Investigation of psychological factors related to compassion fatigue, burnout, and compassion satisfaction among nurses

Nurses are among the basic service providers of health services. Nurses, due to their duties, deal with the difficult treatment processes of the patients and witness the fears, helplessness, stressful and traumatic experiences of the patients. The nursing profession requires constant communication with people. In this process, the information obtained about the patients’ conditions while performing their care and treatment enables them to provide the best service to their patients [1‐10]. Nurses’ long-term therapeutic relationships with patients and patients’ relatives not only cause them to be exposed to more stress but also risk compassion fatigue [3]. In the process of bonding with patients, nurses can perceive positive or negative emotions that eventually lead to compassion satisfaction and compassion fatigue [11]. While an inadequate working environment can be a risk factor for professional compassion fatigue, the satisfaction of being able to serve in an inadequate working environment for another professional may also occur [12].

Compassion fatigue may occur when the nurse cannot control her patients' emotions, is repeatedly exposed to stress and is unable to alleviate the patient's pain. Compassion fatigue decreases in the care capacity. Nurses may experience traumatic stress symptoms or posttraumatic stress disorder due to the intensity of compassion fatigue. Secondary traumatic stress is stress that occurs as a result of wanting to help or helping a person who is suffering or traumatized [1, 3, 5‐10, 13].

Although comparison fatigue is similar to burnout, there is a difference between them [6, 7]. Burnout develops slowly and includes progressively worsening. Compasion differs from stress with symptoms such as a gradual increase in workload, lack of success, loss of idealism, and unsupportive work environment. Compasion stress can occur suddenly, and there is a sense of helplessness and confusion [6, 7, 14]. Burnout and compassion stress have negative features related to work. Both secondary trauma and burnout can cause difficulties in the life of the employee [12]. Nurse burnout is an occupational hazard that affects nurses, patients, organizations and society in general [15]. Burnout, patient care and outcomes (quality of care, patient safety, adverse events, patient dissatisfaction, medical errors, infections, pressure sores, patient falls), employee outcomes and job performance (organizational commitment, nurse productivity, turnover, job performance, general health, sickness absence, etc.) [15‐18].

Compasion satisfaction is the positive feeling that about the task being done well, feeling of satisfaction from helping another, and the ability to make a positive contribution to the work environment or society [12, 14]. The feeling that the professional has fulfilled the requirements of his/her profession, the feeling of satisfaction experienced, reduces the professional’s secondary traumatic stress [19]. A sense of satisfaction is an important component in the development of compassion fatigue resilience [19]. Compassion satisfaction can be considered a protective factor from occupational psychological risks [20]. There was a negative relationship between burnout and compassion satisfaction [18, 21]. According to Yu and Gui (2022), while compassion fatigue and compassion satisfaction directly affect mental health, burnout directly affects physical health [18]. Compasion satisfaction, which is a sense of satisfaction and achievement, and its negative state, compassion fatigue, are critical to nurses' well-being and therefore affect the quality of patient care [11]. Factors that can affect both compasion satisfaction and compassion fatigue and burnout (such as stress and coping methods) need to be well known.

Task-related stress can also cause health workers to experience various mental problems. Mental distress can affect the symptoms of compassion fatigue and burnout, which are a burden of caregiving. Hegney et al. [22]) found a negative relationship between compassion satisfaction and depression; they found a positive relationship between compassion fatigue and burnout and anxiety and a very weak positive relationship between burnout and depression [22]. In a study conducted with nurses during the COVID pandemic, it was found that job satisfaction affects compassion satisfaction, and mental health problems affect compassion fatigue and burnout [23]. As the symptoms of burnout and compassion fatigue increase, the quality of life associated with health decreases. Additionally, as compassion satisfaction increases, the quality of life related to health also increases [24]. The active coping method (Adaptive) positively affects Compass satisfaction, while passive coping creates a risk factor for compassion and burnout. It has been determined that it contributes positively to the development of empathy, resilience, social support, and compassion satisfaction [2]. It was determined that when newly graduated nurses use active coping methods, compassion satisfaction increases, burnout decreases and burnout and secondary traumatic stress are affected when they use passive coping methods [25]. Nurses who work in intensive care units have reported that methods of coping with stress were associated with burnout [26]. As a result, while self-sense satisfaction in nurses is evaluated positively, self-esteem fatigue and burnout are undesirable for employees, service recipients, the institution and ultimately society. It is important to notice and pay attention to prevent potential negative effects and to plan and implement interventions for the factors that cause them. It is necessary to know the factors that may affect them well and to take steps toward them. While there are many studies examining compassion fatigue, compassion satisfaction, and burnout among nurses in the literature, there has been no study in which the levels of affect of these variables from psychological symptoms and coping skills are evaluated together, as far as we know. In this study, we aimed to investigate the relationship between nurses' levels of various psychopathological symptoms and coping skills, compassion fatigue, compassion satisfaction, and burnout levels.

The research questions are stated below.

Most of the 356 nurses in this study were women (94%, n = 336) and married (61%, n = 216), and their average age was 35.86 ± 8.92 (range, 19–64) years. The average working time as a nurse was 14 ± 9.23 (range, 1–44) years. More than half of the nurses (51%, n = 181) reported that they choose their profession willingly, and 44% (n = 157) worked during the day. Descriptive information of nurses about workplace stress factors is included in Table 1. The mean and minimum and maximum values of the variables of the study are shown in Table 2. The correlation values between the Brief Symptom Inventory, the Evaluation of Coping Attitudes, and the Professional Quality of Life Scale subdimensions are given in Table 2. Multiple linear regression models were tested to explore the predictive power of psychological symptoms on ProQOL (Table 3, Model 1; Table 4, Model 1; Table 5, Model 1). Concerning compassion fatigue, psychological symptom variables (somatization) explained 19% of the variance in compassion fatigue (F [5, 350] = 16.46; p < 0.001) (Table 3, Model 1). Concerning burnout, psychological symptom variables (depression) explained 21% of the variance in burnout (F [5, 350] = 19.67; p < 0.05) (Table 4, Model 1). It was determined that compassion satisfaction was not affected by psychological symptoms.

Multiple linear regression models were tested to explore the predictive power of coping skills on compassion fatigue, burnout, and compassion satisfaction (Table 3, Model 2; Table 4, Model 2; Table 5, Model 2). Concerning compassion fatigue, coping skills variables (mental disengagement, turning to religion, restraint coping, and planning) explained 17% of the variance in compassion fatigue (F [15, 340] = 4.27; p < 0.001) (Table 3, Model 2). Concerning burnout, coping skills variables (positive reinterpretation and growth) explained 14% of the variance of burnout (F [5, 340] = 3.96; p < 0.001) (Table 4, Model 2). Concerning compassion satisfaction, coping skills variables (positive reinterpretation and growth) explained 12% of the variance of compassion satisfaction (F [5, 340] = 3.18; p < 0.001) (Table 5, Model 2).

In this study, the ProQOL (compassion fatigue, compassion satisfaction, and burnout) levels, psychological symptoms, and coping skills of nurses working at a tertiary university hospital were examined. In addition, psychological symptoms and coping skills that affect ProQOL were identified. It was determined that the nurses had low-level burnout, moderate-high compassion satisfaction, and low-moderate compassion fatigue symptoms. This result was also similar to previous studies [20, 21, 23, 32, 33]. Low-level anxiety, depression, somatization, hostility, and negative self-concept were detected.

Very few studies have examined the ProQOL levels and psychological symptoms of nurses in the literature. Hegney et al. [22] found that the anxiety and depression levels of nurses were within the normal range [22]. Zhan et al. [23] also found that 85.60% of participants were healthy [23]. In another study conducted with emergency department nurses, 53.46% of the nurses did not have a depressive tendency in the evaluation of depressive or nondepressive tendencies [34]. In another study conducted with nurses working in a tertiary hospital, low levels of depression and anxiety symptoms were found [35]. Individuals use both emotion-focused and problem-focused coping styles in stressful situations [29, 36]. In this research, it was determined that nurses used problem-focused strategies more intensively than emotion-focused strategies. Al Barmawi et al. [37] found that nurses used seeking social support first, followed by problem-solving and avoidance strategies [37].

Nurses use positive coping styles more than negative coping styles [38]. In another study conducted on nurses’ coping styles and work stress, 65.07% of nurses used adaptive coping skills [39]. The findings obtained from our study could not be compared with previous data because the mean values of coping skills and ProQOL were not included in previous studies examining coping skills and ProQoL [2, 25, 26, 40]. Additionally, the differences in the measurement tools used in the studies caused difficulties in comparing the findings. In our research, it was found that nurses used active coping, planning, and seeking social support for instrumental reasons, which were used at moderate-to-high levels, and used restraint coping and suppression of competing activities at a moderate level. Positive reinterpretation and growth and turning to religion were used at a medium–high level, emotional social support and acceptance skills were used at a moderate level, and denial was used at a low level. Additionally, it was found that focusing on and venting emotions and mental disengagement were used moderately, and behavioral disengagement, taking drugs, and joking were used at low levels.

Individuals use both emotion-focused and problem-focused coping styles in stressful situations [29, 36]. In problem-focused coping, people try to change the source of stress. In emotion-focused coping, when the source of stress cannot be changed, the emotional state causing stress is tried to be reduced, that is, to regulate the emotion [29]. In our study, it can be said that nurses first tried to cope with stressful situations using problem-focused skills and then used emotion-focused coping strategies.

ProQoL is the kind of positive (compassion satisfaction) and negative (compassion fatigue and burnout) feeling that professionals feel as a result of having done their job well [12]. In our study, a positive correlation was found between compassion fatigue and burnout [4, 18, 20, 21, 41‐44], and a negative correlation was found between compassion fatigue and compassion satisfaction [20, 41, 42], similar to other studies in the literature. In addition, it was found that there was a negative correlation between compassion satisfaction and burnout [18, 20‐22, 41‐45].

The concept of compassion fatigue includes burnout and secondary trauma. Both affect mental health [18, 23, 24] and physical health [18]. Previous studies have found a positive correlation between anxiety and depression and a positive correlation between burnout and compassion fatigue [22, 46]. A negative correlation was found between burnout and job satisfaction [47, 48]. In addition, a positive correlation was determined between compassion satisfaction and mental health [18], a negative correlation between compassion satisfaction and compassion fatigue [18], and a negative correlation between anxiety and depression [46]. In our study, it was determined that somatization affected compassion fatigue and that depression affected burnout. Ruiz-Fernandez et al. [24] found that general health symptoms and body pain were related to compassion fatigue and burnout [24].

Coping is a cognitive and behavioral effort used to manage internal and external demands. Intervention to the source of stress is defined as problem-focused coping, and the regulation of emotions caused by a stressful situation is referred to as emotion-focused coping [36]. In our study, it was determined that the use of mental disengagement and planning coping skills were effective in reducing the symptoms of compassion fatigue. The mental disengagement involves several activities [29]. It can be functional because it keeps the person away from stress as soon as it is used. Knowing that these strategies will be used in difficult situations may reduce compassion fatigue. Planning involves finding the best method of coping with a stressor. Planning is a method of problem-focused coping; at the same time, an active problem-solving outline is created. This includes thinking about what to do in situations where stress increases [29]. In previous studies, it was determined that active coping reduced compassion fatigue [2, 25]. Preplanned methods that are ready in the face of emergencies may enable nurses to minimize errors that may arise from themselves and therefore reduce the symptoms of compassion fatigue.

In our study, turning to religion and restraint coping affected the increase in compassion fatigue symptoms. Many people use religion as a source of emotional support under stress and as a tool for positive reinterpretation and growth [29]. Thus, turning to religion can serve as active coping because it involves intrinsically positive reinterpretation [29]. Nurses, who witness and intervene in difficult processes of patients during health care practices, may not be able to positively reinterpret internally for many very difficult situations. It may cause nurses to experience a feeling of being stuck in their internal processes, thereby increasing the symptoms of compassion fatigue. Restraint coping is an active coping method for coping with stress. However, keeping a distance from stress and not acting, not trying, is also a passive way of coping [29]. Standing back and doing nothing may cause feelings of helplessness. According to Varadorojan & Rani (2021), there is a positive correlation between distancing and compassion fatigue [26]. Positive reinterpretation and growth, which is an emotion-focused coping method, aims to cope by trying to manage the emotion affected by the stressor instead of dealing with the stressor [29]. In our study, positive reinterpretation and growth coping approaches were effective in reducing burnout while increasing compassion satisfaction. Positive internal reinterpretation is also an active internal coping process [29]. Positive reinterpretation may reduce burnout, and the feeling of overcoming challenges at work may also increase job satisfaction. Varadorojan & Rani (2021) determined that there was a positive correlation between compassion satisfaction and positive reinterpretation and a negative correlation between burnout and positive reinterpretation [26].

Cross-sectional studies do not allow us to interpret the causal relationships. It was assumed that the people participating in the survey reflected their true feelings when responding to the questions on the scale. It was assumed that the participants responded willingly to the questionnaire and answered the questionnaire correctly and completely. It was assumed that the participants understood the true meaning of the survey questions. Another limitation was that the study was limited to Istanbul Province and a university hospital. The fact that the study was conducted using the convenience sampling method can be counted among the limitations of this study.

This research provides information about the relationships between nurses' depression, anxiety, somatization, negative self and hostility levels and symptoms of compassion fatigue, burnout and compassion satisfaction. It also provides information about the coping strategies that nurses use for compassion fatigue, burnout and compassion satisfaction symptoms. Nurses showing somatization symptoms are risk factors for empathy fatigue, and nurses showing depression symptoms are risk factors for burnout, so they should be closely monitored, and necessary support should be given. Considering that mental disengagement and planning can reduce empathy fatigue and that positive reinterpretation and development methods can reduce burnout and increase professional satisfaction, it may be beneficial to provide counseling and training for nurses to use correct coping methods. These findings can be used to increase the general well-being of nurses and to develop psychoeducational studies to increase their compassion satisfaction. Increasing the compassion satisfaction of nurses will contribute to the improvement of service quality and job satisfaction and reduce health mistakes.