Reflecting on the Concept of Compassion Fatigue

Brenda Sabo, PhD, RN


Online J Issues Nurs. 2011;16(1) 

In This Article

Compassion Fatigue (Secondary Traumatic Stress)

The past twenty years have seen a rise in research linking exposure to pain, suffering, and trauma with the health of professionals providing care (Abendroth & Flannery, 2006; Adams, Boscarino, & Figley, 2006; Figley, 1999; Joinson, 1992; McCann & Pearlman, 1990; Pearlman, 1998; Pearlman & Saakvitne, 1995a; Sabo, 2010; Sabo, 2006). An offshoot of burnout, the term compassion fatigue first reflected the adverse psychosocial consequences experienced by emergency room nurses in a study exploring burnout (Joinson, 1992). Compassion fatigue has been described as the "natural consequent behaviours and emotions resulting from knowing about a traumatizing event experienced by a significant other – the stress resulting from helping, or wanting to help, a traumatized or suffering person" (Figley, 1995, p.7). Researchers have suggested that the phenomenon is connected to the therapeutic relationship between the healthcare provider and patient, in that the traumatic or suffering experience of the patient triggers a response, on multiple levels, in the provider. In particular, an individual's capacity for empathy and ability to engage, or enter into, a therapeutic relationship is considered to be central to compassion fatigue. Theorists have argued that individuals who display high levels of empathy and empathic response to a patient's pain, suffering, or traumatic experience are more vulnerable to experiencing compassion fatigue (Adams, et al., 2006; Figley, 2002b).

The dominant theoretical model postulating the emergence of compassion fatigue draws on a stress-process framework (Adams, et al., 2006; Figley, 2002a). Key elements within this model include empathic ability, empathic response, and residual compassion stress. The model is based on the assumption that empathy and emotional energy are the critical elements necessary for the formation of a therapeutic relationship and a therapeutic response. Although empathic ability has been defined as "the aptitude of the psychotherapist to notice the pain of others" (Figley, 2002a, p.1436), descriptions of these factors and of how each factor potentially interacts with another has been limited. The model is depicted as a series of cascading events beginning with exposure to a patient's pain, suffering, and/or traumatic event. Empathic concern and empathic ability on the part of care providers, such as nurses, produce an empathic response which may result in compassion stress (residue of emotional energy). The risk increases if the nurse experiences (a) ongoing exposure to suffering, (b) memories that elicit an emotional response, or (c) unexpected disruptions in her/his life. Limitations of this model include an emphasis on a linear direction, along with the binary dimension of compassion fatigue, i.e., you either have it or you don't. This binary dimension seems antithetical to human behavioral responses where individuals may express varying degrees of response. For example, an individual may not have compassion fatigue, yet may be slightly, moderately, or severely affected by a given interaction with a patient.

Figley (2002) also failed to clearly articulate the interaction(s) among the various influencing factors. The premise appears to be that if nurses care for patients who are suffering and/or traumatized, then they will inevitably experience compassion fatigue because of the use of empathy in their therapeutic or healing relationships. But not all authors view empathy in the same way. Some view empathy as the ability of an individual to enter into the world of others; to perceive other's feelings/emotions and meaning associated with an experience (Walker & Alligood, 2001); and to correctly convey that understanding back to the individual, who in turn acknowledges and understands the other's perceived understanding (La Monica, 1981). La Monica (1981) identified the nurse's ability to pick up on an individual's feelings/emotions as 'helper perception,' 'helper communication,' and 'client perception' (2001). Empathy has also been conceptualized as (a) a human trait, innate rather than taught; (b) a professional state (learned communication skill comprised of behavioral and cognitive elements); (c) caring (an understanding and need to act because of that understanding); and (d) a special relationship (reciprocity) (Kunyk & Olson, 2000). Figley's (2002) model fails to clearly articulate the conceptualization of empathy on which his model is based, making it difficult to determine if one conceptualization may be antithetical to, or have more relevance than another in an understanding of compassion fatigue.

Another limitation of Figley's (2002) model lies in its failure to address the ability 'to get off the run-away train' or to halt compassion fatigue's progress. It also fails to adequately account for the benefits that nurses may derive from their relationships with patients or for how the therapeutic relationship may potentially serve to protect the nurse from experiencing compassion fatigue (Sabo, 2009, 2010). If the relationship is an empathic one, then it seems contradictory to suggest that empathy would lead to adverse effects. Rather, the contrary seems a more likely outcome; that is, when empathy is present the relationship would be more fulfilling.

Given the lack of consideration regarding the benefits derived from the relationship, other factors may need to be explored beyond empathy. These factors may include resilience and hope, which may thwart the development of compassion fatigue allowing the nurse to experience positive effects from caring work. For example, hope may influence actions that individuals take, as well as foster and support relationships (Simpson, 2004). Building on this idea, a shared meaning of hope between nurse and patient may not only enhance the quality of the relationship but also satisfaction with the caring work. Resilience, defined as the capacity to move forward in a positive way from negative, traumatic, or stressful experiences (Walsh, 2006), has been shown to enhance relationships, facilitate emotional insight, and decrease vulnerability to adverse effects from the work environment (Jackson, Firtko, & Edenborough, 2007). Research into the role of personal characteristics, such as resilience and hope, as well as the nature of the relationship among families, patients, and nurses, and also the fit within Figley's (2002) model of compassion fatigue, may help to add clarity and depth to a one-dimensional model.

In contrast to Figley's (2002) explanatory model of compassion fatigue, Valent (2002) has hypothesized that compassion fatigue may emerge as the result of unsuccessful or maladaptive survival strategies. In particular, he attributed the development of compassion fatigue to the "unsuccessful, maladaptive psychological and social stress responses of Rescue-Caretaking. [The responses] are a sense of burden, depletion and self-concern; and resentment, neglect and rejection, respectively" (Valent, 2002, p.26) rather than as resulting from empathy. The description by Valent is somewhat reminiscent of an early label, 'savior syndrome,' used to describe the effect of the needs of nurses in providing care and also their affect responses (NiCathy, Merriam, & Coffman, 1984). Rather than nurses depicted as exemplary and selfless caregivers, they may be perceived as self-absorbed, using the therapeutic relationship for their own needs, instead of facilitating patients' ability to fulfill their own needs. Taking this perspective into consideration, it would appear that a different concept may be at work in influencing compassion fatigue, a concept separate from empathy.

In one study that focused on the prevalence and risk for compassion fatigue among 216 hospice nurses, Abendroth and Flannery (2006) found that survey respondents in the moderate to high risk category for compassion fatigue (N=170) had 'self-sacrificing behaviors' as the major contributing factor for risk. Approximately 34% (N=47) of the 170 nurses who exhibited this behavior were in the high risk category for compassion fatigue. This group of nurses cared more for their patients than for themselves; their experiences increased life demands, post traumatic stress, and a lack of emotional support within the work environment. While the findings supported the notion that hospice care nursing was stressful, what remained unclear was the nature of the relationship among nurses, patients, and families and the role of relationships in either increasing or decreasing the risk for compassion fatigue. Additionally, individual characteristics (such as resilience) and organizational factors (such as management support, workload, values, and beliefs) were not considered. Research is needed to fully explore the role of self-sacrificing behavior as a contributing factor for increased risk of compassion fatigue, as well as the role of individual characteristics and organizational factors. To date, there have been few, if any studies exploring self-sacrificing behavior and the possible effects it may have on the psychosocial health of nurses. Further, there is a need to understand what effect self-sacrificing behavior may have on the ability of nurses' skills, such as empathy and health-promoting personality traits, to self select high demand areas, such as oncology, critical care, or mental health.

Exposure to traumatic stressors does not guarantee that an individual will manifest symptoms of compassion fatigue (Valent, 2002). Nor does targeting the negative aspects and/or symptoms provide answers to what, why, and how it is that some healthcare providers achieve satisfaction/rewards from the very same work that contributes to compassion fatigue in others (Abendroth & Flannery, 2006; Sabo, 2010). In light of this fact, more energy should be focused on exploring both the nature and roles of the relationship (nurse-patient-family) and empathy versus other related concepts, including the savior syndrome and engagement, in the psychosocial health and well being of nurses, and whether the risk changes for nurses working in different specialties.

To date, much of the research has been quantitative in nature. A variety of instruments exist to assess for the presence of secondary traumatic stress, including the Professional Quality of Life Scale-R-IV (Stamm, 2009), the Secondary Trauma Scale (Motta, Kefer, Hertz, & Hafeez, 1999), and the Secondary Traumatic Stress Scale (Bride, Robinson, Yegidis, & Figley, 2004).

While the use of instruments is helpful to highlight the incidence and prevalence of various types of occupational stress and to develop models highlighting influencing factors, it is also limiting. For example, nurses may respond to questions on one of several instruments used to indicate the presence or absence of occupational stress, yet the responses do little to explain how nurses perceive the nature of their work and what factors affect compassion fatigue or other types of occupational stress. The use of qualitative study designs may enhance an understanding of whether empathy and engagement have a role in the development of occupational stress or, perhaps more importantly, whether they serve as protective mechanisms against occupational stress by affording nurses the opportunity to share their stories and experiences in a way that goes beyond the objective and quantifiable (Sabo, 2010).


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