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. 2024 Jan 1;34(1):28–37. doi: 10.5737/2368807634128

An integrative review of strategies to prevent and treat compassion fatigue in oncology nurses

Jodi Collier 1,✉, Tania Bergen 2, Hua Li 3
PMCID: PMC10861234  PMID: 38352927

Abstract

Compassion fatigue is understood as the combination of secondary traumatic stress and cumulative burnout caused by reduced ability to cope with one’s environment. As such, compassion fatigue can be a significant workplace hazard for nurses in oncology. Findings from this integrative review reveal a lack of awareness and understanding of compassion fatigue among oncology nurses even if this group has been identified as high risk for experiencing compassion fatigue. Strategies such as self-care, mindfulness, and resiliency-based interventions to cope with compassion fatigue are reviewed herein along with related effectiveness. Some studies underscore that prevention-focused rather than treatment-focused interventions for compassion fatigue may be more effective. The responsibility for promoting and protecting oncology nurses’ well-being is essential and must be spearheaded by organizations, administration, educational institutions, care teams, and individual nurses.

Keywords: compassion fatigue, secondary traumatic stress, vicarious trauma, burnout, oncology, nurse

INTRODUCTION

A cancer diagnosis and its treatment often represent a traumatic life experience for affected individuals, families, and friends, as well as healthcare professionals. Oncology nurses routinely provide care to patients and their families across the cancer trajectory. Nurses’ desire to make a difference and help those in need draws them to the profession, but the cumulative weight of this type of work is not without occupational, psychosocial, and physical costs. Best understood as the combination of secondary traumatic stress (STS) and burnout, compassion fatigue (CF) impacts an individual physically, psychologically, and spiritually (Todaro-Franceschi, 2019). Compassion fatigue is known to contribute to nurse turnover and negatively impact employe retention, ultimately impacting quality of care (Sinclair et al., 2017). According to the International Council of Nurses (2022), the estimated global nursing shortage has gone from 5.9 million in 2020 to a projected 13 million post-pandemic, adding burden to nurses who also witness daily suffering, acute symptomatology, and death.

BACKGROUND

Compassion fatigue as a concept first appeared in nursing literature in 1992 when Carla Joinson, an emergency room nurse, observed a distinct form of burnout among her colleagues. Building upon Joinson’s observations, Figley (2002) deemed CF as the cost of caring, a result of cumulative exposure to the trauma of others, leading to the depletion of oneself. Antecedents to CF have been identified as: (1) chronic exposure to suffering, (2) compassion, (3) lack of professional boundaries, (4) use of self, (5) exposure to stress, and (6) a lack of selfcare measures (Peters, 2018). Understanding the precursors of CF is an essential step in prevention, risk reduction, and intervention development. Recognizing CF in oneself or in coworkers can be challenging as signs and symptoms can be insidious and overlap with those of other conditions (Todaro-Franceschi, 2019). Avoidance, loss of motivation, loss of purpose, disengagement, substance use, and difficulty concentrating are related to CF (Todaro-Franceschi, 2019). These CF symptoms can extend to cause physical, emotional, spiritual, and behavioural changes in an individual, significantly impacting their quality of life (Sinclair et al., 2017). Risk factors for CF include working in close physical and emotional proximity to patients, working in high-risk settings such as oncology or intensive care, exposure to trauma, heavy workloads, and sustained empathic engagement with patients (Todaro-Franceschi, 2019). Coetzee and Klopper (2010) in their original concept analysis define CF as:

The final result of a progressive and cumulative process that is caused by prolonged, continuous, and intense contact with patients, the use of self, and exposure to stress. It evolves from a state of compassion discomfort which is not effaced through adequate rest, leads to compassion stress that exceeds nurses’ endurance levels and, ultimately, results in compassion fatigue. (p.237).

Burnout

Burnout is best understood as deriving from the employee-employer relationship as a result of heavy workloads, poor management, and staff shortages (Todaro-Franceschi, 2019). Burnout can occur in any occupational setting and is not unique to the nursing profession. Compassion fatigue is differentiated from burnout in that it derives from the nurse-patient relationship (Peters, 2018). Burnout typically follows a cumulative predicative course, whereas CF tends to be more acute and less predictable (Figley, 2002).

Secondary Traumatic Stress & Vicarious Traumatization

Secondary traumatic stress is defined as a type of post-traumatic stress disorder condition resulting from empathetic engagement with patients who have experienced trauma (Arnold, 2020). From diagnosis, to surgery, to the disfiguring side effects of chemotherapy, oncology patients experience a myriad of trauma. Figley (2002) uses STS and CF interchangeably as the same construct, stating that CF is a more palatable label than STS as the individual is not labelled as traumatized. With origins in the discipline of psychology, vicarious traumatization is described as the alteration of one’s worldview and perception of control and safety as a result of the empathetic stress experienced from involvement with a patient who has undergone trauma firsthand (Arnold, 2020). While vicarious traumatization and STS are closely tied, vicarious trauma can be thought of as the act or exposure to trauma with STS as the natural stress response to vicarious trauma (Arnold, 2020).

Compassion Satisfaction

Compassion satisfaction is the positive feelings that a nurse experiences by caring for patients in need (Stamm, 2010). Compassion satisfaction can be understood as the affirming, empowering, uplifting moments that enhance a nurse’s professional quality of life, reaffirming their decision and desire to enter a caregiving profession. Compassion satisfaction is protective for nurses at risk of developing CF (Stamm, 2010).

Despite CF being a relatively new concept in nursing literature, it is likely that the complexity of terms and concepts has prevented the furthering of research regarding a phenomenon that has been lingering unchecked for decades. Burnout, CF, STS, and vicarious traumatization are all closely related yet distinct phenomena that frequently coexist, thus furthering confusion in nursing research and discourse. The spotlight on nurses during the COVID-19 pandemic may have acted as a catalyst, revealing the emotional toll that this profession can have on an individual.

PURPOSE

The purpose of this integrative review is to search the literature for evidence-based strategies published between 2013 and 2023 aimed at preventing and treating CF in oncology nurses. Given the established knowledge that nurses suffering from CF have an increased desire to leave the profession, have increased practice errors, and experience impaired judgement, serve as the fuel for this review (Peters, 2018). Based on findings, the goal will be to add recommendations for future research direction and create awareness about the current state of evidence regarding interventions against CF in oncology nursing.

METHODS

Integrative reviews are an effective tool for uncovering the current state of science on a topic, which can then be used to influence practice or aid in theory development (Whittemore & Knafl, 2005). Using Whittemore and Knafl’s (2005) methodology as a guide, this review will include experimental and non-experimental research to aid in uncovering the effectiveness of current strategies in preventing and treating CF in oncology nurses.

Using Boolean operators, an in-depth search of the CINAHL, PubMed, Google Scholar, and Web of Science databases was conducted for full text, peer-reviewed articles published between 2013 and 2023. Keywords searched include “compassion fatigue” “or” “secondary traumatic stress” “or” “burnout” “and” “nursing” “and” “oncology” “and” “intervention” “or” “strategy.” A total of 860 publications were indentified, as well as an additional four articles found through individual review of the reference lists of initial articles, resulting in 864.

Article abstracts and titles were reviewed by a single reviewer. This initial step in screening titles and abstracts narrowed the selections to 468 publications. Articles were then reviewed based on the following criteria: (1) the article was original research of any type (e.g., qualitative, quantitative, mixed methods), (2) the article was specific to oncology nursing, (3) the article was a peer-reviewed full text English-language publication from January 1, 2013, to December 31, 2022, and (4) the article included an intervention aimed at CF. The review step based on these criteria resulted in a total of 41 publications. The final step included a full manuscript review of the 41 remaining publications and exclusion if: (1) the publication was not original research, (2) did not include a CF-related intervention, and (3) was not done in the oncology setting with at least half of participants being nurses. This left a total of 18 publications. [See PRISMA in Figure 1, Appendix A.] Data extraction was completed using a standard table to delineate: author (year), country, research design, study aim, sample size and scale, and main findings. Summary table of articles is provided in Appendix B.

FINDINGS

A total of 18 articles were retained for this review. Twelve of these studies were conducted in the United States, two from Canada, two from Turkey, one from Portugal, and one from the United Kingdom. The most common study design was pre-test/post-test. Two studies utilized mixed-methods, and one relied on a randomized control trial [RCT]. Sample sizes varied across studies from 13 to 189 with a mean of 65.9 and a total of 1,253 oncology nurses from inpatient, outpatient, pediatric, and stem cell transplant settings. Years of professional experience varied from less than five years (e.g., Jakel et al., 2016) to a mean of 17.7 years (e.g., Esplen et al., 2022). Following an in-depth review of the 18 retained studies, three types of CF-related interventions were identified: mindfulness-based (four publications: Delaney, 2018; Duarte & Pinto-Gouveia, 2016; Hevezi, 2016; & Qualls et al., 2022), self-care (five publications: Anderson & Gustavson, 2016; Hand et al., 2019; Phillips et al., 2020; Sullivan et al., 2019; & Yilmaz et al., 2018), and resilience-based (nine publications: Blackburn et al., 2020; Esplen et al., 2022; Jakel et al., 2016; Klein et al., 2017; Pehlivan & Guner, 2020; Pfaff et al., 2017; Potter et al., 2013; Schuster, 2021; Zajac et al., 2017). See Appendix B for detailed findings. Below, each type of intervention is reviewed.

Mindfulness-based interventions

Mindfulness is the act of intentionally, non-judgmentally, focusing on what one’s mind and body is experiencing in the present moment (Hevezi, 2016). With roots in Buddhist tradition, mindfulness has been identified as a strategy one can use to cope with stressful situations. Traditional mindfulness-based stress reduction interventions consist of two- to three-hour long sessions repeated weekly for eight weeks alongside daily requirements for meditation (Delaney, 2018). Given the substantial time commitment for mindfulness interventions, it is not surprising that the studies included in this review used a modified four-week intervention (Hevezi, 2016; Qualls et al., 2022) or six-week intervention (Duarte & Pinto-Gouveia, 2016) with just one retaining the traditional eight-week timeframe (Delaney, 2018). All four studies were a non-randomized design with one sample, while only the Duarte and Pinto-Gouveia (2016) study included a control group for comparison. Duarte and Pinto-Gouveia (2016) report significant reductions in CF in the experimental group of nurses versus the comparison group, and significant reductions in burnout. Of note, all interventions took place on-site at the workplace during work hours.

Self-care interventions

Self-care strategies include attention to the basic building blocks of health and wellbeing, diet, exercise, sleep, coping strategies, education, and expressive art. Specific strategies identified in this review included knitting, debriefing, massage sessions, story-telling, song writing, self-care education, respite rooms, counselling, and grief support (Anderson & Gustavson, 2016; Hand et al., 2019; Phillips et al., 2020; Sullivan et al., 2019; Yilmaz et al., 2018). Yilmaz et al. (2018) were able to demonstrate increases in compassion satisfaction and decreases in burnout and CF, which may be attributed to the nurse-led design of their intervention. The complexity of the storytelling and song writing intervention employed by Phillips et al. (2020) raises questions of replicability, as the facilitator was an oncology nurse who was also a singer/songwriter.

Resilience-based interventions

A resilient individual is one who has the capability to adapt, endure, and cope in adverse situations (Merriam-Webster, 2020). Important components of resilience include individuals and their environments, and the ability to grow and learn from tough situations. Resilience has been found to be an important strategy for coping with work-related stress in oncology (Pehlivan & Guner, 2020). Resilience-focused interventions have been found to have positive impacts on both individual nurses as well as organizations in the form of staff retention, productivity, and decreased turnover (Blackburn et al., 2020).

Blackburn et al. (2020) implemented the THRIVE© program, which consists of an eight-hour retreat, a six-week facilitated group study on social media, and a two-hour wrap-up session. Results from the THRIVE© program revealed statistically significant increases in resilience (p = 0.0268), decreases in burnout (p = 0.005), and STS (p = 0.004), which were measured and sustained at two, four, and six months post-intervention. A secondary finding from Blackburn et al. (2020) was that nurses who participated in the THRIVE© program had a turnover rate of 6.1% versus the national average of 17.1%, demonstrating benefits for individuals and organizations alike. The continuing education intervention by Esplen et al. (2022) revealed that, despite a mean of 17.7 years of nursing experience, participants reported that this was the first opportunity they had had to learn about CF and their personal risk factors for it. In the same sample (N = 189), 88% reported that their work-related well-being and quality of life were not addressed in yearly performance reviews.

DISCUSSION

Mindfulness-based interventions demonstrate much potential as an effective strategy against CF in oncology nurses. Further information into the exact length and composition of mindfulness interventions is important for organizations to determine feasibility and for individual commitment to the program. Ongoing research is needed to document the feasibility and effectiveness of shorter-, as opposed to longer-term interventions. Overall, mindfulness interventions appear to show significant promise for decreasing CF as well. Participants’ verbatim statements from the mixed-method study (Delaney, 2018) and post-intervention surveys (Duarte & Pinto-Gouveia, 2016) reveal wide acceptance from these participants for mindfulness interventions. Repeated findings such as the noted decrease in burnout and CF post mindfulness intervention adds strength to the argument for this type of intervention.

The use of self-care strategies as a treatment post CF demonstrates mixed results from the studies in this review. A possible explanation for this could be that self-care strategies are better used as prevention, as opposed to treatment. The timing of self-care strategies as a treatment could be viewed more as after-care strategies, as the individual is already affected and struggling to manage their self-care. Another concern with self-care strategies is that many put the responsibility on the individual who is suffering, to fix themselves. It is difficult to understand how appropriate it is to suggest that a nurse try engaging in yoga once they have experienced a soul-crushing trauma. Yoga or art or journaling are incredible strategies for health and wellness, however the timing of these interventions is critical. A medical mindset of diagnose and treat is perhaps influencing the current approaches and understanding of self-care.

Resiliency-based studies used longitudinal design, and different measures administered at different intervals (e.g., at least three months post-test to 12 months post-test). Studies failing to show statistically significant improvements post-intervention noted low baseline burnout and STS in their pre-intervention surveys, thus leaving little room for change, regardless of intervention (Jakel et al., 2017; Pfaff et al., 2017). Inclusion criteria in future studies should include staff that are currently demonstrating at least a moderate level of CF or burnout.

An overwhelming theme in all studies, obtained frequently from the open-ended post-intervention surveys, was positive participant feedback regarding the interventions. In the RCT (Pehlivan & Guner, 2020), a perplexing finding of CF scores increasing in participants immediately post intervention when compared to baseline may tie into the finding by Esplen et al. (2022) that, despite many years of nursing experience, awareness and education around CF remains low among nurses. Nurses identified time as one of the largest limitations for participation in interventions in both the self-care and resilience-based interventions. Support and involvement of organizations are, therefore, a key component in the success and implementation of CF interventions (Pehlivan & Guner, 2020; Pfaff et al., 2017; Schuster, 2020).

LIMITATIONS

Limitations of this review include having a single reviewer, increasing the possibility for human error. A second limitation is the fact that only one RCT was identified and included. Thirdly, the majority of articles originated in the United States. Various healthcare systems could present different challenges. The nursing demographic represented in this review was primarily white females between the ages of 22 and 65 years. As the global nursing population becomes more diverse, a more representative sample will be key for informing current practice.

Limitations in publications included

Of the 18 publications included in this review, multiple limitations, such as the self-selection of study participants, were noted. Participants may have volunteered out of interest and desire for the intervention. Participants in the massage intervention were involved in the design and implementation of the project and self-reported all data. This may have led to bias in their desire to see the project succeed (Hand et al., 2019). Overall, small sample sizes and limited longitudinal follow-up in the studies included in this review make it difficult to determine whether interventions are sustained or only have short-term benefits. Further research that contains follow-up beyond the six-month mark post intervention, as well as including a control groups, is required. Data that could inform ideal duration of the intervention itself would be useful for organizations, as this impacts feasibility and cost to implement. The study conducted by Zajac et al. (2017) did not match the pre- and post-test data to the individual participants and included seven different facilitators in their intervention, which raises the issue of consistency. Despite having a control group, Jakel et al. (2016) provided CF education to both the experimental and control group, thus possibly confounding results. With only one RCT to date evaluating an intervention against CF in oncology nurses, further RCT’s are required.

RECOMMENDATIONS

Creating clinical awareness of CF is an essential first step in addressing CF (Todaro-Franceschi, 2019). Acknowledging CF offers both validation for those suffering and identification for those at risk. The finding that nurses with a mean of 17.7 years of cancer care experience had never heard of CF. or their own personal risk factors reveals a pressing need for more education (Esplen et al., 2022). Along with the need for awareness is the need for ongoing, and not just one-time interventions, as found by Klein et al. (2017) when participants scores were not sustained at the six-month mark. The use of mindfulness interventions and resilience-based interventions should be considered by organizations and individual nurses throughout their career. Armed with the knowledge of what CF is and the ability to identify risk factors nurses and organizations are in a good place to employ and evaluate interventions.

Based on this review, there are multiple mindfulness, selfcare, and resilience-based strategies that can be effective for CF but, unfortunately, there is no one accepted evidence-based approach. A benefit of this finding is that long-term complicated interventions were not necessarily found to be superior to shorter, focused interventions (Pehlivan & Guner, 2020). Considerations from this review are that nurse-led interventions were well received (Hand et al., 2019; Schuster, 2021; Yilmaz et al.2018), the feedback from participants was overwhelmingly positive regardless of intervention type, and resiliency training can influence nurse retention (Blackburn et al., 2020). To screen for and create awareness, simple strategies such as completing the Professional Quality of Life Scale-Version 5 [ProQOL-5] on a yearly basis in annual education or performance reviews can prevent CF from going unchecked (Esplen et al. .2022). Ongoing reinforcement of self-care strategies should not be forgotten as a preventative strategy. The finding that a CF intervention can significantly decrease turnover nearly threefold should strengthen the argument for organizational involvement (Blackburn et al. 2020).

Compassion fatigue intervention model

Based on the findings of this review, a CF Intervention Model has been developed, Appendix C, to encompass the recommendations and findings. The model emphasizes the overarching need for awareness of CF in high-risk settings, as this was the primary finding of this review. The model highlights the need for interventions throughout the trajectory of a nurse’s career, offering broad, as opposed to detailed suggestions given the current state of CF literature.

CONCLUSION

Compassion fatigue is a workplace hazard in oncology nursing (Stamm, 2010). Mindfulness, self-care, and resilience-based interventions demonstrate promise in addressing CF. More research is needed to determine exactly what type and length of intervention is more effective. The current post-pandemic landscape has left the nursing profession in a concerning state that demands action. Acknowledgement of CF by organizations validates the trauma of those suffering and shed light on a previously dark aspect of healthcare.

Appendix A.

Figure 1.

Figure 1

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PRISMA flow chart

Appendix B.

Figure 2.

Figure 2

Figure 2

Figure 2

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Summary of the articles included in the literature review

Appendix C.

Figure 3.

Figure 3

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Compassion fatigue intervention model

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Articles from Canadian Oncology Nursing Journal are provided here courtesy of Canadian Association of Nurses in Oncology

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