compassion fatigue and spiritual practices in emergency room

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COMPASSION FATIGUE AND SPIRITUAL PRACTICES IN EMERGENCY ROOM

NURSES

By

DEBORAH VINESKY MSN, RN

Submitted in partial fulfillment of the requirements for the Doctor of Nursing Practice

Faculty Committee Chair: Deborah Lindell DNP, RN, CNE, ANEF

Frances Payne Bolton School of Nursing

CASE WESTERN RESERVE UNIVERSITY

September 2020

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CASE WESTERN RESERVE UNIVERSITY

FRANCES PAYNE BOLTON SCHOOL OF NURSING

We hereby approve the DNP Project of

Deborah Vinesky

Committee Chair

Dr. Deborah Lindell

Committee Member

Dr. Faye Gary

Committee Member

Dr. Mary Quinn-Griffin

September 2020

*We also certify that written approval has been obtained

from any proprietary material contained therein.

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Abstract

Problem and aims: Emergency room (ER) nurses are at a particular risk for development

of compassion fatigue due to the nature of the work itself. Nurses working in the ER are

exposed to traumatic events on a daily basis, this influence results in secondary traumatic stress

among this population. Research and theory indicate spiritual practices may be associated with a

decreased level of compassion fatigue. However, compassion fatigue and spiritual practices have

not been studied in emergency room nurses. The aim of this DNP project was to describe the

level of CF in ER nurses, their use of spiritual practices, and the relationship between

participants’ spiritual practices and compassion fatigue.

Methods: This study was guided by the Compassion Satisfaction-Compassion Fatigue

(CS-CF) Theory and Model. A descriptive correlational design was employed to collect data

using electronic surveys from nurses who are members of the Emergency Nurses Association

(ENA). Compassion Fatigue was measured using the Compassion Fatigue Short Scale comprised

of vicarious trauma and job burnout subscales. Spiritual Practices were measured with the

SpREUK-P scale which has five factors (religious, humanistic, existential spiritual (mind/body),

and gratitude/awe.

Pertinent findings: The sample was 50 participants. Regarding compassion fatigue,

subscale scores indicated the presence of both vicarious trauma and job burnout in ER nurses.

Regarding spiritual practices, results indicated the most engagement (in order of frequency),

religious, existential, and gratitude/awe. There was less than 50% engagement in humanistic and

mind/body practices. Due to the size of the study, the relationship between compassion fatigue

and spiritual practices could not be explored.

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Conclusions: In this study, the ER nurse participants reported experiencing compassion

fatigue (both vicarious trauma and job burnout) and a high level of participation in religious and

humanistic practices. It is recommended that hospitals provide opportunities for ER nurses to: 1)

openly discuss the risk factors, signs, potential outcomes, and strategies to prevent/manage

compassion fatigue; and 2) learn and engage in mind/body activities such as mindfulness,

meditation, and yoga at their work site and home.

Keywords: Compassion Fatigue in Nursing, Compassion Fatigue in Emergency Room

Nurses, Spiritual Practices in Nursing and Spiritual Practices by Emergency Room Nurses, and

Compassion Fatigue and Spiritual Practices

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Copyright © 2020 by Deborah Vinesky, MSN, RN

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Dedication

This scholarly project is dedicated to ER nurses everywhere. May we love and support them.

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Acknowledgements

There are people who are dear to me who have helped to make this achievement possible.

Thank you to all my family and friends who supported me, but especially my daughters - Jane

and Grace Vinesky, for without their relentless encouragement, I would not be here today. I

would like to acknowledge the Case Western Reserve University Frances Payne Bolton DNP

faculty notably Dr. Faye Gary, Dr. Mary Quinn-Griffin, and Dr. Joyce Fitzpatrick who showed

me a new worldview. I would especially like to thank Dr. Deborah Lindell from the bottom of

my heart for her professional guidance, her intellect, and her unwavering support always; she is

an outstanding person, advisor, and nurse.

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TABLE OF CONTENTS

Abstract .............................................................................................................................. iii

Copyright ............................................................................................................................ iv

Dedication ............................................................................................................................. v

Acknowledgement ............................................................................................................... vi

List of Figures ....................................................................................................................... x

List of Tables ........................................................................................................................ x

Chapter 1: Introduction ......................................................................................................... 1

Background and Significance .................................................................................... 1

Spiritual Practices by Nurses .......................................................................... 2

Problem Statement..................................................................................................... 4

Purpose...................................................................................................................... 4

Study Questions ......................................................................................................... 4

Theoretical Framework .............................................................................................. 4

Theoretical Definitions .............................................................................................. 6

Assumptions .............................................................................................................. 7

Significance for Nursing ............................................................................................ 7

Chapter 2: Review of the literature ........................................................................................ 9

Compassionate Fatigue ............................................................................................ 10

Overview ................................................................................................................. 10

Introductory definitions and history .............................................................. 10

Related Phenomenon .................................................................................... 10

Theories of compassion fatigue................................................................................ 11

ix

Risk Factors ............................................................................................................. 11

Signs and Symptoms .................................................................................... 12

Outcomes ................................................................................................................ 12

Prevention and Management/Interventions .............................................................. 12

Measurements ......................................................................................................... 13

Compassion Fatigue in Emergency Room Nursing ....................................... 13

Prevalence.................................................................................................... 13

Risk Factors ................................................................................................. 14

Outcomes ..................................................................................................... 14

Spiritual Practices .................................................................................................... 14

Overview ................................................................................................................. 14

Definition ..................................................................................................... 14

Types of spiritual practices ........................................................................... 15

Outcomes of spiritual practices .................................................................... 15

Measurements ......................................................................................................... 15

Spiritual Practices and Nurses ...................................................................... 16

Spiritual Practices and Emergency Room Nurses ......................................... 17

Gaps in literature ..................................................................................................... 17

Summary ................................................................................................................. 18

Chapter 3: Methods ............................................................................................................. 19

Design ..................................................................................................................... 19

Setting and Population ................................................................................. 20

Sample ......................................................................................................... 20

x

Measurement ........................................................................................................... 20

Compassion Fatigue ..................................................................................... 20

Spiritual Practice .......................................................................................... 22

Demographic Data ................................................................................................... 24

Protection of Human Rights ......................................................................... 26

Procedure ................................................................................................................ 26

Data Management .................................................................................................... 26

Data Analysis ............................................................................................... 27

Missing Data ................................................................................................ 27

Demographic Data ....................................................................................... 27

Chapter IV: Results ............................................................................................................. 29

Sample .................................................................................................................... 29

Missing Data ................................................................................................ 29

Study Questions ....................................................................................................... 30

Study Question 1 ..................................................................................................... 30

Study Question 2 ..................................................................................................... 31

Study Question 3 ..................................................................................................... 34

Summary ................................................................................................................ 34

Chapter V: Discussion ......................................................................................................... 35

Study Question 1 ..................................................................................................... 35

Study Question 2 ..................................................................................................... 36

Study Question 3 ..................................................................................................... 37

Theoretical Framework ............................................................................................ 38

xi

Limitations .............................................................................................................. 38

Implications and Recommendations ......................................................................... 39

Practice.................................................................................................................... 39

Future Research ...................................................................................................... 40

Conclusions ............................................................................................................. 41

References .......................................................................................................................... 42

Appendices ......................................................................................................................... 48

A. Vinesky Demographic Data ..................................................................................... 48

B. Compassion Fatigue Short Scale .............................................................................. 49

C. SpREUK-P .............................................................................................................. 50

D. Levels of Compassion Fatigue in ER Nurses............................................................ 51

LIST OF FIGURES

Figure 1. The CS-CF Model .................................................................................................. 8

Figure 2. Professional Quality of Life Model ......................................................................... 8

LIST OF TABLES

Table 1. Concepts, Variables, Definitions, and Empirical Referents .................................... 24

Table 2. Mean Scores for Vicarious Trauma (VT) and Job Burnout (JB) ............................. 31

Table 3. Frequency of Participation in Spiritual Practices by ER Nurses ............................ 33

Table 4. Levels of Engagement in Spiritual Practices .......................................................... 34

Running head: COMPASSION FATIGUE AND SPIRITUAL PRACTICES 1

CHAPTER I

INTRODUCTION

Emergency Room (ER) nurses are exposed to life and death situations and have intense,

and occasionally violent, interactions with the public. Nurses who work in Emergency

Departments (EDs) are on the frontline of an extremely challenging healthcare system and often

experience higher levels of stress due to increased patient volumes and acuities. Additionally,

caring for complex patients in a demanding and fast-paced environment, and the fact that

insurance reimbursement is now linked to patient satisfaction scores, contribute to the ER nurse

feeling overwhelmed. These factors put them at risk for developing compassion fatigue; and may

result in ER nurses leaving the ED or leaving nursing altogether (Boyle, 2015).

The role of the nurse manager has been shown to be a significant determinant of the level

of CF on the unit. Hunsaker et al. (2015) determined that the higher the level of manager support

on the unit, the lower the level of CF in the ER nursing staff. Sacco et al. (2015) reported

significant differences in compassion satisfaction and CF based on sex, age, educational level,

unit, acuity, change in nursing management, and major systems change. These research findings

suggest the value of examining hospital policy based on each unit and the typical acuity levels on

those units. According to Boyle (2011) there are emotional, physical, intellectual, social, and

spiritual manifestations of compassion fatigue. This will ultimately affect patient outcomes.

It has been suggested that compassion fatigue (CF) may be prevented or managed

through spiritual practices (Harris & Quinn-Griffin, 2015); however, there was no published to

be found that described the use of spiritual practices by ER nurses. The purpose of the proposed

DNP project was to describe the level of CF in ER nurses, their use of spiritual practices, and the

relationship between the participants’ spiritual practices and compassion fatigue.

COMPASSION FATIGUE AND SPIRITUAL PRACTICES 2

Background

Compassion Fatigue, first described by Joinson in 1992, can have harsh professional

consequences. It can cause the nurse to become inefficient, depressed, and demonstrate apathy

and detachment toward the patients in his/her care. It may result in ER nurses leaving the ED or

leaving nursing altogether. Compassion fatigue not only affects a nurse’s health and well-being,

but more importantly, it can affect the quality of care provided to patients (Hooper, Craig,

Janvrin, Witsel, & Reimels, 2010).

According to Figley (1995) the ER environment increases a nurse’s predisposition to

occupational trauma. This occupational trauma includes repeated exposure to those suffering

from abuse, injury, and death (Figley, 1995). Many ER nurses unknowingly practice ‘self-

neglect’, putting the needs of others before their own. At the heart of CF causation is exposure to

traumatic events. A study by Adrianssens et al. in 2012, shows that ER nurses are regularly

exposed to occupation related traumatic incidents, and that as many as 87% report confrontation

with one or more traumatic events in the last six months (Adrianssens, de Gucht, & Maes, 2012).

This lack of attention to their own mental health can affect their physical, psychosocial, and

spiritual well-being (Salmond & Ropis, 2005).

Nurses working in acute care areas like the ER are especially susceptible to compassion

fatigue; they enter people’s lives at precarious junctures and become their partners rather than

bear witness (Boyle, 2006). This pain and suffering become internalized, emotional boundaries

are blurred, and the caregiver unconsciously assimilates the psychosocial distress being

experienced by patients and their families (Bush, 2009).

It is important that CF be addressed in its earliest phases, as it can permanently alter the

nurse’s ability to provide safe, quality care. CF is currently described as an exhaustive state


dependent on a caring relationship with a loss of the ability to cope (Day & Anderson, 2011).

Harris and Quinn-Griffin (2015) report spiritual emptiness as a consequence of compassion

fatigue.

Spiritual Practices by Nurses

For ER nurses with CF, the use of spiritual practices can be a strategy for self-healing.

Pembroke (2016) examined Christian ethics and Buddhist philosophy as a way to manage the

effects of compassion fatigue. Findings reveal that spiritual practices allow one to cope

effectively with the effects of compassion fatigue.

An extensive review of the literature revealed no published evidence on CF and spiritual

practices by ER nurses. The majority of evidence related to CF and nursing has focused on

hospice nursing, critical care nursing, and adult and pediatric palliative care. Evidence as a result

of research regarding spiritual practices and CF in ER nurses is virtually nonexistent. There is

some confusion in the literature as the terms burnout (BO), secondary traumatic stress, and

compassion fatigue are sometimes used interchangeably. The nature of CF has been interpreted

differently as well. Unfortunately, these factors have contributed to some ambiguity. There is a

need for support and interventions for nurses who witness tragedy and death as they do in the

emergency room.

Spiritual practices can be performed individually or in a group. Yoga is a spiritual

practice that can be performed alone or in a group (White et al., 2011). Engaging in healthy

behaviors, appreciating nature’s splendor, maintaining hope and a positive outlook during

stressful times are also considered spiritual practices (White et al., 2011). Campbell and Ash

(2007) consider the personal pursuit of prayer a spiritual practice. Prayer can occur at any time,

in both religious and non-religious settings, to any deity, and be considered a spiritual practice.


Spiritual practice within the context of meditation may help a nurse reduce depression and

anxiety, improve spiritual health, and improve one’s quality of life (Wacholtz & Pargament,

2008).

Addressing the prevalence of CF in ER nursing and its relationship to spiritual practices

may provide coping strategies to lessen the long-term negative effects on ER nurses. Mentally

and physically stronger ER nurses will provide a higher quality of care to our communities.

Problem

Emergency room nurses are particularly vulnerable to the development of compassion

fatigue. Spiritual practices may be one strategy by which CF is prevented or managed. No

published literature was found which examined CF and spiritual practices by ER nurses.

Purpose

The purpose of the DNP project was to describe the level of CF in ER nurses, their use of

spiritual practices, and the relationship between the participants’ spiritual practices and

compassion fatigue.

Study Questions

This study sought to answer the following questions:

1. What is the level of CF in ER nurses?

2. To what extent do ER nurses use spiritual practices?

3. What is the relationship between ER nurses’ CF and spiritual practices?

Theoretical Framework

The study was framed by the Compassion Satisfaction-Compassion Fatigue (CS-CF)

Theory and Model (Stamm, 2010). The CS-CF theory was introduced in the 1990s and has

developed into a model as well. The purpose of the theoretical model is to examine the effects of


CF on one’s professional quality of life. According to Stamm (2010), research findings from

over 3,000 people worldwide over the past 20 years have helped to clarify the theory and create a

model that is data informed. The Center for Victims of Torture is an international non-profit

organization that provides direct care to victims of torture. The organization also conducts

research on how best to heal survivors; one of the tools used in this research is the CS-CF Model

(The Center for Victims of Torture, 2019).

The CS-CF Model (See Figure 1) involves three environments and is driven by both

positive and negative aspects of caring for others. The three environments involved in the model

are the actual work environment, the environment of the person receiving care, and the personal

environment we bring to our work (Stamm & Figley, 2009).

To understand the CS-CF Model and Theory, compassion satisfaction (CS) and

compassion fatigue (CF) need to be discussed concurrently. Compassion satisfaction and CF are

described by Stamm (2010) as the positive and negative aspects, meaning the good and bad stuff,

with regard to the work of caregivers. Compassion fatigue is the negative aspect of the work and

includes two parts: the negative aspect of helping those who experience traumatic

stress/suffering, and the positive aspect of helping as compassion satisfaction (See Figure 2).

While CF is not a medical diagnosis, it is a descriptive concept an individual may or may not

experience in conjunction with a psychological disorder including post-traumatic stress disorder

(PTSD) (Stamm, 2010).

Compassion fatigue has two parts; the first part includes symptoms of burnout

(exhaustion, frustration, anger, and depression) (Stamm, 2010). Part two is secondary traumatic

stress (STS) and work-related trauma (Stamm, 2010). Secondary traumatic stress is related to


vicarious trauma; vicarious trauma occurs when you are exposed to others’ distressing events as

a result of your work, which happens to nurses working in emergency departments.

The development of CF by an ER nurse can affect both their personal and professional

quality of life. The CS-CF Model provides a means for understanding the concept of CF, as well

as offers implications for the examination of its incidence in emergency room nurses. Using this

theoretical model for the DNP project, both the work environment and the environment of the

person receiving care is the ER, and the personal environment we bring to our work is the inner

environment of the ER nurse. The ER nurse’s inner environment may include participation in

spiritual practices.

Theoretical Definitions

Compassion Fatigue. The term compassion fatigue has been used interchangeably with

secondary traumatic stress, secondary traumatic stress disorder, vicarious stress, and burnout;

this unfortunately has caused some conceptual confusion (Nolte, Downing, Temane, & Hastings-

Tolsma, 2017). Compassion fatigue is a modern-day concept that describes personal vicarious

exposure to trauma on a regular basis (Boyle, 2011). Figley (1995) chose the term compassion

fatigue over secondary traumatic stress disorder (STSD) and described it as a preoccupation with

the trauma experienced by patients. Pembroke (2015) defines CF as a “state of significant

depletion or exhaustion of the nurse’s store of compassion, resulting from repeated activation

over time of empathetic and sympathetic responses to pain and distress in patients and in loved

ones” (Pembroke, 2015, p. 120).

Spiritual Practices. The Spiritual Science Research Foundation (SSRF) defines spiritual

practices as, “honest and sincere efforts done consistently on a daily basis to develop divine

qualities and achieve everlasting happiness or bliss” (SSRF, 2019). With regard to spirituality, as


a concept, much of the previous literature on spirituality has not differentiated between religion

and spirituality. Some disagreement still exists with regard to definitions. Researchers do not

always define important terms, and little agreement exists with regard to definitions (Cohen,

Holley, Wengel, & Katzman, 2012). Ambiguities exist, terms overlap, and definitions are either

too narrow or too broad (McSherry, Cash, & Ross, 2004). The study of spirituality has been

experienced and expressed through a conventional religious understanding.

The study of spirituality as a separate concept has a short history. According to Weathers,

McCarthy, and Coffey (2015), the main term related to spirituality is religion, or religiosity.

Assumptions

Emergency room nurses are at particular risk for the development of compassion fatigue.

Although not entirely preventable, the effects of CF can be minimized, allowing for greater

health and overall well-being in this population. Spiritual practices may be one strategy to

minimize and manage the effects of compassion fatigue.

Significance for Nursing

Compassion fatigue limits the nurse’s ability to engage in caring relationships, which

affects the care provided to patients. Engagement in spiritual practices as a strategy to decrease

the occurrence of CF in ER nurses was the focus of this DNP project. Addressing the prevalence

of CF in ER nurses, and its relationship to spiritual practices, may provide coping strategies to

lessen the long-term negative effects on ER nurses. The DNP project has the potential to yield

valuable data that may improve the quality of life of both nurses and the patients and families

that are served. Understanding the relationship between CF and spiritual practices may

encourage administrative and institutional support for management of compassion fatigue. The


facilitation of changes to hospital policy and workplace culture has the potential to lessen the

detrimental effects of CF in this population of nurses.

Figure 1

The CS-CF Model

Note. Stamm,B.H. (2009), www. ProQOL.org. Copyright 2019. The Center for Victims of Torture (www.cvt.org).

All rights reserved.

Figure 2

Professional Quality of Life Model

Note. Stamm, B.H. (2010). The Concise ProQOL Manual, 2nd Ed. Pocatello, ID: ProQOL.org Copyright 2019. The

Center for Victims of Torture (www.cvt.org). All rights reserved.

http://www.cvt.org/

http://www.cvt.org/


CHAPTER II

REVIEW OF THE LITERATURE

The purpose of the DNP project was to describe the level of CF in ER nurses, their use of

spiritual practices, and the relationship between participants’ spiritual practices and compassion

fatigue.

The study sought to answer the following questions:

1. What is the level of ER nurses CF?

2. To what extent do ER nurses use spiritual practices?

3. What is the relationship between ER nurses and spiritual practices?

This chapter presents a review of the literature as it relates to CF and spiritual practices in

ER nurses. An initial literature review (2014-2019), using the following databases: EBSCO

HOST, Cumulative Index of Nursing and Allied Health (CINAHL), PubMed and Google

Scholar, elicited 71 suitable articles. A second literature review (2019-2020), using the same

databases as used in the initial literature review, produced 19 articles (CF and nursing). The

following terms were searched individually or by combining terms: (a) compassion fatigue, (b)

nurses, (c) emergency room nurses, (d) spirituality, (e) spiritual practices and (f) quality of care.

Initially excluded was compassion fatigue in nursing but it was added to identify the

scope of the overall problem, influencing factors for nurses, patients, and organizational

outcomes, and prevention and management. Topics/Concepts included in the review were:

Compassion Fatigue in Nursing, Compassion Fatigue in Emergency Room Nurses, Compassion

Fatigue and Quality of Care, Spiritual Practices in Nursing and Spiritual Practices by Emergency

Room Nurses.


Compassion Fatigue

Overview

Introductory definitions and history. Compassion fatigue was first described by

Joinson in 1992. Then Figley (1995) defined CF as Secondary Traumatic Stress (STS).

Compassion fatigue was first examined outside of literary sources and was used interchangeably

with the terms burnout, secondary traumatic stress (STS), and vicarious traumatization (Peters,

2018). Besides nursing, CF has been examined in the academic disciplines of psychology and

social work. Boyle (2015) addressed how CF differs in nursing compared to other academic

disciplines. Compassion fatigue was inferred to be an occupational hazard in nursing because

being in the nursing profession places one at risk and CF is described as the natural outcome of

caring (Peters, 2018). According to Boyle (2006), compassion fatigue has been observed in

professional caregivers and discussed in the literature over the past two decades. Boyle (2015)

illustrated that nurses are different from other health professions because of their inherent

“constancy and proximity to tragedy over time. Nurses can’t remove themselves from their

source of distress” (Boyle, 2015, p. 14). This has led to some confusion with regard to concepts

and definitions. Coetzee and Klopper (2010) defined CF in the profession of nursing, which led

to clarification of the concept and provided both theoretical and operational definitions (Coetzee

& Klopper, 2010).

Related phenomena. Worktime demands appear to be important determinants of

psychosomatic complaints and fatigue in ER nurses (Adriaenssens et al., 2011). Additional

information regarding related phenomena can be found under Background in Chapter One.

Theories of Compassion Fatigue


The Compassion Satisfaction-Compassion Fatigue (CS-CF) Theory was introduced in the

1990’s and has developed into a model as well. The purpose of the theoretical model is to

examine the effects of CF on one’s professional quality of life. According to Stamm (2010)

research over the past 20 years has helped to clarify the theory and create a model that is data

informed; data from over 3,000 people has been collected worldwide (Stamm, 2010). White et al.

(2011) attempted to clarify the concept of spirituality beyond religiosity by building upon

Orem’s Self-Care theory. Additional information regarding theories of CF can be found under

Theoretical Framework in Chapter One.

Risk Factors

Mason et al. (2014) examined the direct relationship between CF and work engagement

of critical care nurses and found a significant negative correlation between work engagement and

CF; as work engagement scores increase, the level of CF decreased. Kelly, Runge, and Spencer

(2015) examined the incidence of CF and compassion satisfaction in acute care nurses across

multiple specialties in a hospital-based setting. This cross-sectional electronic survey studied 491

direct care nurses utilizing the ProQOL Scale. Sacco, Ciurzynski, Harvey, and Ingersoll (2015),

examined the incidence of compassion satisfaction and CF among 221 adult, pediatric, and

neonatal ICU nurses, and asked what the contributing demographic, unit, and organizational

characteristics were. Sacco et al. (2015) reported significant differences in compassion

satisfaction and CF based on sex, age, educational level, unit, acuity, change in nursing

management, and major systems change. Older nurses had lower levels of CF and burnout,

possibly due to having developed more coping skills over time. Kelly et al. (2015) revealed

significant predictors of burnout that include lack of meaningful recognition, nurses with more

years of experience and millennial nurses ages 21-33 years old. No significant differences were


noted across nurse specialties or units but Sacco and colleagues found nurses who worked in the

cardiac and vascular ICUs have higher levels of CF and burnout.

Worktime demands appear to be important determinants of psychosomatic complaints

and fatigue in ER nurses. Adriaenssens, DeGucht, Van Der Doef, and Maes (2011) suggests

regular screening for signs/symptoms of CF in ER nurses as their rate of CF is higher than in the

general nursing population, and their work-time demands are greater.

Signs and Symptoms

Signs and symptoms of CF include spiritual emptiness, lack of motivation, fatigue,

disconnectedness to others, personal and career dissatisfaction, and feelings of helplessness

(Harris & Quinn-Griffin, 2015). There are emotional, physical, intellectual, social, and spiritual

manifestations of compassion fatigue (Boyle, 2011).

Outcomes

Hooper et al. (2010) examined CF in ER nurses compared to other nurses in select

settings, as well as best practices to maintain nurses’ caring attitudes that contribute to patient

satisfaction. Hooper et al. used the ProQOL Scale and reported that nearly 86% had moderate to

high levels of compassion fatigue.

Prevention and Management/Interventions

Determinants of CF and interventions related to education were included under the

general heading of compassion fatigue and nursing. Schmidt and Haglund (2017) also addressed

the importance of a debriefing program in the prevention of caring related stress and countering

the effects of CF, and suggest the importance of regular screening, or a personal reflective

debrief. Flarity, Gentry, and Mesinkoff (2013) studied the effectiveness of an educational

program in venting and treating CF in ER nurses. Flarity et al. (2013) did indeed conclude that


an educational program is effective in preventing CF in ER nurses. Boyle (2006) identified CF in

the ER and suggested on-site workplace interventions to address the issue of emotional strain of

nurses; she too addressed preventive measures. Boyle (2006) suggested CF be managed using a

multifaceted approach to include prevention, assessment, and consequence minimization.

Measurement

The ProQOL scale is the most commonly used measure of CF, both its positive and

negative measures. The ProQOL scale, in use since 1995, has sub-scales for compassion

satisfaction, burnout, and compassion fatigue (Figley, 1995). A study by Boscarino, Figley, and

Adams (2004), focused on two main outcome measures: compassion fatigue and job burnout.

These items were derived from the 30-item Compassion Fatigue Scale-Revised (Boscarino et al.,

2004). This scale developed by Figley had been used in two other studies in 2002. The ProQOL

R-IV scale was most recently used effectively in a 2020 research study by Polat, Turan, and Tan

(see Spiritual Practices and Nurses).

Compassion Fatigue in ER Nursing

Prevalence. Dominguez-Gomez and Rutledge (2009) and Hunsaker, Chen, Maughan,

and Heaston (2015) examined the prevalence of CF in ER nurses. While Dominguez-Gomez and

Rutledge (2009) examined 67 ER nurses from three general hospitals in California, Hunsaker et

al. (2015) examined 1000 ER nurses across the country. Dominguez-Gomez and Rutledge (2009)

used an exploratory comparative design, while Hunsaker et al. (2015) obtained data using the

Professional Quality of Life (ProQOL) Scale. Dominguez-Gomez and Rutledge (2009) found

that 85% of nurses reported at least one symptom of CF in the week prior to taking the survey.

Risk factors. Hunsaker et al. (2015) determined that the higher the level of manager

support on the unit, the lower the level of CF in the ER nursing staff. Adriaenssens, DeGucht,


Van Der Doef, and Maes (2011) examined whether ER nurses differ from a general hospital

nursing comparison group. The research revealed that ER nurses report a higher level of time

pressure, more physical demands, and less reward than a general hospital nursing population.

Outcomes. Dominguez-Gomez and Rutledge (2009) and Hunsaker, Chen, Maughan, and

Heaston (2015) concluded that the negative effects of CF contribute to secondary stress to

person/environmental characteristics, coping mechanisms, and exposure to traumatic events.

Like Hunsaker et al. (2015), Hinderer et al. (2014) examined CF and tied its effects to burnout

and secondary traumatic stress. Both groups of researchers conclude that higher levels of burnout

and CF can be used to predict secondary traumatic stress.

Spiritual Practices

Overview

Definition. The Spiritual Science Research Foundation (SSRF) defines spiritual practices

as, “Honest and sincere efforts done consistently on a daily basis to develop divine qualities and

achieve everlasting happiness or bliss” (SSRF, 2019). Another way the SSRF defines Spiritual

Practices is, “Our personal journey of going inward beyond our five senses, mind, and intellect to

experience the Soul (God) within each of us” (SSRF, 2019). There is still a lack of clarity in the

literature with regard to how spirituality is defined; it is still confused with religiosity.

Types of Spiritual Practices

Spiritual practices can be performed individually or in a group. Yoga is a spiritual

practice that can be performed alone or in a group (White et al.., 2011). Engaging in healthy

behaviors, appreciating nature’s splendor, maintaining hope and a positive outlook during

stressful times are also considered spiritual practices (White et al., 2011). Campbell and Ash

(2007) consider the personal pursuit of prayer a spiritual practice. Prayer can occur at any time,


in both religious and non-religious settings, to any deity, and be considered a spiritual practice.

Spiritual practice within the context of meditation may help a nurse reduce depression and

anxiety, improve spiritual health, and improve one’s quality of life (Wacholtz & Pargament,

2008).

Outcomes of Spiritual Practices

Pembroke (2016) found that nurses that practice the skill of non-reactivity to adverse

situations will develop compassion resilience, and that nurses who are faced with the distressing

situation of being powerless to rescue a suffering person will allow themselves to feel the pain

without hating it. Spiritual practices allow one to cope effectively with the effects of compassion

fatigue.

Measurement

Dr. Arndt Bussing designed a generic instrument that could be used in adolescents,

adults, and the elderly - the SpREUK-P scale. This scale is intended to measure the engagement

frequencies of a large spectrum of organized and private religious, spiritual, existential, and

philosophical practices (Bussing, 2015). The SpREUK-P scale differentiates between the

frequency of conventional forms of spirituality/religiosity, and the philosophical practice of

nature/environment focused practices. According to Bussing (2015) the instrument is valid and

reliable and has been successful in health care research to analyze the forms of individuals´

spiritual involvement and to connect their engagement with the specific attitudes and convictions

to cope with illness.

Spiritual Practices and Nurses

Research has been done on how nurses address spiritual care needs in their patient

populations, but not on how nurses address their own spiritual needs through engagement in


spiritual practices and how that translates to nurses’ behavior in and out of the clinical

environment.

The 439 articles elicited using the search terms spiritual practices and nursing all relate to

addressing the spiritual needs of the patients we care for, not to the spiritual practices of nurses.

This most recent literature review (2019-2020), did yield two articles on CF and spiritual

practices. One article addressed the practice of social work, and the second is a study that

explored the spiritual orientation of nurses.

Polat, Turan, and Tan (2020) performed a descriptive relational study on nurses working

in two large hospitals in Turkey. They examined the spiritual orientation of nurses with

compassion fatigue (CF), burnout (BO), and compassion satisfaction (CS). The study utilized the

ProQOL R-IV and the Spiritual Orientation Inventory (SOI). Research revealed high spiritual

orientation and low rates of CF and BO. Practice implications include the regular evaluation of

nurses for CF and BO, and that nurses should question the time they spend on themselves and

leisure time. In addition, this study revealed no correlation between spiritual orientation and CF

and BO.

An Iran study examined nurses’ empathetic behaviors and the direct and indirect effect of

their spiritual orientation. Bouzanjani, Bahadori, and Pardis-Nikoonam (2020) examined a

sample of 247 Muslim nurses who worked in a cardiovascular hospital in Shiraz. The study’s

purpose was to investigate the effect of nurses’ spiritual orientation on their empathy toward

their patients. The researchers concluded that the nurses’ empathetic behavior is rooted in their

spiritual values.

Spiritual Practices and Emergency Room Nurses


There were ten articles that addressed spirituality as a concept and ER nurses, but none

were valuable; they did not discuss spiritual practices.

Gap in the Literature

Current evidence reveals that there is no useful supporting research on CF and spiritual

practices by ER nurses. The majority of evidence related to CF and nursing has focused on

hospice nursing, critical care nursing, and adult and pediatric palliative care. Under the general

heading of CF and nursing, studies pursued the prevalence, incidence, and the potential

relationships of other concepts to CF, but the nature of CF has been interpreted differently. There

is also confusion in the literature as the term’s burnout, STS, and CF have been used

interchangeably. Researchers describe the serious nature of CF and agree that in addition to the

harmful effects on nurses, care will suffer, affecting quality and placing patients at risk.

Prevention, on-site interventions, administrative and institutional support, and education have

been addressed, but the gap in the literature is related to the treatment of CF once identified, that

has not been adequately addressed. Additionally, since there is confusion related to terms, the

problem cannot be properly identified and addressed.

The organizational culture of most hospitals has not embraced caring or support

interventions for ER nurses affected by CF, but the research on critical care nurses has

demonstrated that work engagement and managerial support has led to a decrease in the

incidence of compassion fatigue in this population.

Summary

Nurses who work in EDs are exposed to particular stressors that are related to the specific

work environment of the ED and report higher levels of stress than nurses who work in other

hospital units (Yuwanich et al., 2018). Compassion fatigue exists, but interventions have not


been adequately addressed. Spiritual practices can be performed individually, or in a group.

Spirituality and its role in nurses’ performance are beginning to gain some attention in nursing

research. Correlations have still not been made between spiritual practices and the prevalence of

compassion fatigue. Engagement in spiritual practices while not altogether eliminating the

incidence of CF in ER nurses, has the potential to significantly decrease it.


CHAPTER III

METHODS

The purpose of this DNP project was to address the incidence of CF in ER nurses and to

identify its relationship to spiritual practices. The proposed study sought to answer the following

questions: What is the level of CF in ER nurses? To what extent do ER nurses use spiritual

practices? What is the relationship between ER nurses’ CF and spiritual practices?

Design

The scholarly project used a correlational research design with electronic surveys

administered to participants. The scholarly project examined levels of CF in ER nurses and the

extent that ER nurses participate in spiritual practices. A correlational study aims to determine

whether two variables are related: and in this case, compassion fatigue and spiritual practices.

The researcher was unable to establish a relationship between ER nurses’ CF and spiritual

practices because the sample size was inadequate. A power analysis using G*Power a Statistical

power analysis program (3.1.9.6) revealed reduced statistical power. Fifty (50) completed

surveys were received; 616 surveys were necessary to obtain statistical power.

Correlational research examines the relationship among variables without any active

interventions by the researcher (Polit & Hungler, 2013). A positive correlation occurs when an

increase in one variable results in an increase in the other, and when a decrease in one results in a

decrease in another, and vice versa. It is possible that two variables are not related, and no

correlation exists. Although correlational research cannot determine causality, it is beneficial for

predicting the level of one variable based on an understanding of another.

Setting and Population


The setting for this study was the Emergency Nurses Association (ENA). The ENA

consists of over 43,000 members; 57% of which are staff nurses (ENA, 2019). The extent of

ENA members is: 21% have one to two years; 19%, three to five years; 22%, six to ten years;

14%, 11 to 15 years; 9%, 16 to 20 years; and 15%, greater than 20 years’ (ENA, 2019).

Sample

The inclusion criterion for this study was ENA members who self-identified as RN staff

nurses. The exclusion criterion was ENA members who self-identify as nurse managers, and

advanced practice nurses (APRNs).

A power analysis using G*Power a Statistical power analysis program (3.1.9.6) indicated

616 surveys were necessary to obtain statistical power. An Exact-family, one-tailed Correlation

Bivariate normal model A priori power analysis was conducted: Correlation p H1 0.10, alpha err

probability 0.05, Power (1-β err probability) 0.80, and Correlation p H0 0 (Yeager, 2012).

Measurement

Compassion Fatigue

The Compassion Fatigue Short Scale (CF-Short Scale) was used to measure compassion

fatigue. The CF-Short Scale is a 13-item self-reported questionnaire consisting of two subscales:

secondary trauma and job burnout. The secondary trauma scale consists of five items, and the job

burnout scale consists of eight items. There was no total score for this scale.

“On the basis of his extensive clinical research, Figley proposed a two-factor model and

developed a scale (the Compassion Fatigue Self-Test, CFST) that consists of two subscales (CF

and burnout). Later, Gentry et al. suggested that CF comprised secondary traumatic stress/CF

and burnout. They removed some items from the CFST and developed the Compassion Fatigue

Scale-Revised (CFS-R), which has been used in many previous studies. Using a sample of social


workers who cared for victims of the 9/11 attack in New York City, Boscarino et al. assessed the

psychometric properties of the CFS-R and revised the scale again to develop the Compassion

Fatigue (CF)-Short Scale, which consists of two subscales: vicarious trauma (VT) and job

burnout (JB). Adams et al. examined the reliability and validity of the CF-Short Scale, and the

results showed that the scale had excellent reliability, construct validity, and predictive validity”

(Sun, Hu, Yu, Jiang, & Lou, 2016, p. 3).

According to Adams, Boscarino, and Figley (2006), the Cronbach’s alpha coefficients of

the subscales range 0.80 to 0.90 respectively; these numbers are indicative of internal reliability.

In 2010, Boscarino, Adams, and Figley wanted to address limitations in their previous research

by studying a random sample of senior social workers with a master’s degree or higher in clinical

practice affected by the September 11 terrorist attacks. Results indicated that scales used were

valid, and the burnout and vicarious trauma scales are appropriate assessment tools for

identifying at risk professionals (like ER nurses).

“The results of our analyses support our contention that the scales used were valid.

Therefore, the burnout and vicarious trauma scales seem to be appropriate assessment tools for

identifying professionals at risk for compassion fatigue and other psychological difficulties. In

summary, using these scales, we showed that working with traumatized patients is related to

vicarious trauma, but not job burnout, and that both vicarious trauma and job burnout

(compassion fatigue) are associated with psychological problems” (Boscarino et al.., 2010, p.

106). Sun et al. (2016), studied Chinese medical workers and firefighters, and all three subscales

confirmed acceptable internal consistency reliabilities in all groups studied; that the Compassion

Fatigue Short Scale has good psychometric properties.


The Compassion Fatigue Short Scale consists of 13 items: five for vicarious trauma and

eight related to job burnout. This survey asks respondents to consider individual scale items, then

indicate how closely it currently reflects their experience, using a 10-point, Likert-type scale (1 =

never or rarely, 10 = very often). Items are separated into vicarious trauma or job burnout, and

scores are tallied. A score of 15+ suggests that vicarious trauma may be present, and a score of

30+ suggests that job burnout may be present (Adams, Figley, & Boscarino, 2008).

Spiritual Practice

The SpREUK-P was used to measure spiritual practices. The instrument was developed to

measure the frequency of organized and private religious, spiritual, philosophical, and existential

practices; it focuses on behaviors and practices rather than cognitive and emotional attitudes

(Bussing, 2015). The generic SpREUK instrument was designed to measure the engagement

frequencies of an extensive range of organized and private, religious, spiritual, existential, and

philosophical practices (Bussing, 2015). Bussing states, “It avoids the intermix of

cognitive/emotional attitudes and convictions on the one hand with the engagement in forms of

practice (action, behaviour) on the other” (Bussing, 2015, p.2). The description of the instrument

is as follows, “The generic SpREUK-P is part of the modular SpREUK system. The contextual

SpREUK main manual addresses spirituality as a resource to cope. There was no total score for

this scale.

The SpREUK-P has 24 items and five (5) factors, including:

1. Existential (alpha = 0.83), i.e., self-realization, spiritual development, meaning in life,

turn to nature etc.

2. (Formal) Religious (alpha = 0.84), i.e., praying, church/mosque/synagogue attendance,

religious events, religious symbols etc.


3. Humanistic (alpha = 0.76), i.e., help others, consider their needs, do good,

connectedness etc.

4. Spiritual (mind body) (alpha = 0.80), i.e., meditation, rituals, reading spiritual/religious

books, etc.

5. Gratitude /Reverence (alpha = 0.76), i.e., feeling of gratitude, reverence, experience

beauty

The shortened SpREUK-P SF17 has 17 items and differentiates the same five (5) factors,

i.e., Religious (alpha = 0.82), Humanistic (alpha = 0.79), Existential (alpha = 0.77),

Gratitude/Reverence (alpha = 0.77), and Spiritual (mind body) (alpha = 0.72)” (Bussing, 2015).

For this DNP project, the 17-item SpREUK-P was used. (Appendix B).

With regard to reliability, “The internal consistency estimates range from 0.76 to 0.84

(24-item version) and 0.72 to 0.82 (17-item version) respectively” (Bussing, 2015, p.2). The

strength of the instrument is that it distinguishes between spiritual, religious, existential, and

philosophical practices and avoids combining attitudes, convictions, and practices, which can be

measured with other instruments (Bussing, 2015). Regarding validity of the SpREUK-P

instrument,

“Religious practices correlate strongly with Trust in Higher Guidance (which is a

measure of non-organized intrinsic religiosity): Spiritual practices with Search for

Spiritual Support and Trust in Higher Guidance; Existential practices with Search for

Spiritual Support (which deals with patients ‘search for a beneficial spiritual source to

cope with illness), and Humanistic practices moderately with Trust in Higher Guidance”

(Bussing, 2015, p. 2).


The items of the SpREUK-P are scored on a 4-point Likert type scale (0=never,

1=seldom, 2=often, 3=regularly). The scale is divided, and items grouped into five separate

factors: existential, religious, humanistic, spiritual (mind/body), and gratitude/reverence. The

five total scores are then transformed into a 100% scale which translates into degrees of

engagement in the distinct forms, or individual factors of a spiritual/religious practice

(engagement scores). Scores greater than 50% indicate higher engagement, while those scores

less than 50% indicate rare engagement (Bussing, 2015).

Demographic Data

The researcher-developed Demographic Data Sheet (Appendix A) is a self-report

instrument designed to gather information regarding age, gender, ethnicity, years as a registered

nurse, years as an RN in an ED, and the average number of hours worked per week.

Table 1

Concepts, Variables, Definitions, and Empirical Referents

Concept Variable Theoretical Definition Operational Definition Empirical

Reference

Compassion

Fatigue (CF)

Professional

Quality of Life

(PQOL)

Pembroke (2015)

defines CF as a “State of significant depletion

or exhaustion of the

nurse’s store of compassion, resulting

from repeated

activation over time of empathetic and

sympathetic responses

to pain and distress in

patients and in loved ones (Pembroke, 2015,

p. 120).

The CF-Short Scale is

a 13-item self-reported questionnaire

consisting of two

subscales: vicarious trauma and job

burnout. The vicarious

trauma subscale consists of items c, e,

h, j, and l, and the job

burnout subscale

consists of items a, b, d, f, g, i, k, and m.

Likert Scale:

1 (never) to 10 (most often)


Concept Variable Theoretical Definition Operational Definition Empirical Reference

Spirituality Spiritual

Practices

The Spiritual Science

Research Foundation (SSRF) defines

spiritual practices as,

“Honest and sincere efforts done

consistently on a daily

basis to develop divine

qualities and achieve everlasting happiness

or bliss” (SSRF, 2019)

Spiritual practices will

be measured by answering 31

statements describing

how often one engaged in the 31

spiritual practices. The

SpREUK-P consists

of 24-items and five factors:

Religious (P1, P2,

P19, P20); Humanistic (P22, P23,

P25, P26); Existential (P13, P14,

P10, and P9);

Spiritual

(mind/body)(P4, P8, P6); and

Gratitude/Awe (P29,

P30, P31).

Likert Scale:

0=Never 1=Seldom

2=Often

3=Regularly

Demographic

Data

Age Chronological age Age in years

Gender Gender refers to the

socially constructed characteristics of men

and women including

norms, roles, and relationships. It is

societal (World Health

Organization (WHO),

2019).

Participant’s self-

report of gender

Male,

Female, Other,

Prefer not to

Respond

Ethnicity Participant’s self-report

of ethnicity.

White,

Black,

Latino,

Asian or Pacific Islander,

Native American,

Other (specify) Employment Time as RN

Time worked in ED

Work effort

Years

Years

Average

hours/week


Protection of Human Rights

The CWRU Institutional Review Board (IRB) determined the study exempt from review.

A modification in February 2020 allowed the researcher to recruit at conferences. Information

regarding informed consent was provided prior to beginning the survey and consent was implied

by completion of the survey. Participation was strictly voluntary, and anonymity was maintained.

Security protocol was explained about how data was collected in an encrypted environment.

Participants were informed that there were no risks associated with participation in this study.

The risks were minimized by individual decision to participate in the study. In addition,

participants were made aware that there were no direct benefits to each individual participating

in the study.

Procedure

Following IRB review, the survey and consent were entered into Qualtrics and all study

related materials were submitted to [email protected] for review. Once approved by the ENA, the

survey was made available on the ENA’s research website from January 23 through April 30,

2020. The researcher also recruited at a chapter meeting of the Ohio ENA on February 26, 2020.

Data Management

The data was transferred from Qualtrics to IBM SPSS (Statistical Software for the Social

Science) version 26. The data were analyzed, and the results are maintained on a secure

encrypted laptop locked in the researcher’s home. Only the researcher and the researcher’s

faculty advisor (Dr. Deborah Lindell) and committee members (Dr. Deborah Lindell, Dr. Faye

Gary, and Dr. Mary Quin-Griffin) have access to the data.


Data Analysis

Missing Data

Only complete surveys (responses to all items) were analyzed.

Demographic Data

Descriptive statistics were used to describe the characteristics of the sample. Age, gender,

and ethnicity are nominal-level variables. Number of years as a registered nurse, number of years

as an RN in an ED setting, and the average number of hours worked per week are ratio-level

variables. Nominal-level variables were grouped into categories; they have no meaningful order

and cannot be ranked or quantified.

Study question #1: What is the level of ER nurses CF?

The Compassion Fatigue Short Scale was employed. The Compassion Fatigue Short

Scale used in this survey consists of two subscales: vicarious trauma and job burnout, which are

integrated within the instrument itself. Descriptive statistics were used to calculate the number

and percentage of the total number of participants who meet or exceed the cut-off for vicarious

trauma (VT) and burnout (BO). Regarding levels of CF in ER nurses, means and standard

deviations were obtained for individual survey items. These survey items were categorized as

either VT or JB; means were obtained which provided indicators for the presence of either VT or

JB, or both.

Richard Adams is the Professor and Chair in the Department of Sociology at Kent State

University in Kent Ohio. Professor Adams has done extensive research with the creator of the CF

scale (Dr. Charles Figley) and Dr. Joseph Boscarino. According to Professor Adams, CF can be

calculated using a total score, or two separate scores one for VT and one for JB (R. Adams,

personal communication, July 28, 2020). Dr. Richard Adams states it is a matter of preference


with regard to terminology used when describing CF (R. Adams, personal communication, July

28, 2020). In the literature, secondary stress, vicarious trauma, and job burnout have all been

used within the same context in discussions on CF. The researcher has chosen to use the terms

VT and JB in describing CF in keeping with the survey used.

Study question #2: To what extent do ER nurses use spiritual practices?

The 27-item SpREUK-P instrument is comprised of five factors: Religious, Humanistic,

Existential, Spiritual (mind/body), and Gratitude/Awe. Participants were asked to report the

frequency describing how often they engaged in spiritual practices on a four-point scale;

Regularly, Often, Seldom, or Never.

The frequency of participation in spiritual practices by ER nurses was obtained by

percentages broken down by occurrences: regularly, often, seldom, and never. Items were

identified according to one of five factors: religious, humanistic, existential, gratitude/awe, and

spiritual. A percentage level of engagement was calculated for each factor by multiplying the

means for each factor by 33.3. The percentages indicate degrees of engagement. This syntax was

provided by the survey’s creator, Dr. Arndt Bussing.

Study question #3: What is the relationship between ER nurses’ CF and spiritual practices?

The Pearson R test is a statistical formula that measures the direction of association

between two continuous variables (level of CF and participation in spiritual practices). The

researcher was unable to establish a relationship between ER nurses’ CF and spiritual practices

because the sample size was inadequate. A power analysis using G*Power a Statistical power

analysis program (3.1.9.6) revealed reduced statistical power. Fifty completed surveys were

received; 616 surveys were necessary to obtain statistical power.


CHAPTER IV

RESULTS

Emergency room nurses may experience compassion fatigue due to repeated exposure to

life and death situations, and occasionally violent interactions with the public. Being on the

frontline of an extremely challenging healthcare system puts them at risk for developing CF. It

has been suggested that compassion fatigue (CF) may be prevented or managed through spiritual

practices (Harris & Quinn-Griffin, 2015).

Sample

Missing Data

Seventy-eight (78) surveys were received and checked for missing data. First,

participants who did not finish the survey were removed using the variable finished. Sixty-five

(65) participants with complete surveys were kept and 23 participants with incomplete surveys

were removed from the data frame. Following this, there were still participants containing

missing data for all survey items. These participants consistently missed the first few survey

items, so these participants were removed based on data missing from the first four survey items.

This then excluded another 10 participants from the data. Following this, five participants did not

complete all items to calculate the SpREUK-P factor scores, so these too were excluded from the

analytic set. The result is a data frame with 50 complete observations. In total, 38 participants

were removed from the original resulting in a final sample of 50 (64.1%).

Characteristics

Years of experience as a registered nurse ranged from 1 to 43 years with a reported mean

of 16.8 years (SD=12.1). The participants’ years of experience in an Emergency Room ranged


from 1 to 40 years with a reported mean of 14.7 years (SD=11.1). Nurses ranged in age from 24

to 66 years, with a mean of 42.1 years (SD=11.06).

Regarding gender, eight (14.8%) were male, 45 (83.3%) were female, and one (1.9%)

chose not to respond. Regarding ethnicity, 48 (90.6%) respondents were white, two (3.8%) were

black or African American, one (1.9%) was Latino, one (1.9%) was Asian or Pacific Islander,

and one (1.9%) responded as other. With regard to number of hours worked, 45 (88.5%) worked

full-time, eight (10.2%) worked part-time, and one (1.3%) worked per diem.

Study Question

Study question #1: What is the level of CF in ER nurses?

Participants were asked to consider their work/life situation and choose the number that

best reflects their experiences using a 1-10 rating scale that ranged from Never/Rarely to

Sometimes, to Very Often. Data levels relating to CF are displayed in Appendix D. Compassion

fatigue subscales for vicarious trauma and job burnout were 21.06 and 39.88 respectively. Both

subscale scores indicate the presence of both CF and JB in ER nurses. The most common

indicator of CF was the ER nurse frequently feeling weak and tired as a result of working as a

caregiver, followed by feeling trapped and experiencing flashbacks related to caring for patients.

The CF scale consisted of 13 items. Cronbach’s alpha for the 13 items was .924.


Table 2

Mean Scores for Vicarious Trauma (VT) and Job Burnout (JB), N=50

Work/Life Considerations

VT Mean JB Mean

I have had flashbacks connected to my

patients

5.67 I have felt trapped by my work 5.83

I experience troubling dreams similar

to a client of mine

3.51 I have thoughts that I am not

succeeding in my life’s goals

5.44

I have experienced intrusive thoughts

after working with especially difficult

clients/patients

5.10 I feel that I am a failure in my work 3.68

I have suddenly and involuntarily

recalled a frightening experience while

working with a client/patient

3.76 I have felt a sense of hopelessness

associated with working with

clients/patients

4.57

I am losing sleep over a client’s

traumatic experiences

3.02 I have frequently felt weak, tired, or

rundown as a result of my work as a

caregiver

7.17

I have felt depressed as a result of my

work 5.15

I feel like I am unsuccessful at

separating work from personal life

4.17

I have a sense of worthlessness,

disillusionment, or resentment

associated with my work

3.87

VT Total Score = 21.06 JB Total Score = 39.88

Note: A score of 15+ suggests that vicarious trauma may be present and a score of 30+ suggests

that job burnout may be present (Adams, Figley, & Boscarino, 2008)

Study question #2: To what extent do ER nurses use spiritual practices?

The 27-item SpREUK-P instrument is comprised of five factors: Religious, Humanistic,

Existential, Spiritual (mind/body), and Gratitude/Awe. Participants were asked to report the

frequency describing how often they engaged in spiritual practices on a four-point scale;

Regularly, Often, Seldom, or Never. Percentages describing frequency of participation in


spiritual practices are displayed in Table 3. A score greater than 50% indicates higher

engagement, and less than 50%, rare engagement.

Emergency room nurses most commonly engaged in religious factor practices (96%)

which included privately praying, going to church/mosque/synagogue, recognizing the

importance of religious symbols, and participating in religious events. Existential factor practices

included reflecting on the meaning of life, gaining insight into self, and working on self-

realization indicated that 71.3% of ER nurses engaged in these practices. Gratitude/awe factor

practices also revealed greater engagement of ER nurses practicing feelings of gratitude and

wondering awe (69.2%). Humanistic factor practices including helping others, considering the

needs of others, thinking of those in need, and doing good surprisingly indicated rare

engagement (43.6%). Lastly, ER nurse engaged in spiritual factor practices the least amount of

time (11.1%) including engagement in meditation, yoga, mindfulness, and other traditions other

than their own. The SpREUK-P consisted of 27 items. The Cronbach’s alpha for the 27 items

was .899.


Table 3

Frequency of Participation in Spiritual Practices by ER Nurses (N = 50)

Spiritual Practice in Percent (%) Regularly Often Seldom Never

I privately pray for myself or others 30.8 17.3 23.3 28.8

I go to church/mosque/ synagogue 20.4 3.7 25.9 50.0

I make an effort for other people 57.4 31.5 9.3 1.9

I meditate either Western or Eastern styles 11.1 7.4 25.9 55.6

I recite distinct holy texts 5.6 13.0 16.7 64.8

I read religious/spiritual books 9.3 20.4 22.2 48.1

I work on mind/body discipline

(yoga/qigong/ mindfulness/etc.)

20.8 15.1 34.0 30.2

I perform distinct rituals originated in

other religious spiritual traditions other

than mine

5.6 7.4 18.5 68.5

I turn to nature 24.1 35.2 31.5 9.3

I reflect upon the meaning of life 24.1 46.3 20.4 9.3

I try to get insight also into myself 31.5 42.6 18.5 7.4

I work on my self-realization 25.9 29.6 37.0 7.4

I work on my spiritual development 18.5 29.6 25.9 25.9

I try to achieve a higher level of

consciousness

24.1 16.7 27.8 31.5

I am aware in the way I treat the world

around me

39.6 49.1 9.4 1.9

In my private area, religious symbols are

important to me

11.1 24.1 20.4 44.4

I participate in religious events

(congregations, etc.)

18.5 13.0 18.5 50.0

I believe in a (my) guardian angel 24.5 15.1 22.6 32.7

I help others 81.5 4.8 3.7 0

I consider the needs of others 79.6 18.5 1.9 0

My thoughts are with those in need 51.9 42.6 9.6 0

I do good 73.6 26.4 0 0

I feel connected with others 53.7 33.3 13.0 0

I work voluntarily for others 33.1 48.1 13.0 5.6

I have a feeling of great attitude 25.9 55.6 16.7 1.9

I have a feeling of wonderful awe 14.8 33.3 42.6 9.3

I still have learned to experience and

value beauty

33.3 48.1 18.5 0


Table 4

Levels of Engagement in Spiritual Practices (N=50)

SpREUK Factor and Items Engagement in Percent (%) Average

Religious:

I privately pray,

I go to church/mosque/synagogue,

In my private area, religious symbols are important to me,

I participate in religious events

96.0

Humanistic:

I help others,

I consider the needs of others,

My thoughts are with those in need,

I do good

43.6

Existential:

I reflect upon the meaning of life,

I try to get insight (also into myself),

I work on my self-realization

71.3

Gratitude/Awe:

I have a feeling of great gratitude,

I have a feeling of wondering awe

69.2

Spiritual:

I meditate (either Eastern or Western styles),

I work on a mind-body discipline (i.e., yoga, qigong, mindfulness, etc.),

I perform distinct rituals (originated in other religious/spiritual traditions other

than mine)

11.1

Study Question #3: What is the relationship between ER nurses’ CF and spiritual

practices?

Study question 3 could not be answered as the sample was too small to meet the required

power.

Summary

Results for study questions one and two was obtained. Emergency room nurses are

suffering from CF and were least engaged in spiritual practices compared to religious factor

practices like participation in private prayer, group worship, and partaking in religious events.


CHAPTER V

Discussion

This DNP project sought to describe the level of CF in ER nurses, their use of spiritual

practices, and the relationship between participants’ spiritual practices and compassion fatigue.

This study added insights into CF and spiritual practices as there is no previous research that

looked specifically at the ER nurse population. According to the most recent National Workforce

Nursing Survey performed by the National Council of State Boards of Nursing (NCSBN), 9% of

nurses are male (NCSBN, 2017). The 2020 national survey is currently underway. The survey

revealed that 14.3% of the survey respondents were male, which is higher than the national

average. Although male nurses represent just a small fraction of the nursing workforce, they

typically are attracted to the ER and to critical care units.

The nature of the problems related to CF have been under addressed because CF has been

interpreted differently, leading to confusion in the literature. Additionally, the terms burnout,

STSD, and CF have been used interchangeably resulting in a lack of clarity. In the literature,

secondary stress, vicarious trauma, and job burnout have all been used within the same context in

discussions on CF. The researcher has chosen to use the terms VT and JB in describing CF in

keeping with the survey used.

Study Question #1: What is the level of CF in ER Nurses?

The most frequently reported descriptor of CF was frequent complaints of feeling weak,

tired, or rundown as a result of working as a caregiver (mean 7.17); 26.9% of nurses chose the

highest number 10 on the 1-10 scale. Worktime demands appear to be important determinants of

psychosomatic complaints and fatigue in ER nurses. Adriaenssens, DeGucht, Van Der Doef, and


Maes (2011) suggests regular screening for signs/symptoms of CF in ER nurses as their rate of

CF is higher than in the general nursing population, and their work-time demands are greater.

The least common complaint relating to CF reported by participants is loss of sleep (mean 3.02);

only 1.3% of nurses reported the highest number 10 on the 1-10 scale. Additionally, nurses are

not feeling like failures in their work (mean 3.68) but do report flashbacks (mean 5.67) and feel

“trapped” by their work (mean 5.83). Hooper et al. (2010) examined CF in ER nurses compared

to other nurses in select settings. Hooper et al. used the ProQOL Scale and reported that nearly

86% had moderate to high levels of compassion fatigue.

These results align with recent literature by Peters (2018) who inferred that CF is an

occupational hazard in nursing because being in the nursing profession places one at risk and CF

is described as the natural outcome of caring. Boyle (2015) illustrated that nurses are different

from other health professions because of their inherent constant proximity to tragedy over time

and they are unable to remove themselves from the source. The Cronbach’s alpha of .924

indicates an excellent internal consistency as it is greater the 0.9.

Study Question #2: To what extent do ER nurses use spiritual practices?

Reported levels of engagement in spiritual practices from highest to lowest are Religious

factor (96%), Existential factor (71.3%), Gratitude/Awe (69.2%), Humanistic factor (43.6%),

and lowest is the Spiritual factor (11.1%) (individual percent scores reported out of a total of

100%). Further interpretation of data implies that few nurses are meditating, working on a mind-

body discipline like yoga or mindfulness, or participating on rituals other than their own.

Concerning specific practices, 34.6% reported never going to church/mosque/synagogue,

38.5% replied never to meditating, and 68.5% report never to performing rituals originating in

other spiritual/religious traditions other than their own. Concerning the consideration of the


needs of others, thoughts are with those in need, doing good, feeling connected with others, and

learning to experience and value beauty, every respondent responded with regularly, often, or

seldom; no one responded never. Nurses are inherently caring individuals. Compassion

satisfaction is described by Stamm (2010) as the positive aspect, meaning the good stuff, with

regard to the work of caregivers. It did not surprise the researcher that survey respondents

responded never to consideration of the needs of others, thoughts are with those in need, doing

good, and feeling connected with others.

With regard to praying privately for self and others, 20.5% report regularly, while 19.2% report

never. Campbell and Ash (2007) considered the personal pursuit of prayer a spiritual practice as

well and found that prayer can occur at any time, in both religious and non-religious settings, to

any deity, and be considered a spiritual practice. Only 14.1% of respondents state they work on

a mind/body (yoga/mindfulness) discipline regularly, while 21.8% attempt to get insight into

themselves, and 16.7% of respondents turn to nature (individual percent scores report out of a

total of 100%). White et al. (2011) also explored the appreciation of nature’s splendor as a

spiritual practice and reported that it was effective in promoting a positive outlook during

stressful times. The Cronbach’s alpha of .898 indicates a good internal consistency (0.9 > α >

0.8.).

Study Question #3: What is the relationship between CF and spiritual practices in ER

nurses?

A correlation between ER nurses CF and spiritual practices was unable to be made due to

too few survey participants and insufficient power. A 2020 report of a descriptive relational

study of nurses working in two large hospitals in Turkey examined the spiritual orientation of

nurses with compassion fatigue, burnout, and compassion satisfaction (Polat, Turan, & Tan,


2020). Although this study did not include ER nurses, it did examine the relationship between

the spiritual orientation of nurses with CF. Polat et al. 2020 found that both professional

satisfaction and high spiritual orientation of the nurses was high, and burnout and CF were low.

A second study examined Iranian nurses’ empathetic behaviors and the direct and indirect effect

of their spiritual orientation. Bouzanjani, Bahadori, and Pardis-Nikoonam (2020) examined a

sample of 247 Muslim nurses who worked in a cardiovascular hospital in Shiraz. Bouzanjani et

al. 2020 found that nurses’ spiritual orientation has a positive effect on their psychological

investment and empathetic behaviors. They concluded that nurses’ empathetic behaviors reflect

their spiritual orientation (Bouzanjani et al., 2020).

Rather than just examining the spiritual practices of our patient populations and its effect

on health and healing, spiritual practices, and its role in the performance of nurses is beginning to

gain attention from nurse researchers. Previous researchers have not examined this relationship.

The role of the frontline worker is now more important than ever, as nurses attempt to navigate

their practice in light of a global pandemic. Because a patient’s healthcare experience often

begins upon entering the ER, the behaviors of the nurse can have a direct effect on the patient’s

health and well-being, as well as contribute to the quality of care provided. Adequate attention

has not been given to the level of CF the nurse may be experiencing. Addressing the spiritual

practices of the staff may be one way that these effects are prevented, or at least minimized.

Providing opportunities for the ER nurse to fully engage in their work may also foster feelings of

compassion satisfaction rather that fatigue.

Theoretical Framework

The development of CF by an ER nurse can affect both their personal and professional

quality of life. The CS-CF Model provided a means for understanding the concept of CF, as well


as offered implications for the examination of its incidence in emergency room nurses. Using

this theoretical model for the proposed DNP project, both the work environment and the

environment of the person receiving care was the ER, and the personal environment we bring to

our work was the inner environment of the ER nurse. The ER nurse’s inner environment may

include participation in spiritual practices. The researcher recommends using it again as it

provided an effective framework in examining CF in ER nurses.

Limitations

The major limitation of this study is the small number. The number (78) of surveys

received, is a very small proportion of the total membership of the ENA which is approximately

40,000 nurses (Emergency Nurses Association, 2019). Moreover, after accounting for missing

data, the final sample was 50 participants. The small sample may have been influenced by wo

factors: mode of delivery of the survey, and the survey itself.

A second limitation is that the sample was obtained only from ENA members and ENA

membership is not a requirement for working in an emergency department. There is a possibility

that the respondents have additional attributes solely by being ENA members not identified by

the researcher that contribute to the presence of compassion fatigue and their responses.

An added limitation may have been that both nurse managers and advance practice nurses

were excluded from the study. The inclusion of both nurse managers and advance practice nurses

may have given the researcher the respondents necessary to complete the relationship between

ER nurses CF and participation in spiritual practices.

Mode of Delivery

Web-based research surveys tend to have lower response rates than other modes of

deliver; however, they are more cost effective (Timmins, 2014; Hardigan, Succar, & Fleisher,


2012, and Manzo & Burke, 2012). Low response rates affect validity of the study as little is

known about those that do not respond.

Factors Related to the Survey

In the current study, 28/78 participants started, but did not complete the survey. Factors

influencing “drop out” may include survey is too long, participant is not interested in the survey

or parts of the survey; participant is disqualified or does not receive incentive after answering

several questions; participant does not see how the survey or a particular question applies to

them; asking multiple difficult to understand or answer questions; reward isn’t worth the effort;

survey contains broken links; and using too many words when a few will do (Biocentric, 2015;

SurveyMonkey, 1999-2020).

Strategies to Increase Participant Response

Many strategies have been suggested to improve response rates for web-based surveys,

including clear aim contact name/email provided; address confidentiality or anonymity; attention

to digital images, access, and layout; announce completion time, indicate progress; and provide

incentives which include 1) material (such as lottery for gift card) and 2) non-material such as

pre-notification, personalized invitation, and reminders with response rates (Manzo & Burke,

2012; McPeake, Bateson, & O’Neil, 2014, Timmins, 2014).

In this study, a particular challenge was the ENA posted the study on their research site

and notified members in e-newsletters. Thus, the researcher was not able to send direct emails to

invite members to participate individually.

Suggestions for future research with this population include review the survey instrument

to improve interest by participants and explore alternate strategies for recruitment and modes of

deploying the survey.


Implications and Recommendations

Practice

These findings confirm that emergency nurses do demonstrate both VT and JB.

Regarding levels of engagement in spiritual practices, ER nurses scored greater than 50% in the

areas of religious, existential, and gratitude/awe indicating higher engagement, and less than

50% in the areas of spiritual and humanistic factors, indicating rare engagement. The researcher

suggests the use of a spirituality scale rather than a spiritual practices scale used in this study.

Managerial and institutional support for nurses requires an understanding of the factors

that contribute to CF, in addition to an understanding of prevention strategies. The facilitation of

changes to hospital policy and workplace culture has the potential to lessen the detrimental

effects of CF in this population of nurses. Mason et al. (2014) examined the direct relationship

between CF and work engagement of critical care nurses and found a significant negative

correlation between work engagement and CF; as work engagement scores increase, the level of

CF decreased. Hunsaker et al. (2015) determined that the higher the level of manager support on

the unit, the lower the level of CF in the ER nursing staff. Research has shown that it does

behoove senior leadership to take a vested interest in preventing and addressing CF.

Prevention strategies should be addressed during orientation to the ER and should

continue throughout the nurse’s tenure in the department. Education programming including a

nurse mentoring program would assist the nurse in recognizing signs and symptoms of CF in

themselves and their peers. ER nurses should be evaluated regularly for signs and symptoms of

CF. Fostering a culture of acceptance among the nursing staff would encourage early recognition

and treatment of at-risk staff.


Compassion fatigue limits the nurse’s ability to engage in caring relationships, which

affects the care provided to patients. Engagement in spiritual practices as a strategy to decrease

the occurrence of CF in ER nurses has the potential to prevent or at least minimize the

occurrence of CF. Addressing the prevalence of CF in ER nurses and its relationship to spiritual

practices may provide coping strategies to lessen the long-term negative effects on ER nurses.

Participation in spiritual practices may improve the quality of life of both nurses and the patients

and families that we serve. The researcher recommends examining a nurse’s spiritual orientation

as a construct in the identification and prevention of CF in ER nurses.

An intervention may take the form of some less experienced ER nurses meeting weekly

or bi-weekly with an assigned mentor or more experienced ER nurse. Discussing one’s feelings

and concerns can support the newer ER nurse and assist with an action plan and coping strategies

in the event that the nurse develops compassion fatigue. Spiritual practices can be performed

individually or in a group. Yoga is a spiritual practice that can be performed alone or in a group

(White et al., 2011). Spiritual practice within the context of meditation may help a nurse reduce

depression and anxiety, improve spiritual health, and improve one’s quality of life (Wacholtz &

Pargament, 2008).

A designated room where the nurse can get away during a long and stressful shift is one

way in which the nurse can practice prevention strategies. According to Marberry (2018) a Zen

Den wish list includes meditation/nap chairs, massage chairs, meditation cushions, calming

lights, throw blankets, yoga mats, artwork, Himalayan salt lamp, a shoe rack to prevent infection,

a feng shui table fountain, air plants, and two low table storage units. Promoting a culture of

taking a break as being a positive idea may require a culture shift on some units. This is


inexpensive but its rewards are far greater than financial when optimal patient care is the end

result.

In 2011, an ER trauma nurse Jonathan Bartels at the University of Virginia implemented

“The Pause” as a way of honoring the death of a patient. Jonathan worked with the School of

Nursing as an integral member of the Compassionate Care Initiative to help nursing students and

physicians in the practice of promoting resiliency. The Pause has since been embraced by teams

across the United States, including the Cleveland Clinic, and has been translated into six

different languages. Jonathan describes how detachment can lead to unhealthy outcomes for the

nurse working in the ER. Jonathan describes a patient’s death as a shared experience and that

pausing afterward is a means of ritually marking the importance of the moment. At Metro

Hospital in Cleveland, Ohio, this researcher completed practicum hours participating in “Trauma

Moons”; faculty in-services held in preparation for the upcoming trauma season. These in-

services provided an opportunity for camaraderie among all staff including advanced nurse

practitioners, staff, and nurse managers. Topics provided included mindfulness and resiliency.

Staff participated in an individual and group art project.

It is vital that research examines prevention strategies and treatment related to

compassion fatigue. It may be helpful to know the patient profile where the survey participant

practices. This information can be included in demographics as there are levels of emergency

care from a small few bed ER to a level 1 trauma center. Acuity levels of the patient population

may affect levels of staff compassion fatigue.

New ER nurses need to be made aware of available resources provided by the workplace.

Most hospitals now include an employee assistance program in some form. Pastoral Care

departments may also offer support and/or counseling if needed. Spiritual practices have the


potential to provide coping behaviors for this population of nurses. A nurse’s spiritual orientation

may be an indicator of whether or not he/she develops CF. Future research examining

compassion satisfaction and work engagement when considered within the context of CF may

also yield valuable data on CF. Additional research should examine an ER nurse’s spiritual

orientation in addition to participation in spiritual practices. Future research should attempt to

identify behaviors that when practiced regularly by the nurse, will prevent, or at least minimize

the physical and emotional effects of CF.

Conclusions

Emergency Room (ER) nurses are exposed to life and death situations and have intense

and occasionally violent interactions with the public. Nurses who work in Emergency

Departments (EDs) are on the frontline of an extremely challenging healthcare system and often

experience higher levels of stress due to increased patient volumes, as well as patient acuities.

Additionally, caring for complex patients in a demanding and fast-paced environment, and the

fact that insurance reimbursement is now linked to patient satisfaction scores, contribute to the

ER nurse feeling overwhelmed. These factors put them at risk for developing compassion fatigue

and may result in ER nurses leaving the ED, or leaving nursing altogether (Boyle, 2015).

This study examined the concepts of CF and spirituality and began out of a desire to see

if there was a correlation between ER nurses CF and engagement in spiritual practices. The

researcher’s aim was to demonstrate that participation in certain spiritual practices may provide a

means of coping with the stressors related to CF. Even though the research failed to provide

complete data, the study did yield valuable information on the presence of CF and nurse’s

engagement in spiritual practices, in addition to recommendations to future research, which is

encouraging.


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Appendix A

Vinesky Demographic Data

Hello:

You are invited to participate in this survey regarding the relationship between compassion

fatigue and spiritual practices in Emergency Room Nurses. Members of the Emergency Nurses

Association (ENA) who agree to participate will be asked to provide some information about

themselves and complete two surveys about compassion fatigue and spiritual practices.

It will take approximately 20-25 minutes to complete the questionnaires. Your participation in

this study is completely voluntary. There are no foreseeable risks associated with this project.

However, if you feel uncomfortable answering any questions, you can exit from the survey at

any point. Your survey responses will be strictly anonymous and data from this study will be

reported only in the aggregate.

If you have questions at any time about the survey or the procedures, you may contact Deborah

Vinesky MSN, RN at 440-670-0902, or by email at [email protected], or Dr. Deborah

Lindell DNP, RN at [email protected] or 216-368-3740. Thank you very much for

your time and support.

1. Which gender do you identify as (please select all that apply)?

1. Male

2. Female

3. Prefer not to respond

2. How old are you? ______ Years

3. How would you identify your race/ethnicity (please select all that apply)?

1. White

2. Black

3. Latino (any race)

4. Asian or Pacific Islander

5. Native-American

6. Other (Please specify)

4. Number of years as a Registered Nurse. ______ Years

5. Number of years as an RN in an ED Setting. ______ Years

6. What is the average number of hours you worked per week? ______ Hours

mailto:[email protected]

mailto:[email protected]


Appendix B

Compassion Fatigue Short Scale


Appendix C

SpREUK-P


Appendix D

Levels of Compassion Fatigue in ER Nurses

Descriptors of CF N Min Max Mean SD

I have felt trapped by my work 50 1 10 5.83 3.01

I have thoughts that I am not succeeding in achieving

my life’s goals.

50 1 10 5.44 3.10

I have had flashbacks connected to my patients. 50 1 10 5.67 3.45

I feel that I am a failure in my work. 50 1 10 3.68 2.66

I experience troubling dreams similar to a client of

mine.

50 1 10 3.51 3.22

I have felt a sense of hopelessness associated with

working with clients/patients.

50 1 10 4.57 3.00

I have frequently felt weak, tired, or rundown as a

result of my work as a caregiver.

50 1 10 7.17 2.82

I have experienced intrusive thoughts after working

with especially difficult clients/patients.

50 1 10 5.10 3.07

I have felt depressed as a result of my work. 50 1 10 5.15 3.41

I have suddenly, and involuntarily, recalled a

frightening experience while working with a

client/patient.

50 1 10 3.76 3.19

I feel I am unsuccessful at separating work from

personal life.

50 1 10 4.17 2.68

I am losing sleep over a client’s traumatic

experiences.

50 1 10 3.02 2.33

I have a sense of worthlessness, disillusionment, or

resentment associated with my work.

50 1 10 3.87 3.09

Note. This data was obtained using SPSS software. Min = minimum score and Max = maximum

score on a 1-10 scale.

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