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Nurses are challenged with maintaining the balance between everyday stressors and work stressors. Palliative care nursing is a demanding nursing subspecialty, requiring time and continual contact with patients and caregivers who are suffering. The prolonged contact with these individuals during times that they are at end stages of serious illnesses predisposes palliative care nurses to physical, emotional, spiritual, and psychological distress, possibly limiting their ability to provide compassionate care [1]. Compassion fatigue has been used to describe the distress that results from work-related stressors and has been defined as a state of exhaustion and dysfunctionV biologically, physically, and socially as a result of prolonged exposure to compassion stress and all that it evokes [2]. Compassion fatigue in nurses can impact job satisfaction and patient outcomes and can lead to nurses leaving a profession already plagued by staffing shortages [3-5]. Of significance, compassion fatigue has been seen in diverse nursing settings and has been associated with stemming from caring, a foundational component to nursing. Identification of symptoms is important for reducing occurrences of compassion fatigue, improving patient care, and retaining nurses [3]. Palliative care nurses are predisposed to distress, because they are surrounded by seriously ill or dying patients on a regular basis [1]. The focus of this concept analysis is to define compassion fatigue for palliative care nursing to assist in recognition of occurrences and future implications for this discipline.

Compassion fatigue emerged as a concept in health care by Joinson [6] in 1992, when it was introduced as a synonym for burnout. Figley [7] a psychologist, originally introduced the new concept of secondary catastrophic stress reactions as synonymous with the phenomena of secondary traumatic stress disorder (STSD) and later clarified STSD as compassion fatigue in 1995 [2]. After years when compassion fatigue, STSD, and burnout became interchangeable terms, Coetzee and Klopper [8] defined compassion fatigue in terms of nursing practice in 2010. Compassion fatigue is complex, because its consequences affect nurses, organizations, and patients. The multiple levels of stress that are experienced place nurses who have symptoms in a state of vulnerability. These nurses may find the duties of their jobs in direct competition with their distress and find difficulties in providing compassionate care. This places patients at risk for circumstances that include low staffing, errors, abuse, and neglect, as well as poor caring relationships. Health care organizations face the challenges of retaining nurses and maintaining safety outcomes by preventing, identifying, and relieving the symptoms of compassion fatigue. Palliative nurses care for sick and suffering patients on a continuum. Palliative care is a type of care that encompasses the patients and the caregivers through a holistic approach to manage the symptoms of serious illnesses, while addressing pain, symptoms, psychosocial issues, spirituality, and quality of life. The World Health Organization identifies palliative care as an approach that improves quality of life of patients and their families facing the problem associated with life-threatening illness. Because the focus of care is comprehensive, palliative nurses bear witness to patient and caregiver suffering on multiple levels that include physical, psychological, social, emotional, and spiritual. Hospice and palliative nursing are frequently used as interchangeable terms, programs, or types of nursing care. However, hospice care is a type of palliative care where the care delivery is intensified, because the disease is identified as terminal or end-stage, with a prognosis of 6 months or less. The movement for end-of-life care and bereavement services began with Dame Cicely Saunders, a registered nurse from the United Kingdom. She saw the need for extended support during the dying process and opened the first hospice in England in 1967. As recognition for services spread, the hospice philosophy eventually came to the United States, with hospice also becoming a Medicare benefit during the 1980s. In the United States, the terminology may be confusing, because the hospice Medicare benefit provides coverage that includes nursing care, medications, equipment, and psychosocial support for patients who are determined eligible by physicians. Hospice and palliative care nurses are focused on delivering quality health care to their patients and caregivers as they approach the end of life, and it is imperative that they maintain quality and health in their own lives. Palliative care nurses may experience three stressors unique to this discipline [9]. The first stressor arises from personal factors from the palliative nurse and includes the nurse’s discomfort with the patient’s illness or treatment plan, inadequate preparation or training to manage the illness, or external distractions from outside life. The second stressor is derived from the patient or caregiver and includes patient health decline or noncompliance with the treatment plan. The third stressor is related to the work environment and includes practice issues such as poor staffing and resources. These stressors are distinct to the palliative care discipline and are associated with the struggles in finding a balance between intimacy and empathy in the working relationship. The identification of predisposing stressors has become critical to providing future support for palliative care nurses. As palliative care nurses experience an intense relationship with their patients and their caregivers, there is a greater risk for compassion fatigue, placing emphasis on the need to define compassion fatigue for the discipline of palliative care nursing.

Compassion fatigue was a newer term; however, it appeared in nursing and medical dictionaries as well as in the online dictionaries reviewed. Compassion fatigue, palliative care, and hospice were used as search terms or keywords and then were narrowed down to subjectspecific terms to eliminate non relevant data. A second search was conducted with the search terms concept analysis and compassion fatigue in the same manner. Abstracts, reviews, and commentaries were excluded from this search. Studies that involved compassion fatigue outside nursing or helping professions were excluded. Duplicate results were eliminated. Seventy-one articles within the identified time frame were found. Six concept analyses related to compassion fatigue were found. There were two analyses for other nursing subspecialties other than palliative care; however, the search did not yield one for palliative care nursing. Twenty-eight studies were identified, with four specifically related to palliative care or hospice nurses and compassion fatigue. The other disciplines that were studied were oncology nurses, student nurses, intensive care nurses, critical care nurses, general nurses, pediatric nurses, military nurses, mental health nurses, social workers, and genetic counselors. Two dissertations in palliative care nursing were found. Three recent literature reviews within the search years were found, reviewing compassion fatigue across all nursing care. Articles that were used outside the search parameters were those by the original developers, as several other articles referenced preliminary work in the area of compassion fatigue concept development. Two books were found to be relevant to the time frame and to the search terms.

Use of the concept: The terms for the concept were identified in and out of the nursing literature to explore other uses of concept language. Palliative is identified as relieving care without curing or an individual who relieves an uncomfortable condition. The word hospice has origins in Latin that means guests or hosts, and its current use is as a care model or a location for care. Tabers cyclopedic medical dictionary defined it slightly differently than other sources; here, it was described as a program derived from palliative and supportive services, interdisciplinary in nature that focused on the physical, spiritual, social, and economic needs of terminally ill patients and their caregivers. Compassion is defined as having pity or the urgent desire to help or aid someone. It is also identified as a synonym for sympathy. Fatigue is defined in different contexts that include manual work; an exhaustion from labor, stress, or exertion; or a loss of power induced by a sensory receptor. It can also be defined in military terms as a unit or a uniform worn. The medical definition of fatigue placed it in the context of a diminished capacity for work in the mental and physical domains and also identified acute, alert, chronic, muscle, and volitional fatigue in addition to compassion fatigue. Compassion fatigue is medically defined as cynicism, emotional exhaustion, or self-centeredness occurring in a health care professional previously dedicated to his or her work and clients. Compassion fatigue is described as a form of exhaustion resulting from prolonged exposure to caring for sick or traumatized patients. Compassion fatigue is also defined as fatigue, emotional distress, or apathy resulting from the constant demands of caring for others or from constant appeals from charities. This definition of disinterest is fairly consistent with a 1983 public policy application by The New York Times that described the United States’ detachment in helping refugees after the Soviet occupation of Afghanistan.

Conclusion

Nurses who are satisfied and engaged are likely to provide better care for themselves and their patients. Ongoing assessment of staff and development of programs that encourage appropriate engagement activities are some ways to support palliative care nurses. Offering specialized education, self-care resources, and individualized staff bereavement programs may decrease professional stressors. Compassion fatigue is a concept that is inversely related to compassion satisfaction. Currently, there is a gap in the literature regarding the theoretical connection that future research might explore and bridge in the discipline of palliative nursing. Developing a better understanding of the relationship between these two concepts could provide more insight for palliative nursing care.

Conflict of Interest:

Author declares no conflict of interest.

Acknowledgement:

Not applicable.

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