Chapter 1: Overview of the Study

Introduction

Registered nurses, the largest healthcare occupation, numbered about 2.6 million in the United States in 2008 ([Bureau of Labor Statistics, 2011](/dissertation/references)). Global concerns have been voiced since the mid-1990s regarding an increasing shortage of nurses, and declining numbers ([Grafton, Gillespie, & Henderson, 2101](/dissertation/references)). Although compassion and empathy are key components in a therapeutic relationship with a patient ([Van Hook, 2008](/dissertation/references)), display of compassion is not a commodity which can be controlled, trained, and dispensed as needed ([Miller, 2007](/dissertation/references)). If nurses are not supported in providing compassionate care, they can be at risk for developing CF ([Potter et al., 2010](/dissertation/references)). Studies have indicated that 80% of these nurses may be at risk for burnout, compassion fatigue (CF), or secondary trauma ([Abendroth & Flannery, 2006; Hooper, Craig, Janvrin, Wetsel, & Reimels, 2010](/dissertation/references)). The costs of CF are both financial and psychological ([McMullen, 2007; Tehrani, 2007; Van Hook, 2008](/dissertation/references)). Compassion fatigue has been shown to result in loss of quality patient care, increased staff turnover, and attrition ([Abendroth, 2011; McMullen, 2007; Sprang, Clark, & Whitt-Woolsey, 2007](/dissertation/references)).The highest rate of attrition from CF occurs during the first two or three years of nursing, leading to an increased average age ([Abendroth & Flannery, 2006](/dissertation/references)). A universally accepted definition of CF has not yet formed ([B. Sabo, personal communication, January 18, 2012](/dissertation/references)), despite the numerous studies based on Figley‘s model (see Figure 1 in [chapter 2](/dissertation/chapter-2)). Studies based on Figley‘s 2002 model usually describe CF as a stress disorder based on caring too much for patients, clients, or victims, producing a reduced ability to feel or convey caring support, empathy, or genuine understanding

([Hofmann, 2009](/dissertation/references)). A more complete description of compassion fatigue is provided in [chapter 2](/dissertation/chapter-2). Quantitative studies have indicated certain areas of medical care provision, such as palliative care, have a high risk for CF ([Abendroth & Flannery, 2006](/dissertation/references)). The compassion involved in palliative care includes a long-term connection with patients and their families, empathic perspective taking, noticing, listening, and responding ([Miller, 2007](/dissertation/references)). This type of extended and increased familiarity with patients and families frequently leads to emotional contagion, and then CF. Recent research has demonstrated psychoneuroimmunological links between negative emotional contagion and biological well-being ([Grafton et al., 2010; S. Smith, 2011a](/dissertation/references)). There are, however, a number of gaps in knowledge about CF which cannot be filled using quantitative research ([Earle, 2010](/dissertation/references)). One of these gaps, how nurses experience resiliency to CF, is the focus of this study. Although certain areas of medical care provision may be at high risk for CF, it is not a foregone conclusion that all medical professionals in those areas will develop CF, despite having high empathic ability ([Grafton et al., 2010; Sabo, 2011](/dissertation/references)). Looking through a positive psychology lens, and examining the phenomenon of empathic people who have a resiliency to CF will advance understanding about what CF is, and what it is not. Understanding more about resiliency to CF will help in developing resiliency and preventing CF, in addition to lessening risk factors for CF.

Problem Statement

CF is commonly used to describe nurses who feel they can no longer give empathic attention to their patients, friends, or family. The diagnosis may be overused

due to the lack of clear definition ([B. Sabo, personal communication, January 18, 2012](/dissertation/references)). Although Figley (2002) provided a model and theory for CF, he did not define compassion or fatigue, or make clear distinctions between compassion and empathy, CF and burnout, or between CF and secondary trauma or vicarious trauma. Research, based primarily on his theory, generally has been quantitative, providing information about risk levels for various traits corresponding to Professional Quality of Life (ProQOL) axes ([Hooper, Craig, Janvrin, Wetsel, & Reimels, 2009; Potter et al., 2010; Sabo, 2011](/dissertation/references)). This has led to training programs for CF risk avoidance ([Abendroth & Flannery, 2006](/dissertation/references)), but not for strengthening resiliency to CF. The problem this study addresses, therefore, is lack of knowledge about the essence of resiliency to CF may be leading to less effective training programs for healthcare professionals ([Harrison & Westwood, 2009](/dissertation/references)).

Nature of the Study

The study advances knowledge about the experience nurses and other healthcare professionals (HCPs) have with CF, and resiliency to it. Seven nurses from various areas of hospital medical practice, each with more than 15 years of experience in nursing, were interviewed. The in-depth semi-structured interviews explored the meanings these people assigned to their experience of CF, and resiliency to it. The results (found in [chapter 4](/dissertation/chapter-4)) combine interpretative and descriptive phenomenological methods, melding the richness and variability into a collective essence of the experiences. ―Phenomenology is the study of essences‖ ([Merleau-Ponty, 1962, p. vii](/dissertation/references)). The proposed sample of nine healthcare professionals was not needed, as data saturation was achieved after seven people had been interviewed, coming from three different hospitals in Seattle. Five nurses worked at

a prominent northwestern American teaching hospital and its affiliated clinics. In addition to field notes and journaling the study, NVivo 10 software was used to categorize and analyze the data. As results developed, they were returned to participants for accuracy checking. I was the only interviewer, transcriber, and analyst, as decribed in Role of the Researcher in [chapter 3](/dissertation/chapter-3). A more detailed description of the entire study context and process appears in [chapter 3](/dissertation/chapter-3).

Research Questions

The primary research question was: What is the collective essence of healthcare professionals‘ experience of resiliency to compassion fatigue? The secondary questions were: Research Question 2: What distinctions and similarities do healthcare professionals experience between burnout, CF, and vicarious trauma? Research Question 3: What qualities and characteristics do health care professionals experience as supportive to being empathic and yet resilient to CF?

Purpose of the Study

The purpose of this study was to determine the essence of the phenomenon of resiliency to compassion fatigue from the viewpoint of healthcare professionals (HCPs). This description of the CF resiliency phenomenon provides more clarity with regard to the concepts underlying strength-based training in resiliency to CF.

Conceptual Framework

The current model of CF, based on Figley‘s (2002) theory, includes many facets: empathic ability, response, and concern; exposure to client; degree of life disruption; and

traumatic memory. Having compassion or empathy, in other words, may lead to CF. Untreated CF can lead to seriously lowered personal and professional functioning ([Benoit, Veach, & LeRoy, 2007](/dissertation/references)). Additional theoretical bases for the study are: an interpretative or constructivist view of social reality ([Bennett, 1998b; LeCompte & Schensul, 1999a](/dissertation/references)); and the expansion of Bonanno‘s model of resiliency ([Linley & Joseph, 2005](/dissertation/references)). A positive psychology paradigm ([Seligman, 2008](/dissertation/references)) underlies the proposed investigation of resiliency, as opposed to investigation of risk factors for CF.

Operational Definitions

Many of the terms basic to this study have had various definitions, making it important to provide the operational definitions used in this study: Burnout: A condition of mental and physical health decline due to the impact or overload of a person‘s work, or work environment ([Rothschild, 2006](/dissertation/references)). Collective essence: A distillation of individual points of view regarding a specific phenomenon; fundamental nature of a phenomenon from the viewpoint of several individuals ([Merleau-Ponty, 1964](/dissertation/references)). Cognitive flexibility: The ability to use existing knowledge to create innovative solutions to new problems, using new strategies, reflecting on results, and incorporating feedback ([Shamay-Tsoory, Tomer, Berger, & Aharon-Peretz, 2003](/dissertation/references)). Compassion: A prosocial emotion, being present and feeling for another, with a desire to help, but being aware that one‘s feelings are separate from the other person‘s ([Austin, Goble, Leier, & Byrne, 2009; Sabo, 2006](/dissertation/references)).

Compassion fatigue: ―A combination of physical, emotional, and spiritual depletion‖ ([Lombardo & Eyre, 2011, p. 1](/dissertation/references)) and becoming overwhelmed by repeated and prolonged exposure to clients and patients who are coping with trauma and severe illness or disability ([Benoit, Veach, & LeRoy, 2007](/dissertation/references)). Countertransference: A healthcare professional‘s (HCP) reactions to a client or patient which are rooted in the HCP‘s past ([Rothschild, 2006](/dissertation/references)). Emotional contagion: The automatic and unconscious transferring of emotions from one person to another, essentially pre-attentive and unconscious ([Hatfield, Cacioppo, & Rapson, 1992](/dissertation/references)). Empathy: Participation, sometimes unconsciously, in another person‘s experience, accepting their reality, even though it may differ from our own ([Bennett, 1998a; Wispé, 1986](/dissertation/references)). Empathic response: The physical mirroring of another‘s physioemotional state, which happens without thought ([Iacoboni, 2007](/dissertation/references)). Healthcare professionals: Nurses, physicians, and therapists who provide care directly to patients. Secondary trauma: The stress reaction resulting from emotional engagement with a traumatized or suffering person. ([Shindul-Rothschild, 2001; Stewart, 2009](/dissertation/references)). Sympathy: Imagining how we might feel if we were in the other person‘s place, not accepting their separate reality ([Bennett, 1998a](/dissertation/references)). Vicarious trauma: The cumulative physical, emotional, and cognitive reaction, as if experiencing the trauma of clients or patients, with the possibility of developing post- 7 traumatic stress disorder, without having the actual traumatic experience ([Harrison & Westwood, 2009](/dissertation/references)). Assumptions, Limitations, Scope, and Delimitations

Assumptions

This phenomenological study was based on the following assumptions, in order to establish internal validity, credibility, and integrity:  CF resiliency among empathic HCPs is a phenomenon of lived experience.  The phenomenon of CF resiliency can be expressed best by those who have witnessed or experienced it.  The questions asked in the interviews did not bias the responses, and elicited information about the elements of interest to the study, providing internal validity.  The participants provided honest responses.  The results of the analysis of their responses are authentic.  Multiple realities and experiences are interrelated, and can be researched best by using phenomenology. A single reality of CF resiliency does not exist.

Limitations

Several weaknesses may exist for this phenomenological study, such as bias in self-selection of volunteer participants, as well as reluctance of the participants to discuss fully their own experiences of CF. Due to the small sample used, the full experience of

CF, and of resiliency to it, could not be explored. Different cultures and ethnicities may have significantly different experiences, but as this study did not use theoretical sampling, this additional information is not included.

Scope and Delimitations

The study was limited in scope to nine nurses from three northwestern American hospitals, and is not suitable for generalization. Psychopathological explanations for CF resiliency are not included.

Significance of the Study

The implications for positive social change from this research include the benefits to the healthcare workers‘ personal health, as well as patient care, of more effective policies at the facility level for in-service CF training and intervention, and for the prospect of a rise of economic productivity in services at the community level. The study adds to the research concerning CF, as well as resiliency in the nursing profession, filling in gaps in the relevant literature. It will serve as groundwork for additional theory development, enhancing the Figley (2002) model. It will help to make distinctions between burnout, empathic contagion, CF, and vicarious or secondary trauma.

Overview of the Chapters

In summary, this study of healthcare professionals‘ experience of resiliency to CF increases understanding of CF. This increased understanding of CF can be used to improve training programs curricula for healthcare professionals with regard to CF. In- depth interviews captured the data, checked for accuracy by the participants. The data

was analyzed using the phenomenological methods of Moustakas and van Manen, with assistance from NVivo 10. The analysis was developed into textural and structural descriptions of the phenomenon, resiliency to CF. The chapters which follow: [chapter 2](/dissertation/chapter-2) reviews and discusses research and current literature; [chapter 3](/dissertation/chapter-3) presents the proposed methodology for the study. [Chapter 4](/dissertation/chapter-4) presents the results of the study and [chapter 5](/dissertation/chapter-5) discusses the implications of the results of the study.