Historical Review in Understanding Burnout, Professional Compassion Fatigue, and Secondary Traumatic Stress Disorder From a Hospice and Palliative Nursing Perspective

Christina S. Melvin, MS, PHCNS, BC, CHPN


Journal of Hospice and Palliative Nursing. 2015;17(1):66-72. 

In This Article

Literature Review

This literature review encompasses both historical and current definitions of the terms burnout, PCF, and STSD. The differences and similarities are evident; however, symptoms overlap within the PCF and STSD phenomena. Stamm[3,4] described similar symptoms that appear in burnout, PCF, and STSD in the definition of Professional Quality of Life, which encompasses both Compassion Satisfaction and Compassion Fatigue. Professional quality of life is defined as "the quality one feels in relation to their work as a helper."[3,4] The descriptive terms PCF and STSD represent intersecting lines of evidence.[3,4] The concept of professional quality of life examines job satisfaction at both ends of the spectrum and may become a more comprehensive descriptor of these unique terms.


Freudenberger[5] originally brought the term burnout to professional and public awareness in 1973. He began to recognize significant negative changes in mood, attitude, motivation, and personality among volunteers working in a free clinic. Figley[6] described burnout as the physical, emotional, and mental exhaustion caused by long-term involvement with emotionally demanding situations.

Slatten et al[7] defined burnout as "an organizational hazard for employees and managers working in difficult organizational environments." A disconnect arises when the employee is unable to meet role expectations that the employer cannot support due to organizational structure.

In subsequent research, Maslach and Leiter[8] described burnout as for individual's relationship with his/her job; the definition has been further conceptualized as a continuum between the negative experience of burnout and the positive one of engagement. There are 3 interrelated dimensions to this continuum, including exhaustion-energy, cynicism-involvement, and inefficacy-efficacy. Exhaustion is not just something that is experienced, but rather it prompts actions whereby the employees distance themselves emotionally and cognitively from their work, presumably as a coping mechanism. Cynicism (or depersonalization) is an attempt to put distance between oneself and various aspects of the job.[8] Within the work environment, burnout is at 1 end of a continuum as people establish work relationships, whereas at the other end of the continuum, people experience energy, are involved with their work, and experience feelings of effectiveness.[8] The 2 primary drivers of burnout include excessive workload and conflicts of personal values with organizational values.[9] Thus, burnout is caused by unmet role expectations within an organization and is more related to organizational expectations. Symptoms of burnout develop as a result of demanding situations in the work place in contrast to symptoms related to the exposure to trauma and/or suffering of others (PCF/STSD).

Case Study. (The following case study was developed by the author as an exemplar). This nurse is suffering from burnout as she deals with the ongoing demands from her workplace, caring for 2 young severely burned patients and caring for her own young children.

I have worked on this burn unit for 3 years. After a long shift with 2 severely burned 30-year-old patients, I was asked to work a double shift. I am totally exhausted and have to go home to my children. I feel guilty when I refuse. I need to leave this unit and find another job as I cannot cope with these repeated demands and being short staffed. Patient safety is a risk.

Professional Compassion Fatigue

The term compassion fatigue first began to appear in the literature in the early 1990s. As often done in the literature, the terms compassion fatigue and PCF will be used interchangeably in this article. Professional compassion fatigue was used to describe nurses who were worn out by daily hospital emergencies and is insidious in nature with long-term consequences that are often difficult to reverse.[6] Professional compassion fatigue is a result of repeated exposure to the suffering and trauma of others, whereas burnout tends to be related to the work environment itself.[8,10,11] LaRowe[12] describes compassion fatigue as "a heavy heart, a debilitating weariness brought on by repetitive, empathic responses to pain and suffering of others,"whereby nurses may absorb and internalize the emotions of patients and, at times, coworkers. Repeated exposure will likely contribute to nurses experiencing negative long-term health effects.

Figley,[13] in his seminal work, described compassion fatigue as a formal caregiver's reduced capacity or interest in being empathetic or bearing witness to the suffering of patients and is the emotional state that results from knowing about the traumatizing events that another human being experienced. Figley[6] reasoned that nurses are at particular risk for PCF because compassion and empathy are core values of nurses. Using these values in their everyday practice predisposes nurses to being "wounded by their work" as they routinely deal with the suffering, trauma, serious illness, and/or death of their patients.[14] A nurse's history of psychological trauma also increased the likelihood of developing compassion fatigue.[6] Professional compassion fatigue is often described as the emotional burden of being exposed to traumatic events of patients and may manifest itself by the loss of a sense of self, meaning and purpose, compassion, or ability to be empathic.[15] Furthermore, Sabo[16] stated that the health care provider's declining ability to provide empathy in a therapeutic relationship is considered a key symptom of PCF.

Conant[17] stated that although PCF is not "listed as an illness in many diagnostic manuals…it can be seriously debilitating." Professional compassion fatigue is an "evolving syndrome encompassing multiple behaviours and symptoms that extend from frazzled tiredness and anxiety to psychological and physical illness."[18] Symptoms include anxiety, intrusive thoughts, apathy, depression, lessened enthusiasm, desensitization, diminished ability, irritability, emotionally feeling overwhelmed,[19] hypervigilance, emotional disturbances, and disordered thinking.[7] Coetzee and Klopper[19] further described PCF as all-encompassing, including energy fatigue, energy expenditure outstripping the restorative process and the loss of power of recovery of the health care provider. It is evident that PCF has the potential to have devastating effects on nurses, which frequently results in nurses leaving the field.

Hooper et al[20] describe additional effects experienced by health care workers. These effects include increased absenteeism and staff turnover, decreased quality of patient care, decreased patient safety, and difficulty recruiting and retaining staff. The following exemplar highlights some of these findings.

Case Study. (This exemplar demonstrated a nurse who refused intervention from her nurse manager after the death of a child with whom this nurse had developed a strong relationship. Some of the symptoms the nurse was demonstrating included anxiety, intrusive thoughts, and decreased patient safety).

A nurse in a study conducted by Feldstein and Gemma, who worked for a large university medical center, began caring for Laurie Ann, who was age 8 years, upon graduating from nursing school. The nurse noted: "I grew up caring for Laurie Ann!"[21] After 2 years of caring for this child, the nurse learned one morning that Laurie Ann had died. The nurse manager, noting the nurse's distress, attempted to console her, but the nurse could not allow herself to indulge her feelings of sadness as she had other patients to care for, including a new child with the same diagnosis. In the following weeks, this nurse described herself as "being preoccupied with thoughts of Laurie Ann's death."[21] During this same period, the nurse made a medication error and was late for work several times.

Secondary Traumatic Stress Disorder

In 1995, Figley began using the term PCF interchangeably with STSD in describing the repeated exposure of empathetic caregivers who indirectly experienced the trauma of their patients.[10] Secondary traumatic stress disorder is defined as "the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person" that affects caregivers.[6]

Regularly, people in the helping professions are secondary witnesses to trauma, such as soldiers who have experienced war, people who have experienced violence (physical, emotional, sexual), or people who have experienced traumatic accidents.[23] As nurses witness trauma and suffering through the eyes of their patients, they cannot help but be affected emotionally. Although it is a privilege to care for those in need, "there is a cost to caring."[24] Showalter[23] stated that as healers, "we collect bits and pieces of their (patient's) trauma by exposure to their lives." Many helping professionals carry home these images in their minds and intense feelings in their bodies at the end of their work day. "Those who are strongly empathetic may be most at risk."[23] This repeated exposure is highly personal to the nurse and has the potential for negative consequences in a nurse's everyday life. Unlike posttraumatic stress disorder, the caregiver does not experience the traumatic event personally but rather experiences the event vicariously by caring for the traumatized person.[16]

Quinal et al[22] surveyed 43 oncology nurses regarding secondary stress using the Secondary Traumatic Stress Scale. A score of 38 or higher indicated the presence of secondary traumatic stress. Sixteen oncology nurses (38%) experienced secondary traumatic stress. The 5 most frequently reported symptoms were difficulty sleeping, intrusive thoughts about patients, irritability, fore-shortened future, and diminished activity levels. Two other studies using different assessment processes reported rates of PCF/STSD as 25% in forensic nurses and 78% in hospice nurses.[25,26] Additional symptoms of STSD have been noted to include disturbing dreams about patients, avoidance of patients, emotional numbing, avoidance of people and places, and detachment from others.[27]

Case Study. (The following case study was developed by the author as an exemplar).

It is not uncommon as death approaches for veterans to reexperience the traumas from their days in the battlefield. A nurse working on a palliative care unit in a US Veteran's Hospital for more than 10 years stated: "I have seen many veterans die. What distresses me most is that while I witness the actual dying process, so do I experience their trauma on the battlefield through their eyes. I go home and I cannot get the images out of my head as they describe the maimed bodies of their comrades, dead women, and children and total devastation. I sit with the veterans as they relive these experiences and it is as if I was in the battle too."