Concept Analysis Compassion Fatigue and Effects

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Concept Analysis Compassion Fatigue and Effects

Concept Analysis Compassion Fatigue and Effects

Walker and Avant’s method of concept analysis was used to delve into the initial understanding of compassion fatigue, a relatively new concept being explored with critical care nurses and other health care professionals. The term was originally used in 1992 involving research exploring burnout experienced by critical care nurses when a trend emerged where nurses appeared to have lost their “ability to nurture.” The term has since been used synonymously with secondary traumatic stress disorder. Two important goals exist for this article: First, theoretically to conduct a concept analysis of compassion fatigue, thereby providing information for critical care nurses to understand the concept as a universal human experience. Second, from a caring perspective, identifying the effects related to critical care nurses provides an opportunity to address physical and somatic consequences of compassion fatigue that will ultimately become important to nursing practice, education, and research. Key words: burnout, compassion fatigue, secondary traumatic stress

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T HE PROCESS that will be followed withinthis article is the model developed and implemented by Walker and Avant.1 Eight stages are outlined within the model, and a brief explanation is provided of each. The first stage of the model is to select a concept. Con- cept selection is very important and should be one of interest to the authors or related to the actual work of the authors. This concept should be manageable yet not too broad. Sec- ond, the authors should determine the aims or purposes of the analysis. This section should answer the question why is this concept im- portant to the authors. Third, identification of the uses of the concept that you can discover

Author Affiliations: Belmont University, Nashville, Tennessee (Ms Jenkins); and Department of Nursing, University of Tennessee, Martin (Dr Warren).

The authors have disclosed that they have no signif- icant relationships with, or financial interest in, any commercial companies pertaining to this article.

Correspondence: Nancy A. Warren, PhD, RN, De- partment of Nursing, University of Tennessee, 136 H Gooch Hall, Martin, TN 38238 (nwarren@utm.edu or belinda.jenkins@pop.belmont.edu).

DOI: 10.1097/CNQ.0b013e318268fe09

in the literature supports the definition of the concept. During this stage, through available literature, dictionaries, thesauruses, and col- leagues, the authors will identify possible uses of the concept. The review of literature will provide the evidence-based foundation for the analysis. During the fourth stage, the defin- ing attributes will be determined. Through the literature reviews regarding the concept, all the similar characteristics emerge. Fifth, a model case is identified. The model case pro- vides the reader an example of the defining at- tributes of the concept; this can be provided in a borderline, related, contrary, invented, or illegitimate case. These are provided in the sixth stage. The seventh stage includes identification of the antecedents and conse- quences. Antecedents are defined by Walker and Avant as those events or incidents that must occur or take place prior to the occur- rence of the concept, and consequences are defined as those events or incidents that occur as a result of the occurrence of the concept. The last stage defines the empirical referents, which are defined as classes or categories of actual phenomena that by their existence or presence demonstrate the occurrence of the concept itself. The goal of this article was Concept Analysis Compassion Fatigue and Effects

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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mailto:nwarren@utm.edu
mailto:belinda.jenkins@pop.belmont.edu
Compassion Fatigue 389

2-fold: Theoretically, to conduct a concept analysis of compassion fatigue, thereby pro- viding an understanding of the concept as a universal human experience and, from a car- ing perspective, identifying the effects related to critical care nurses by addressing physical and somatic consequences of compassion fa- tigue that will ultimately become important to nursing practice, education, and research. Perhaps, an ongoing dialogue regarding com- passion fatigue and the effects upon nurses in the critical care unit may facilitate actions to identify and prevent compassion fatigue. Concept Analysis Compassion Fatigue and Effects

PERSONAL AIMS OF CONCEPT ANALYSIS

Reflecting upon the experiences of the au- thors personally gained throughout our nurs- ing career, we believe that we have felt the effects of compassion fatigue and witnessed nursing coworkers showing the effects as well. Past nursing experiences have included time in high-stress environments, where mo- ments in time were crucial, and decisions made immediately affected the outcome of the patient—life or death. Past intensive care unit experiences where seeing uncooperative patients, interstaff conflicts, dying patients, and those patients affected by massive trauma on a daily basis lead to those effects. Over time, fatigue takes a toll upon critical care nurses. The outcomes have involved sleepless nights and still visualizing the faces of the in- jured or dead when trying to sleep, particu- larly if the deceased were young and in the prime of life, or worse yet, a young child. But as one sees those faces of the injured, not in a haunting sense, one reviews one’s perfor- mance and wonders what more could have been done. What could have been done dif- ferently, and would different actions have led to a difference in the outcome of the patient becomes a consuming question. We have also felt emotionally and physically drained after a 12-hour work shift and still tired before arriv- ing at work the next night after resting all day. While feeling and living these emotions, a con- cept to identify with the emotions was nonex- istent. As health care professionals, while tak-

ing care of others, critical care nurses and health care staff tend to lose sight of taking care of themselves. In exploring compassion fatigue and the potential affect upon critical care nurses, perhaps an enhanced awareness and understanding of compassion fatigue can be gained or at least ignite the conversations of others who have had similar experiences.

LITERATURE REVIEW

Taber’s dictionary defines compassion fa- tigue as “cynicism, emotional exhaustion or self-centeredness occurring in a health care professional previously dedicated to his or her work and clients2(p499); compassion as deep awareness of the pain and suffering of oth- ers: empathy; and fatigue as an overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at the usual level, and as the condition of an organ or tissue in which its response to stimulation is reduced or lost as a result of overactivity. This definition can cross the lines for many disci- plines and be used to describe compassion.

A phrase that does loosely describe compas- sion fatigue is feeling the pain of the world, with German philosophers addressing this state as “weltschmertz.”3 While compassion fatigue has risen in nursing research only re- cently, nurses have felt the concept world- wide. Some researchers noted that persons who work with the suffering end up suffer- ing themselves, particularly when working with the suffering over time.4,5 While com- passion fatigue is noted more in the litera- ture relating to health care workers, it crosses over into other disciplines. The concept has been addressed in social workers, paramedics, law enforcement personnel, and lawyers. A lack of empirical studies was noted; however, the “clinical” law literature has raised aware- ness of the responses of attorneys working with difficult or traumatized clients who be- gan to feel countertransference and identifica- tion with the victims who were being repre- sented. Increased awareness of this concept has prompted the need for additional train- ing in law schools to assist professionals to Concept Analysis Compassion Fatigue and Effects

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

390 CRITICAL CARE NURSING QUARTERLY/OCTOBER–DECEMBER 2012

prepare for the intense, face-to-face, and highly personal relationships that evolve from the attorney-client relationships. Police offi- cers also reported a greater number of psycho- logical distress and posttraumatic stress symp- toms than mental health care professionals.3-6

Law enforcement officers face stress in vari- ous ways, from working shift work to the na- ture of the job itself as in continuous exposure to violence and suffering. Figley4 propounded that emergency responders and crisis work- ers were at great risk for compassion fatigue. Emergency workers and critical care nurses absorbed the traumatic stress of the victims who were being assisted, particularly if the outcome of the nursing interventions still re- sulted in death. Furthermore, the nurse’s pri- mary focus is on preserving the life of the patient at all costs, so addressing the ensu- ing reactions to death and the reaction of the family members may be distressing and at op- posite ends of the spectrum of preservation of life at all costs. Critical care nurses may suffer their own grief at losing a patient after giv- ing all of their self to the preservation of life, yet family members may require communica- tions regarding critical interventions provided by nurses and supporting health care work- ers. While family members are stressed by the critical care environment and fear related to the many tubes and monitors, the critical care nurses may be stressed and fatigued by family members’ presence and ensuing questions re- garding what happened. Because the nurses are so involved with the physical care of the patient, they frequently have inadequate time to response to family members’ emotional needs, thus adding more stress to a complex situation. Family members may have unrealis- tic goals and expectations of the critical care nurses and assign blame tacitly or overtly to the nurses for the loss of their loved one while in the trust of the nurses.

Compassion fatigue has been described as a natural consequence of caring between 2 people, one who has been traumatized (the critical care patient) and the other who is affected by the first’s traumatic experience (the critical care nurse). It can have a sud- Concept Analysis Compassion Fatigue and Effects

den onset compared with burnout, which is a gradual progression caused by repeated ex- posure to chronic stressors. Caregivers tend to focus most of the attention to the per- son who is directly involved in the incident and fail to pay attention to their own needs. Compassion fatigue may change the personal and professional lives of the most caring of health care workers, social workers, and per- sonal support workers alike. These changes were noted as difficulty concentrating, intru- sive imagery, loss of hope, exhaustion, and irritability, which many critical nurses seem to have experienced.7,8

In review of the literature, defining charac- teristics emerge repeatedly that describe com- passion fatigue. Dr Charles Figley, PhD, has studied the effects of compassion fatigue. In his studies, Dr Figley found many common characteristics that occur prior to compas- sion fatigue. In 2001, Figley developed an al- gorithm for compassion fatigue, which flows from left to right when printed. The algorithm is called the compassion fatigue process, with the left side of the chart presenting the care- giver exposed to suffering, empathic ability, and concern for the patients. These 3 charac- teristics lead the nurse to respond; however, the critical care nurse may feel detachment or, conversely, feel a sense of satisfaction with the care provided. Over time, this leads to a residual compassion stress. If this continues, then the repeated exposure can possibly lead to the caregiver feeling compassion fatigue from prolonged exposure to suffering and de- mands of caring for another person.

Whatever discipline, whether a critical care nurse, physician, social worker, emer- gency responder, law enforcement officer, or lawyer, the defining antecedent that is most evident is the continuous and repeated expo- sure to stressors. This repeated exposure can lead to emotional exhaustion. Working long hours, with gradual results and exposure to sensitive information can have an emotional toll on the caregiver.8,9 When caregivers ex- perience compassion fatigue, the end result can also be a loss of empathy and a deper- sonalization. Depersonalization refers to the

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Compassion Fatigue 391

process where the client is viewed as less than human. In a national study of persons experiencing compassion fatigue, one-third reported having experienced high levels of depersonalization. Whenever a person is ex- periencing depersonalization, a dramatically increased risk of incorrectly interpreting in- formation that is disclosed to the caregiver becomes apparent. Often when compassion fatigue is experienced, a change in ethical and clinical values appears. For critical care nurses, evidence of compassion fatigue can be lack of appropriate documentation in the chart, or noting that the patients’ best inter- ests are not readily apparent in the nursing care. Negative feelings toward the patient can lead to substandardization of care.

Compassion fatigue is a progressive and fi- nal end result that evolves over time. Empir- ical referents that are present after the nurse has prolonged, and continuous and intense, contact with patients will experience symp- toms both of mental and physical traits. The mental symptoms include feelings of burnout, absence of energy, accident proneness, and emotional breakdown feelings.9,10 Emotion- ally, the person with compassion fatigue will be irritable, emotionally overwhelmed, with desensitization and lack of enthusiasm for pa- tient care. The physical symptoms can in- clude weight loss/gain, loss of strength, re- duce output, diminished performance, loss of endurance, and an increasing in physical com- plaints such as stomach pains and headaches. Spiritually, the person with compassion fa- tigue will experience a lack of spiritual aware- ness or lethargy. Concept Analysis Compassion Fatigue and Effects

RELATED CONCEPTS

In the literature review, related concepts were often noted and should be presented within this article. Along with compassion fa- tigue, a term that is often used interchange- ably is secondary traumatic stress, which is secondary traumatic stress as the result of knowledge about a traumatizing event expe- rienced by another and the subsequent stress resulting from helping or wanting to help

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