerable benefits, including
more positive leadership and more effective mentoring
of novice nurses (Nelsey & Brownie, 2012). Team
cohesiveness may help with nursing staff retention.
High turnover is expensive for any healthcare organization.
Turnover costs an average of $20,561 in
the United States and $26,652 in Canada per nurse
(Duffield, Roche, Homer, Buchan, & Dimitrelis, 2014;
McPhee, 2014).
The retention of nurses will not only assist in
closing the nursing shortage gap by increasing job
TABLE 2. Descriptive Statistics of Secondary Traumatic Stress, Burnout,
and Compassion Satisfaction by Country
Subscale —X SD Min Max Interpretation
United States (N = 486)
Compassion satisfaction 42.37 5.27 25 50 High risk
Burnout 22.66 5.74 10 38 Low to medium risk
Secondary traumatic stress 22.65 5.77 10 42 Low to medium risk
Canada (N = 63)
Compassion satisfaction 42.6 4.7 31 50 High risk
Burnout 22.49 4.84 14 35 Low to medium risk
Secondary traumatic stress 22.41 5.6 12 37 Low to medium risk
Note. Secondary traumatic stress and burnout are the two components of compassion
fatigue.
Note. For compassion satisfaction, scores range from 10–50, with higher scores
indicating greater satisfaction derived from job activities. For burnout and secondary
traumatic stress, scores range from 10–50, with higher scores indicating greater risk.
max—maximum; min—minimum
E166 VOL. 43, NO. 4, JULY 2016 • ONCOLOGY NURSING FORUM
satisfaction, but also facilitate building patient relationships
from greater continuity of care and improving
communication among interdisciplinary professionals
(Oncology Nursing Society, 2015). Lack of teamwork
can have detrimental effects, such as increasing patient
mortality as a result of poor communication and
problem-solving skills (Brunetto et al., 2013).
Some of the study respondents presented with
health problems that may be related to workload and
the nature of cancer care that leads to compassion
fatigue and decreased job satisfaction. In the American
and Canadian cohorts, high levels of compassion
fatigue and burnout were found to be associated with
nurses’ tendency to sacrifice personal and psychological
needs to satisfy the needs of their patients. The
nature and profession of nursing is deeply rooted in the
concept of care, with oncology nursing being more pronounced
because of the nature of cancer care (Watson,
2014). Although the human-to-human relationship and
humanistic care of nursing remains socially pervasive,
advances in technology and disease management have
demanded that nurses become more skilled and technically
proficient, placing nurses at risk for compassion
fatigue and burnout (American Nurses Association,
2011). The incongruence between social and institutional
expectations has only increased the pressures
and stress of the nursing profession. Healthcare institutions’
policies and expectations of nurses’ performance
on measures of overtime and workload will affect
fatigue, burnout, stress, and nurses’ overall experience
in the workplace.
The negative consequences of prolonged exposure
to compassion fatigue and burnout have been well documented
(Aycock & Boyle, 2009; Meadors & Lamson,
2008; Perry, 2008; Potter et al., 2010) because nurses’
physical and mental health may directly affect the
quality and safety of patient care (Potter et al., 2010).
American nurses who reported a diagnosis of depression
or PTSD, as well as episodes of headaches, were
found to experience high levels of compassion fatigue
and burnout. Canadian nurses who reported a history
of headaches had similar experiences of compassion
fatigue and burnout. Although this study did not investigate
the source of these reported health conditions,
it does suggest a possible coexisting relationship. A
combined high level of compassion fatigue and burnout
warrants an assessment for depression and PTSD
because this may be secondary to experiences of compassion
fatigue and burnout (Stamm, 2009).
Although Canadian nurses did not report a relationship
of depression or PTSD to experiences of
compassion fatigue and burnout, this may be partly
because of social and cultural differences between
Canada and the United States. Depression and PTSD
are more pronounced in the United States and are
overall more acceptable and recognizable conditions,
but mental health concerns continue to be routinely
stigmatized in Canada and are underreported (Stuart,
Patten, Koller, Modgill, & Liinamaa, 2014). However,
this is not a conclusive inference because Canadian
oncology nurses’ representation was significantly
lower than the representation of their American counterparts.
These findings point to the need for future
research that explores differences in the healthcare
structuring and model-of-care delivery between these
two countries, particularly for cancer centers that
are private and/or public with differing policies for
clinical protocols and healthcare delivery structuring.
The study also revealed that the more experienced
American nurses were at lower risk for compassion
fatigue compared to their less experienced counterparts.
Nurses aged 40 years or younger were found
to be at higher risk for compassion fatigue. This finding
parallels previous studies (Grafton, Gillespie, &
Henderson, 2010; Perry et al., 2011), which suggests
that insufficient transition from student to staff nurse,
maladaptive behaviors, and lack of support and
resources in the workplace environments were contributing
factors to their consideration of leaving the
profession. Experienced nurses tend to have greater
intuitive knowledge and expertise. They are also more
equipped to handle difficult situations (Grafton et al.,
2010; McPhee, 2014). This would help explain the finding
that American nurses experienced higher levels
of compassion satisfaction with an increased number
of patient death encounters. Similarly, nurses who
witnessed more traumatic deaths were also less likely
to experience compassion fatigue and burnout. More
seasoned nurses may be more accepting of death and
dying and have a greater understanding of advanced
disease processes and may be able to derive better
satisfaction from their work by being able to provide
TABLE 3. Two-Way Frequency Table of Level
of Compassion Satisfaction, Burnout,
and Secondary Traumatic Stress by Country
United States
(N = 486)
Canada
(N = 63)
Variable n % n %
Compassion satisfaction
Average 203 42 26 41
High 283 58 37 59
Burnout
Low 251 52 34 54
Average 235 48 29 46
Secondary traumatic stress
Low 255 52 33 52
Average 229 47 30 48
High 2 < 1 – –
ONCOLOGY NURSING FORUM • VOL. 43, NO. 4, JULY 2016 E167
better quality care to patients and families (Grafton et
al., 2010; Meadors & Lamson, 2008; Perry et al., 2011).
Experienced nurses may also be more likely or willing
to work additional hours or overtime given the
positive feedback and experiences, which may also
help explain the finding that nurses who work more
hours (36 hours or more per week) experienced higher
levels of compassion satisfaction.
In addition, more educated nurses in the American
cohort were found to experience high levels of compassion
satisfaction, which differs with previous research.
Potter et al. (2010) found that nurses holding advanced
degrees were more likely to experience burnout, and
bachelor’s degree–prepared nurses were more at risk
for compassion fatigue. More educated nurses may
need to achieve a higher threshold of accomplishment
TABLE 4. Frequency of Risk of CS, Risk of Burnout, and Risk of STS, and Significant Study Variables
for Participants From the United States
Risk of CS Risk of Burnout Risk of STS
Average High Low Average Low
Average
or High
Variable n % n % n % n % n % n %
Age (years) (N = 484)
40 or younger 80 46 95 54 81 46 94 54 77 44 98 56
41–50 42 38 70 63 67 60 45 40 66 59 46 41
51 or older 80 41 117 59 103 52 94 48 111 56 86 44
Years in nursing profession (N = 485)
10 or less 76 43 99 57 86 49 89 51 84 48 91 52
11–25 58 41 82 59 69 49 71 51 68 49 72 51
26 or greater 68 40 102 60 96 57 74 44 102 60 68 40
Highest level of nursing education
(N = 477)
Diploma or associate degree 52 40 77 60 64 50 65 50 61 47 68 53
Bachelor’s degree 109 47 124 53 117 50 116 50 118 51 115 49
Master’s degree or doctorate 37 32 78 68 67 58 48 42 69 60 46 40
Headaches (N = 485)
Yes 72 48 79 52 59 39 92 61 63 42 88 58
No 131 39 203 61 191 57 143 43 191 57 143 43
Financial stress (N = 481)
Yes 120 46 142 54 106 41 156 60 103 39 159 61
No 81 37 138 63 141 64 78 36 148 68 71 32
Caring for traumatic death (N = 485)
Yes 152 42 212 58 175 48 189 52 182 50 182 50
No 50 41 71 59 76 63 45 37 73 60 48 40
Sacrifice needs (N = 484)
Yes 142 43 185 57 140 43 187 57 137 42 190 58
No 59 38 98 62 110 70 47 30 117 75 40 26
Staff functioning cohesively
as a team (N = 486)
All the time 18 25 53 75 44 62 27 38 49 69 22 31
Most of the time 135 43 179 57 170 54 144 46 161 51 153 49
Some of the time, rarely, or never 50 50 51 51 37 37 64 63 45 45 56 55
Number of patient deaths in the
past 30 days (N = 486)
None 35 51 34 49 38 55 31 45 41 60 28 41
1–2 67 48 73 52 65 46 75 54 74 53 66 47
3–4 57 38 92 62 82 55 67 45 79 53 70 47
5 or greater 44 34 84 66 66 52 62 48 61 48 67 52
CS—
compassion satisfaction; STS—secondary traumatic stress
Note. Bolded values indicate statistical significance at p < 0.05.
E168 VOL. 43, NO. 4, JULY 2016 • ONCOLOGY NURSING FORUM
in the workplace to feel job satisfaction. They may also
experience incongruence between personal expectations
and the realistic nature of oncology nursing.
One reason for this discrepancy may be because of
the inclusion of advanced practice nurses (n = 44, 9%)
in this study. The work settings for advanced practice
nurses are typically in the outpatient setting providing
treatments to patients with less acute conditions.
Limitations
Several limitations existed in this study. The small
number of responses from the Canadian cohort is not
adequate to fully capture the experiences of Canadian
nurses and may not be generalizable for all Canadian
locations. Male nurses’ experiences are an important
factor to consider in the recommendations and development
of interventions, and a lack of male participants
existed. According to Jaslow (2013), a growing
number of male nurses and their experiences exist,
and risks for compassion fatigue and burnout may
differ in characteristics and presentation compared
to their female counterparts. A wide age range in the
current study provides lack of age gaps for more accurate
response options. Because age was found to
be significant to the nursing experience, smaller age
brackets with more options may be more appropriate
to identify a more specific age range in relation
to individual subscales. It may be best to separate
advanced practice nurses from staff nurses to see if
the distribution of education makes a difference in
experiences among those with higher education and
in leadership positions.
Implications for Nursing
and Conclusion
A healthy and supportive workplace environment
is imperative to nurses’ health, well-being, and satisfaction
in the workplace (Fetter, 2013). The findings
in this research study may be used to implement
institutional changes, such as creating policies and
guidelines toward the development of preventive
interventions or psychosocial support for nurses
who are constantly faced with situations that demand
compassion and care for patients with life-threatening
conditions. Improvements in the workplace environment
may help prevent many negative sequelae,
such as poor health outcomes for patients and
nurses, as well as decrease nurse turnover and reduce
healthcare expenditures.
The findings demonstrated a decrease in compassion
fatigue and burnout and maintenance of compassion
satisfaction when the oncology unit is a well-managed
environment. Supportive work environments emerge
from responsible workforce designs that lead to
teamwork and effective engaged leadership styles
(Potter et al., 2010). Experiences that oncology nurses
have in common with other nurses, what is specific
to them, and leadership styles that foster interdisciplinary
teamwork are important to explore in future
studies. Hospitals are also increasingly forced to
limit inpatient days that decrease the oncology nurse
and patient encounter time, which does not help to
enhance patient care and safety (Potter et al., 2010).
This study demonstrated that oncology nurse and
patient time is a strong predictor of compassion satisfaction.
Future research could inform hospital oncology
units novel ways to extend the quality of nurse–patient
relationships to compensate for less encounter time. In
practice, this study demonstrates that oncology nurses
who have the qualifications and the dedication to care
for patients with cancer through the cancer trajectory
need some tools to care for themselves as well. Future
research needs to explore how supportive and positive
work environments correlate to decreased compassion
fatigue and burnout, as well as enhanced compassion
satisfaction for oncology nurses.
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