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


There is no universal recognition of the potential negative effects of nurses providing care to those who are suffering, traumatized, seriously ill, and/or dying. Resiliency may explain how some nurses cope better than others do. There are innate strengths that some nurses possess, including resiliency, as well as learned methods of managing stressful situations (self-care, support, spirituality, etc) that clearly affect a nurse's ability to cope.

Grafton et al[30] describe resiliency as an accessible inner strength or resource within an individual that enables a positive stress response that can be enhanced or supported by external sources. In other words, resiliency does seem to be innate and is enhanced by external forces. Grafton et al[30] developed the Resilience Development Model, which described innate resiliency and the process of enhancing innate resiliency (Figure). In this model, resiliency was defined as a cyclical process of uncovering, using, and developing the innate self, motivating life force, human spirit, or strength that lies within. In addition, resiliency seemed to involve a spiritual component.[30] Resiliency seemed to positively affect a nurse's ability to cope with stress, recover from or prevent depletion of self, and reduce one's vulnerability to the impact of future stress.[31,32] According to Zautra et al,[33] resilience describes one's ability to recover easily and quickly from setbacks that occur during his/her life. Resilience is described as strength that people possess and people who are described as resilient are said to be able to persist in overcoming challenging obstacles.[34]


Resilience Development Model. Copyright 2010 by ONS. Reprinted with permission.

Yoder[35] suggested strategies to address PCF/STSD, which included taking vacations, changing assignments, developing supports, developing personal awareness, having rituals, and changing jobs. If nurses neglected themselves and failed to recognize symptoms of PCF/STSD, they could compromise their ability to provide quality patient care.[36] Nurses need to be educated about their vulnerability when working with suffering, traumatized, seriously ill, and/or dying patients, as well as the signs and symptoms of PCF/STSD, risk factors, and coping behaviors.

Other self-care strategies included maintaining adequate sleep patterns, good nutrition, regular exercise, and relaxation. Developing techniques such as meditation, mindfulness, deep breathing, self-reflection, and humor and massage could also be therapeutic.[37] Engaging in nonwork activities often rejuvenated and restored the nurses' energy, commitment, and focus. The ability for the nurse to provide distance from the work environment is vital to healthy coping.

Another key self-care strategy included the need for nurses to be assertive, to express personal needs and values, and to balance work with their personal life. For example, 1 oncology registered nurse noted: "I learned to try to keep a piece of me aside—lock a part of my heart away just for me and my personal life."[38] Without this balance, the compassionate nurse is at risk for developing PCF.[39] Learning to say the word "no" is imperative as well. Showalter[23] described how important it is for health care professionals to be able to set boundaries to maintain personal/professional balance. "Professional caregivers must learn to live a balanced life, allowing their professional life to enhance their personal life, not compromise their well-being."[23] Thus, nurses should not feel guilty when turning down requests for overtime, extended shifts, and others.

Among mental health professionals, social support came from friends, family members, or significant others outside the work environment or from coworkers and supervisors within the work environment. Overall, the evidence suggested that coworker support is very important to the mental health professional and is applicable to nurses as well.[40–42]

In researching PCF/STSD, Figley[43,44] argued that social workers who did not have time to debrief after a traumatic session were more likely to experience compassion fatigue compared with those who did engage in debriefing. These findings have direct implications for nurses who often care for several seriously ill patients at a time. If nurses are not supported emotionally, the negative effects of PCF/STSD are more likely to develop. Establishing debriefing sessions for nurses after difficult clinical situations, which could be facilitated by a social worker, advanced practice registered nurse, or psychologist, could be highly beneficial. In the absence of formal debriefing, processing with a peer or friend may still prove beneficial.

Attending to one's spiritual needs is also important. Yoder[35] described the role of religion for some nurses. One nurse stated, "[I'm] praying for strength to be cool and calm…to be aware of patient's needs and have enough strength to meet them…that my support systems will support me…that I can be the nurse that that patient needs."Other nurses found support through journaling, painting, quilting, and others. Still, others found it rejuvenating to be out in nature—walking or gardening—and described the miracle of growing things.

Jezuit[45] described the role of the nurse manager in identifying and assisting distressed nurses. Nurse managers have a unique ability to assist distressed nurses who are suffering as a result of the repeated exposure to patient and family trauma and suffering as well as the dying. Nurse managers must create a safe environment where a nurse may express his/her distress and discuss treatment strategies. The argument can be made that there is a potential ethical conflict with the nurse manager providing emotional support to a distressed nurse and then, at a later time, evaluating that same nurse. Inherent in this practice is a dichotomy between providing emotional support and subsequent evaluation. In many cases, it would be more appropriate for a third person to serve as the facilitator in providing emotional support. This person (facilitator) could be a colleague, social worker, advanced practice registered nurse, or psychologist. The facilitator could assist a nurse(s) in identifying emotional triggers and developing coping strategies. A group of ambulatory care gynecologic oncology nurses organized a compassion fatigue support group that met monthly and reported that they found the group highly beneficial.[46] Employee assistance programs for distressed nurses are additional resources.

In many cases, it is the nurse manager who establishes the working environment, albeit a supportive working environment or one that is not. Laschinger et al[47] found that lower levels of burnout (emotional exhaustion) were associated with work environments that fostered support of nursing practice and civil working relationships and promoted a sense of empowerment.

Nursing scholars have long advocated for the establishment of undergraduate nursing courses that address care of seriously ill and dying patients. The goal of specific clinical assignments would be to reduce death anxiety among student nurses, which would result in registered nurses being more prepared to care for these patients upon graduation.[1,48]

In addition, practicing nurses would likely benefit from continuing education programs that focus on the care of this patient population. Suggested topics include identifying personal coping strategies, developing caring communication styles, establishing boundaries in professional relationships with patients and families, understanding family systems theory, and resolving interpersonal relationship problems in the work place ( Table ).[24] Through continuing education, nurses can learn ways to prevent PCF/STSD and learn strategies to increase resiliency. The study of Townsend and Campbell[25] indicated that peer support, experience as a nurse, and additional continuing education were positive factors that influenced a nurse's resilience to PCF/STSD.