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TOPIC 3 - CNO Best Practice Guideline: Code of Conduct 

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TOPIC 3 - CNO Best Practice Guideline: Code of Conduct 

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TOPIC 3 - Artifact 2 “Culturally safe healthcare shows respect for culture and identity. It incorporates a person’s needs and rights and is free of discrimination.” Quote from Healthcare excellence Canada 

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TOPIC 3 - Artifact 2 “Culturally safe healthcare shows respect for culture and identity. It incorporates a person’s needs and rights and is free of discrimination.” Quote from Healthcare excellence Canada 

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This quote resonates with me because it represents the goal of relational and person-centered nursing care. I believe that cultural safety goes beyond simply acknowledging a person’s background. I think that it means actively doing your best to make sure that their culture is respected and incorporated in their care. I have learned in clinical experience how asking about someone’s culture and how it can be incorporated in their care can change someone’s experience.

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TOPIC 3 - Measuring Cultural Safety in Health Systems: Canadian Institute for Health Information

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TOPIC 3 - Measuring Cultural Safety in Health Systems: Canadian Institute for Health Information

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This piece of art was inspired by a story from my mental health clinical. I was caring for a patient who had put his family through some hard things. He was struggling as he did not want to be feeling the way he did. It was amazing to me to see how his family still supported him despite the things that he had done. They truly just wanted him to get better and feel in control of his thoughts. For me this experience exemplified the importance of understanding a patient’s context before making judgements about them. We cannot understand a patient’s situation without knowing what has influenced it. This has been one of my biggest take aways throughout this course.

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I have included this ad as an artifact for this topic as it was one of my first exposures to campaigns destigmatizing mental health. The goal of this campaign is to help people open up and have discussions about mental health, share their stories and ask questions. This Ad reminds me of the importance of really engaging patients in discussions about their mental health. Social media campaigns can feel surface level and one ad would not make me want to open up to someone. This is a reminder for me that as someone in healthcare it is my responsibility to listen and support people struggling with mental health. I hope to be able to further the destigmatization of mental health in healthcare.

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This photo is the cover for an article about the racism that indigenous people face, and its impact on mental health. Indigenous people have been facing racism since colonizers came to Canada. Generational trauma and current racism that they continue to face can have massive impacts on one’s mental health. It is evident that more needs to be done to help our indigenous population. It begins with breaking down the racism that they face. As a person in health care, it is my job to make sure that I treat indigenous people with dignity and cultural safety. Stopping stigma starts with us, making sure that we are carful to be sensitive and caring for indigenous people, the things that we say as healthcare professionals have an impact, it is important that it is for good.

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Racism is increasingly recognized as a factor that plays a role in mental health as well as disparities in mental health care. This can be particularly true among many of the most marginalized groups, including Indigenous communities.

Indigenous communities can be found in countries throughout the world and make up an estimated 5% of the world's total population. While these communities are unique and differ from one another in a variety of ways, they do have a shared history of trauma, forced migration, discrimination, and segregation that have had lasting effects on generations of Indigenous peoples.

Racism is a significant factor contributing to the onset of mental health conditions, but it also plays a major role in increasing disparities that contribute to worsening mental health.

Research suggests that racism affects health and well-being by increasing unhealthy psychological responses, contributing to poor health behavior, physiological dysregulation, sleep disruptions, and higher rates of substance use.﻿﻿

Indigenous Communities Face Prevalent Racism

Racism directed toward Indigenous people is a common problem throughout the world. In the United States, research suggests that both discrimination and harassment are widely experienced among Native Americans.

These experiences occur in multiple domains and locations including in health care, education, and the criminal justice system. Racism can come in a variety of forms including racial slurs, harassment, exclusion, and microaggressions.

The mental health effects of past traumas are also something that these communities continue to grapple with. Racist policies in the United States subjected Native Americans and Alaskan Natives to significant psychological trauma. Such policies were aimed at stripping people of their cultural identity and heritage.

For example, children were often removed from their families as part of forced assimilation programs, separated from their parents, siblings, and extended families for months or even years at a time.

They were unable to speak their own languages and were barred from participating in their spiritual and cultural traditions. Such practices created massive collective and intergenerational trauma, damaging families, their children, and entire communities.

The cumulative effects of these experiences can take a tremendous toll on physical, emotional, and psychological well-being. In the U.S., Native Americans face issues including poorer health, lack of quality health care, higher mortality rates, and higher rates of suicide, drug and alcohol use, and sexual violence.

Such issues are not confined to the U.S., however. Indigenous people live in counties all over the world and often experience various forms and degrees of racism. One survey of Aboriginal people in Victoria, Australia found that 92% of those surveyed had experienced racism during the previous year. Those who experienced the most racism also reported the highest levels of psychological distress.

Such reports suggest that finding ways to reduce racism can play an important role in improving the mental health of people who are part of Indigenous communities.

Press Play for Advice On Dealing With Trauma

Mental Health Effects of Racism

According to the most recent census data, 1.3% of the U.S. population identifies as Native American or Alaskan Native.﻿﻿ Of these individuals, the Substance Abuse and Mental Health Services Administration (SAMHSA) reports that 19% have experienced a mental illness during the past year.

Evidence suggests that people who experience racism are at a greater risk of developing a variety of mental health conditions including depression, anxiety, and post-traumatic stress disorder (PTSD).

Some evidence suggests that exposure to racism can have particularly harmful effects when it occurs during important developmental windows in childhood.

One study found that Aboriginal and Torres Straight Islander children who experienced direct racial discrimination during early childhood had an increased risk for negative mental and physical health outcomes during middle childhood compared to kids who had not experienced such racism.﻿﻿

Substance and Alcohol Use Disorders

In the U.S., Native Americans and Alaskan Natives are significantly more likely to report having experienced the symptoms of an alcohol or substance use disorder in the past year than other races.

While a number of variables may contribute to the higher substance and alcohol use rates among American Indian people, research has suggested that factors such as racism, discrimination, and historical trauma play a significant role.

Participants in one small study of tribal members in the state of Montana cited racism as a contributing factor to the onset of substance use as well as a major barrier to recovery. Other risk factors that are known to play a part in high substance use rates include trauma exposure, poverty, and post-traumatic stress disorder.

Some participants in the study cited the intertwined effects of racial trauma and poverty as key factors driving substance and alcohol use. "People can't understand...there's intergenerational trauma, and then this need to belong, with such a high rate of poverty, a high rate of unemployment-they say it's like 80% on the reservation," one participant explained.

Statistics show that Indigenous communities all over the world are frequently impacted by suicide at much greater rates than the non-Indigenous population. In the United States, the Indian Health Service reports that the suicide rate for Native Americans and Alaskan Natives is 1.6 times higher than it is for all other races found in the U.S.

A 2011 report by Statistics Canada found that the suicide rate among Indigenous people in Canada was three times higher than it was for non-Indigenous Canadians. In particular, young people between the ages of 15 and 24 as well as women were found to be particularly vulnerable.

What are some explanations for the increased suicide risk faced by Indigenous peoples? Current racism as well as the effects of cumulative grief and historical trauma can all play a role in contributing to high suicide rates among Indigenous communities.

Historical trauma refers to the cumulative psychological effects that affect people across generations due to a significant collective trauma.

Statistics also suggest that Indigenous communities face higher rates of domestic violence. Native American and Alaskan Native women experience among the highest races of intimate partner violence and sexual assault.

The Association on American Indian Affairs reports that women, girls, and Two Spirit people are most impacted by violence, with nearly 85% of American Indian and Alaska Native women reporting that they have experienced violence during their lifetime.

Missing and Murdered Indigenous Women

Treatment Issues

In addition to the mental health effects of racism, race-based discrimination can also play a role in treatment. Systemic racism and relationships between Indigenous and non-Indigenous cultures can influence a variety of factors related to mental health treatment.

The American Psychiatric Association reports that the utilization of mental health services by Native Americans and Alaskan Natives is low. This is likely due to the combination of several factors, which include a lack of mental health services, a low number of culturally trained providers, and the stigmatization of mental health conditions in Indigenous communities.

Attitudes Toward Treatment

Because of the high prevalence of racism directed toward many Indigenous communities, people may be less likely to seek out treatment when they are facing mental health issues. For example, researchers have found that 1 in 6 Native Americans report seeking medical assistance because of anticipated discriminatory or unfair treatment.﻿﻿

Indigenous beliefs about mental illness can also play a role in the type of help people decide to seek. In many cases, people may be more likely to seek help from a traditional or spiritual healer who is part of their community rather than from a medical source.

Because Indigenous worldviews differ from those of many non-Indigenous cultures, expressions of emotional distress may also be different from the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the resource used by doctors to diagnose mental health conditions.

Access to Services

Racism can also play a role in affecting the availability and accessibility of mental health services in Indigenous communities. Some research suggests that people may be more likely to prefer ethnically matched providers, particularly among groups who have been historically marginalized by non-Indigenous people.

Indigenous communities also often lack access to health services. Healthcare accessibility is often impacted by policies that neglect the needs of Indigenous communities. Access to mental health services is also often severely limited by a number of factors including lack of insurance coverage and a lack of accessible clinics serving Indigenous communities. While tribal reserves may provide mental health services, many Indigenous people live outside of these areas.

Lack of Culturally Trained Providers

Culturally competent mental health care is important in order to understand and address the needs of people who are part of Indigenous communities. The Indian Health Service reports that more than 50% of mental health programs and more than 80% of substance and alcohol abuse programs are tribally operated.﻿﻿

This helps to ensure that people are better able to access holistic, integrated, community-based services that incorporate cultural and traditional practices while addressing issues such as racism, historical trauma, and cultural healing.

People are also affected by Western views of mental well-being that neglect Indigenous views of mental health and trauma. In his book Healing the Soul Wound: Counseling With American Indians and Other Native Peoples, psychologist Eduardo Duran describes the concept of a "soul wound," which describes the way traumatic events disrupt the interconnections between the mind, body, and spirit. Duran suggests that mental health practitioners need to provide interventions that address these holistic connections.﻿﻿﻿

In order to address the effects of trauma and provide quality mental health services, it is essential for providers to consider the perspective and experiences of Indigenous peoples.

Racism in Healthcare

In a report exploring experiences with the Canadian healthcare system, Indigenous people reported widespread racism and discrimination that impacted both access to care and health outcomes. Approximately half of non-Indigenous health care workers reported witnessing racist or discriminatory actions toward Indigenous patients and nearly 30% of Indigenous people reported hearing racist comments regularly.

Such discrimination often takes various forms but included such things as:

Denial of service

Poor communication

Minimizing problems

Assuming drug or alcohol use

Poor pain management

Lack of respect for cultural protocols

"The overall tone of what I can only describe as 'disdain' that was shown to my family day in and day out for taking up space in the hospital. The glances, the glares, the apathy was heavily noted by many of us, as it seemed they would prefer that we not be there," explained one First Nations woman of her family's ICU experience while her father was dying.

Indigenous patients also report that health care workers are often resistant to even hearing about cultural health practices. Thirty percent of respondents reported that requests to follow cultural practices with regards to events such as birth and death were often denied.

How Indigenous Communities Cope

Because of the serious detrimental effects of racism, finding ways to reduce discrimination and its impact are important to the health and well-being of Indigenous communities. There are a number of other factors that can be helpful in mitigating the mental health impacts of racism.

Indigenous worldviews can serve as a protective force. Many Indigenous cultures throughout the world hold worldviews that emphasize the importance of family, social bonds, and connectedness. Such connections and supportive relationships can play an important role in bolstering the mental health and well-being of Indigenous communities.

The American Psychiatric Association reports that protective factors that can reduce the risk of negative mental health effects and promote increased well-being include:

Adaptability

Appreciation for the wisdom of elders

Connections to the past

Family

Strong identification with culture

Traditional health practices﻿﻿

Indigenous Mental Health Resources

Some programs that offer mental health resources for Indigenous communities include:

One Sky Center: Offered by the American Indian/Alaska Native National Resource Center for Health, Education, and Research, One Sky Native has resources related to mental health, substance use, and suicide prevention.

StrongHearts Native Helpline: This service offers a national helpline that people can call (1-844-762-8483) for anonymous and culturally sensitive help with dating and domestic violence.

WeRNative: Aimed at and created by Native youth, this site offers information on mental health, culture, relationships, and LGBTQ/Two Spirit issues.

A Word From Verywell

There is an abundance of research demonstrating the profound negative effects that racism can have on Indigenous communities. The widespread prevalence of continued racism demonstrates that such issues need further intervention that seeks to end discrimination.

Because of the prevalence and impact of racism, addressing it over the course of treatment can be important for recovery. However, research suggests that racism and its effects are rarely discussed by mental health professionals during treatment.

The mental health effects of racism on Indigenous communities points to the need for both policy and social changes that can help reduce stereotypes and discrimination while addressing the economic, health, and social inequalities that continue to reinforce the lingering impact of colonization and racial trauma.

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Mental Health Effects of Racism on Indigenous Communities

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Racism is increasingly recognized as a factor that plays a role in mental health as well as disparities in mental health care. This can be particularly true among many of the most marginalized groups, including Indigenous communities. Indigenous communities can be found in countries throughout the world and make up an estimated 5% of the world's total population.

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Stigma remains a barrier to mental health care with 60% of people not seeking help for fear of being labelled

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This Mental Health Week, CMHA is “Unmasking Mental Health” to break down barriers, challenge stigma and support open conversations Toronto, (ON), April 22, 2025 – Despite growing awareness around mental…

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TOPIC 2 - Mental Health Commission of Canada Article 

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TOPIC 2 - Mental Health Commission of Canada Article 

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Pervasive Stigma remains a harsh reality for people living with Mental Health or Substance Use Disorders

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It is important that we highlight to people living with a mental illness or substance use disorder: You are not alone in these experiences.

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TOPIC 4 - CNO Therapeutic Communication Practice Standard 

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TOPIC 4 - CNO Therapeutic Communication Practice Standard 

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This quote reminds me that advocating for yourself can be just as important as advocating for patients. Something that I have learned throughout this clinical rotation is that caring for people who struggle with mental health can be difficult. So can caring for sick children. As much joy as there can be in nursing it can also be very hard care for others at times. It is important to make sure that you speak up for yourself as well as for your patients. Sometimes stepping away from a difficult situation for even 5 minutes can make a huge difference.

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This song is about empowerment and fighting for one’s life and the things in it. As nurses it is our job to help our patients fight for the things that they feel are important to them. Whether it be information, cultural practices, or social support; it is our job to help them achieve their goals while they are in our care. Often times patients that we care for as nurses don’t feel like they have a voice of their own. It is our job to help give patients their voice back.

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Rachel Platten - Fight Song (Official Video)

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The Seven Domains of Health: A Theoretical Framework for Addressing Nursing Self Advocacy

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This song emphasizes the importance of showing up for friends or patients in the case of nursing who need someone to lean on. The song talks about how we all face sorrow and how we will all eventually need someone to lean on. For me this song holds significant meaning, as a nurse it is my job to be there for my patients to lean on. When we encounter people especially on the maternal/child and mental health floors, we are often meeting patients in some of the highest and lowest moments of their lives. Our ability as nurses to provide a listening ear can make a huge difference in how they perceive their care and condition.

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Bill Withers - Lean On Me (BBC In Concert, May 11, 1974)

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I have included this image as an artifact because I like the way that it displays the nurse-patient relationship. It shows a nurse coming alongside a patient and actively listening to her. I think that truly listening to patients is one of the most important things that a nurse can do for a patient. Active listening makes patients feel heard. During a day of my clinical rotation on the mental health floor, after finishing my assessment on a patient, he said “thanks for really listening to what I have to say”. For me, that solidified the importance of listening. Making a difference in a patients day can be as simple as lending an ear when they need to talk.

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Introduction

Communication is a two-way process and good communication requires many skills. The two-way process consists of a person that will provide information to another person in the form of verbal, written, feelings, or expressions. The person sending the information is considered the sender, and the person receiving the information is considered the receiver. It is imperative that the receiver gives feedback to the sender to inform the sender that they received all of the information the sender was trying to relay. This type of communication does not come naturally and needs to be practiced and perfected to create professional teamwork and great patient relationships required for positive outcomes. Good communication will allow teams to effectively solve problems and decrease patient safety errors. In the healthcare arena, many workers are surprised by the difficulty of this task, which adds stress to the work environment. In the operating room, for example, everyone is very busy and task-oriented towards a good patient outcome and this focus allows teammates to answer questions with very short answers so that they can continue with the tasks they were performing. Short answers can be interpreted or misconstrued which causes more stress within the team. [1]

Function

When the sender relays the information, feelings, or ideas that they want to communicate to the receiver, the receiver cannot just acknowledge that they heard or saw the information. The information may be perceived as positive or negative and can change the outcome that the sender wants to get. To be effective, the receiver must provide feedback to the sender. Feedback is a response from the receiver that includes an acknowledgment but also a recap of what they perceived from the sender. By recapping the thought, the sender has an opportunity to agree that the message was received correctly or to restate their original intentions for clarification. This process allows the receiver a chance to also ask questions for their understanding of the message. This type of communication and clarification process does not take any additional time or time away from the tasks being performed but instead allows for much better patient care.[2][3][4]

Issues of Concern

Many additional factors can get in the way of effective communication with a two-way communication process and they can inhibit "active listening." The delivery of a sender's message is just as important as the content of the message. The tone of a message can be misinterpreted very easily, which is why a feedback mechanism is necessary. Verbal communication is written or oral and contains an underlying tone that can have a dramatic outcome on the receiver's interpretation of the message. This can lead to many conflicts not only in the workplace but also with the patients being cared for. In the operating room, answers are usually required to be very brief and contain the most accurate information but the tone with which that information is delivered is important as well. The tone of the information or feelings behind the words of the sender can cause misunderstandings and miscommunications. The written form of verbal communication can create more negative feelings because of an implied tone compared to communication that takes place face-to-face, which tends to be more straightforward. It is easy to misinterpret a tone simply from the written words; this happens many times in the surgical environment because teams are detailed, task-oriented, and state their messages to only reflect the information wanting to be delivered. Pleasantries are usually left out.[5][6]

Another factor is nonverbal communication, which includes body language, touch, and silence. The body language applies to both the sender and the receiver; either party can exhibit good or poor body language. A person's body language can show their true emotions on the subject matter even when their words may be saying something different. Some body language examples include walking abruptly away after receiving or giving information, rolling of the eyes, sighing, shaking heads, lacking eye contact, placing hands on hips, and having a rigid posture. Touch can be used to express empathy or control. In most instances, the action seems innocent but some may find it unacceptable. Personal boundaries must always be adhered to for team members and patients. Finally, silence sends a strong message that may indicate the person is contemplating the message. The message may have left them speechless or in total shock which, in turn, rendered them speechless. During this time, it is important to allow the person to process the message and to give them time to contemplate a response. Dead space does not always need to be filled with idle chatter.

Clinical Significance

Before a receiver can give good feedback, he or she must have positive listening skills and allow the sender to confirm message delivery. There are several tips to be a good listener:

1. Listen to the message, not what you want to hear.

2. Do not start judging the sender if your relationship is not solid. Watch the sender's body language to assess information about the sender's attitude about their message.

3. Make sure to repeat back in your own words what you thought you heard them say.

4. Ask clarifying the question if needed to help you understand the message.

5. If the sender seems to start to go off-topic, redirect the conversation to the original issue/concern.

6. While listening to the sender, do not let yourself get sidetracked or make assumptions.

7. Finally, never start formulating a response before you have heard the entire message.

Active Listening requires participation. Our teammates and patients will greatly appreciate this improved communication tool.

Enhancing Healthcare Team Outcomes

Cultural competence is important in the healthcare field and can play a role in active listening. Working and communicating with people from other cultures can alter the communication techniques outlined above. People from different cultures have their own set of "norms," and they do not necessarily conform to what people in the United States see as the "norm." Medical professionals need to attend training programs or informational sessions to understand different cultures, especially in the demographic region that they serve. These training sessions should be ongoing and include speakers of different ethnic backgrounds to speak on behalf of their culture and communication styles.[7][8] Interpreters are a widely used service for patients with language barriers and while they contribute to better patient satisfaction, the role of active listening, such as body language and gestures can still maintain a sense of connection for the patient-provider relationship.[9] People deserve to preserve their cultural values and everyone needs to be respected for who they are. Training, knowledge, and cultural awareness allow for better teamwork, communication, and overall better patient outcomes.[10]

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Communication is a two-way process and good communication requires many skills. The two-way process consists of a person that will provide information to another person in the form of verbal, written, feelings, or expressions. The person sending the information is considered the sender, and the person receiving the information is considered the receiver.

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This meme reminds me of the struggle it can be for nurses to deal with other people’s trauma. It can be difficult to handle others issues especially when you feel your own pressing in. As nurses we often must set aside what is going on in our lives to be there for our patients. I have learned through my placement how hard it can be to not let the things that patients say, or their stories affect you. When you are dealing with the same patient’s week after week it can become difficult to not be invested in them and their stories. We need to be reminded to set boundaries to protect both ourselves and patients.

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I have included a picture of my diploma from Fleming College as my second artifact for this topic. When I become emotionally exhausted from work or school, it helps me to remember where I started and how far I have come. I often think back to the reasons why I started my nursing journey as reminders for why I should continue pushing through. My younger self would be proud of how far I have come and want to see me complete my goals. Sometimes it helps to take a step back and remember that my journey isn’t just about the patients that I care for but also about myself. Nursing has impacted me as a person and changed how I view the world. When I feel exhausted by the job, it is helpful to remember these things. Taking a step back and taking care of myself every once in a while is what keeps me going.

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TOPIC 1 - Clinical nurses’ compassion fatigue psychological experience process: a constructivist grounded theory study

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TOPIC 1 - Clinical nurses’ compassion fatigue psychological experience process: a constructivist grounded theory study

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Abstract

Background

Clinical nurses are susceptible to compassion fatigue when exposed to various types of traumatic events in patients for extended periods of time. However, the developmental process, staging, and psychological responses distinct to each stage of compassion fatigue in nurses are not fully clarified. This study aimed to explore the processes of compassion fatigue and the psychological experiences specific to each phase of compassion fatigue among clinical nurses.

Methods

Charmaz's Constructivist Grounded Theory methodology was used in this qualitative research. Semi-structured interviews were conducted with 13 clinical nurses with varying degrees of compassion fatigue from December 2020 to January 2021. Interview data were analyzed using grounded theory processes.

Results

The data were categorized into five separate categories and 22 sub-categories. This study found that the process of compassion fatigue is dynamic and cumulative, which was classified into five phases: compassion experience period, compassion decrement period, compassion discomfort period, compassion distress period, and compassion fatigue period.

Conclusion

Clinical nurses who experience compassion fatigue may go through five stages that are stage-specific and predictable. The findings can shed light on local and global applications to better understand the problem of nurses' compassion fatigue. The interventions for addressing compassion fatigue in clinical nurses should be stage-specific, targeted, and individualized.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-023-01665-3.

Keywords: Clinical nurses, Compassion fatigue, Psychological experience, Constructivist grounded theory, Qualitative study

Background

Compassion, as one of the core professional attributes of nursing care, is described as understanding another person's suffering and trying to eliminate or alleviate it [ 1- 3]. As professionals, nurses are expected to have empathy for their patients [ 4]. However clinical nurses have the most direct contact with patients and continuous exposure to patient pain, grief, and suffering, which put nurses at high risk of developing compassion fatigue [ 2]. Compassion fatigue has been recognized as an occupational hazard and has attracted scholars' attention worldwide [ 5, 6]. Despite extensive literature that has explored nurses' experiences of compassion fatigue, limited evidence demonstrates nurses' compassion fatigue psychological experience process [ 7, 8]. Shedding light on this complexity would inform nursing practice and education globally.

Compassion fatigue describes the emotional, physical, and psychological weariness as a result of prolonged and intense work-related stress exposure [ 9]. Compassion fatigue in nursing refers to a cumulative and progressive process of absorbing patients' pain and suffering that nurses experience as a result of their compassionate contact with patients and their families [ 10]. The conceptual structure of compassion fatigue proposed by Figley includes burnout and secondary traumatic stress [ 11], they both combine to raise the risk of compassion fatigue [ 12]. Compassion fatigue symptoms include headaches, insomnia, poor self-esteem, depression, tardiness at work, avoidance of work, and frequent sick leave [ 13]. Consequently, compassion fatigue can result in high turnover rates of nurses, decreased concentration and productivity, and even increased medication errors which ultimately affect patient satisfaction and safety [ 14, 15]. Compassion fatigue can happen to any nurse, at any time during the job course [ 10]. A meta-analysis including 21 studies found compassion fatigue is widespread among clinical nurses, with a prevalence of up to 52.55% [ 16]. Therefore, exploring the occurrence and development of compassion fatigue among nurses is warranted to effectively avoid compassion fatigue.

Nurses' experiences can be thoroughly explored through qualitative research, which can then help us comprehend how they feel and behave when they suffer from compassion fatigue. After review of the literature revealed that current research on compassion fatigue in nurses mainly focuses on their experiences, facilitating factors, and coping strategies. For example, Pérez-García et al. [ 2] found that the lack of time and resources to provide comprehensive nursing care were facilitating factors of compassion fatigue. Compassion stress and overload can lead to compassion fatigue. Some strategies to reduce compassion fatigue are proposed, such as self-care, increased self-compassion, support and recognition from colleagues and family, and better work-life balance [ 7].

Based on the comprehensive literature review, we found that the current research about compassion fatigue among clinical nurses mainly focuses on the physical and psychological symptoms of compassion fatigue, facilitating and hindering factors, coping strategies and gains, etc. The processes of compassion fatigue and the psychological experiences specific to each phase of compassion fatigue among clinical nurses remain unknown, which brings obstacles to proposing targeted intervention programs for nurses in different stages of compassion fatigue. Therefore, this study aims to explore the processes of compassion fatigue and the psychological experiences specific to each phase of clinical nurses. We anticipate that the findings will be helpful and valuable in developing tailored, stage-matched intervention programs for clinical nurses.

Methods

Study design

A grounded theory methodology is a prospective approach to obtaining theoretical knowledge of psychosocial phenomena [ 17]. According to Charmaz's constructivist grounded theory, the interaction between the researcher and the subject shapes the reality of the research findings. Because this interaction takes place within a broader social context, it highlights both the social construction process and the process of interaction between the two parties involved in the research [ 18]. This study attempts to articulate the psychological process of clinical nurses experiencing compassion fatigue and the psychological experiences specific to each stage, which is a reality formed in a specific historical and social developmental context, as well as an articulation and interpretation of the meanings co-constructed by the researcher and the participants. Charmaz's constructivist grounded theory is highly compatible with the research purpose and content of the study, and therefore we chose this approach to guide this study. The Standards for Reporting Qualitative Research (SRQR) checklist was employed to present the results [ 19].

Participants

Clinical nurses in a tertiary hospital in Changsha, China, were selected. Purposive sampling and theoretical sampling were used to choose the participants in accordance with the grounded theory approach's guiding principles. At the beginning of the interview, purposive sampling was used. The inclusion criteria were the following: registered nurses in employment and working on the frontline, and nurses with different levels of compassion fatigue (mild, moderate, and severe) measured by the Professional Quality of Life Scale [ 20]. Stamm developed the original version [ 21], which was translated into Mandarin [ 22]. The scale was tested, and the findings demonstrated that it had strong validity and reliability and could be utilized to assess compassion fatigue among clinical nurses [ 23, 24]. The Chinese version of the professional quality of life scale has three dimensions: compassion satisfaction, burnout, and secondary traumatic stress [ 22]. The total score critical value of the above three dimensions is < 37 points, > 27 points, and > 17 points respectively [ 22]. If the total score of the three dimensions does not exceed the critical value, there is no compassion fatigue; if the total score exceeds the critical value of any dimension, it is mild compassion fatigue. If the total score of any two dimensions exceeds the critical value, it is moderate compassion fatigue, and if the total score of all three dimensions exceeds the critical value, it is severe compassion fatigue. Before the interview, 20 nurses were tested by the professional quality of life scale. Among them, 18 nurses had different levels of compassion fatigue and through objective sampling and theoretical sampling, finally, 13 nurses completed the interview. Data saturation was reached after 13 interviews when no new theoretical insights emerged as the information was analyzed.

Data collection

Semi-structured interviews were conducted from December 2020 to January 2021. Prior to recruiting nurses, the researchers obtained consent from the directors and head nurses of each institution explaining the study's purpose. Following the clinical nurses' expression of interest in the study, an electronic version of the Professional quality of life scale was used to assess their level of compassion fatigue via Wenjuanxing (a Chinese online crowdsourcing platform). The principal researcher who was professionally trained in qualitative research contacted the participants by telephone and gave them a detailed introduction to the research content and purpose. Since this study was conducted at a time when COVID-19 was severe in China, phone interviews or video interviews through WeChat (a social networking software in China), relatively safe interview methods, were chosen to avoid the risk of infection to the participants and the researcher. The researcher established a trusting relationship initially by talking briefly with the interviewees before the formal interview, which proceeded smoothly because the primary researcher was a former clinical nurse and had many common topics. The researcher appropriately used techniques such as questioning, responding, verifying, summarizing, and silencing during the interviews to encourage the interviewees to express their inner feelings. The length of the interviews ranged from 30 to 70 min. Based on the literature review and pre-interviews, the researcher developed an interview guide, which included the following aspects: (1) feelings and experiences in the process of providing care to patients; (2) changes in feelings or experiences in the process of providing care to patients from the beginning to the present; (3) own awareness of compassion fatigue; (4) how to deal with compassion fatigue; (5) impressive cases in the process of experiencing compassion fatigue.

Data analysis

Nvivo 11.0 was used to manage, store, and analyze the interview data. Data were systematically analyzed using initial coding, focused coding, theoretical coding, and constant comparative methods. Initial coding was carried out by continually "asking questions" of the original data through line-by-line coding and looking for nuances, explicit statements, and implicit meanings [ 17]. The initial codes with comparable meanings and features are then grouped together by ongoing comparison of the original codes, and the more pertinent and conceptual codes are then identified for focused coding [ 18]. The process of focused coding ultimately yielded five categories. By comparing, generalizing, and summarizing the codes and analogies, the continuous comparative analysis methodology is adopted throughout the study to comprehend the psychological experiences particular to each step and the process of clinical nurses' compassion fatigue. The analysis was completed by the first author, who also consistently discussed it with the co-authors. Finally, the possibility of having preconceived notions about the study data was reduced by conducting a literature review pertinent to the research after the data analysis.

Study rigor

The rigor of the study was accomplished in a variety of ways, including confirmability, credibility, and transferability [ 25]. To ensure confirmability, the researcher emailed the transcribed text to the participants and asked them to determine if the transcribed text was consistent with their views and experiences. In addition, the research team met frequently to discuss findings, plan future data collecting, examine transcripts, and evaluate data [ 26]. To ensure credibility, the research team accurately reviewed the interview transcripts, compared the extracted codes to the initial data, and repeatedly checked the analysis against the views of the study participants to maintain reflexivity and avoid the researcher's views influencing the study data. To ensure transferability, a thick description strategy as a way of achieving a type of external validity was used [ 27]. The thick description strategy was used to describe not just the behavior and experiences, but their context as well [ 28]. For instance, nurses' positive and enthusiastic work in this study was linked to their perception that their work will provide them with a feeling of achievement and that they are highly motivated to work every day.

Results

The participants were all female, aged 23 to 46 years, with 3 to 24 years of experience; two of them had mild compassion fatigue, five had moderate compassion fatigue and six had severe compassion fatigue (Table 1). The data were categorized into five separate categories and 22 sub-categories (Fig. 1). This study found that the process of compassion fatigue is dynamic and cumulative, which was classified into five processes: compassion experience period, compassion decrement period, compassion discomfort period, compassion distress period, and compassion fatigue period (Fig. 2).

Table 1.

Number

Department

Sex

Age

Position

Education

Working Years

Level of compassion fatigue

Fig. 1.

Stages and features of compassion fatigue development

Fig. 2.

Schematic diagram of the developmental stages of compassion fatigue

Powerlessness

Clinical nurses feel helpless and powerless when faced with patients, especially those whose conditions change rapidly and who suffer more pain.

I can only say that I am so helpless, and then sometimes I want to cry when they (patients) cry. Because I can't solve their problems. (N2)

Clinical nurses can feel very helpless about the progression of a patient's condition, and they can only do their best to make it better for them.

I can't control the patient's condition, it's just really helpless. I can only do my best to make them (the patients) feel better. (N2)

Stage IV: compassion distress period

Deliberate avoidance of work and patients

Clinical nurses want to escape such a work environment and deliberately avoid contact with patients.

I dread going to work every day. I want to postpone going to work and just accomplish what I must do now. I want to go (leave the hospital). (N8)

Clinical nurses lack enthusiasm for their work and feel that their work is just numb work with no emotional input. They feel that they are not promoted in all aspects either, and will experience burnout and even want to leave their jobs.

I feel like I'm not making any progress and I'm tired of working nonstop. Others claim that there is an incentive for work, yet I want to change my job. (N5)

Role conflict

Clinical nurses present with a work-life imbalance that is impossible to achieve.

Unpleasant things at home do not affect my work, but things at work affect my life, probably because I regard my work as more important. (N6)

After working for so long, I still feel that I will bring some emotions from work into my life, and I feel that I can't distinguish between life and work. (N3)

Negative emotional stress

Clinical nurses develop a sense of depression and fatigue.

My character is more serious, so when I unknowingly give more of myself emotionally, it is simple to walk in that mood. Sometimes, I even worry that I'll carry that emotion home, which causes me to feel anxious and depressed (Silent crying). (N7)

Helplessness

Clinical nurses can become helpless, with nowhere to go to relieve their fears and anxieties, feeling that some people will not understand their state and not knowing whom to turn to for help.

I don't know where to express my bad emotions, and I feel helpless. I'm not even able to mention these things to some people since they could not understand you and even believe you can't handle the suffering. (N2)

Discussion

Our study outlined the stages of compassion fatigue and its characteristics in clinical nurses. The whole process of compassion from the initial giving of compassion to the gradual development of compassion fatigue was demonstrated. Coetzee et al. [ 29] after a comprehensive literature review outlined the process of compassion fatigue as a progressive and cumulative process, from compassion discomfort to compassion stress to compassion fatigue, which is partially consistent with the results of this study. Our research expanded and enriched with a more detailed division into five stages, including the compassion experience period, compassion decrement period, compassion discomfort period, compassion distress period, and compassion fatigue period.

In this study, nurses at the beginning of their careers experience a period of compassion characterized by positive and enthusiastic work, recognition of work value, realization of role change, revisiting the meaning of life, and positive personal growth. Mei et al. [ 30] indicated that in the initial stage of nurses demonstrating compassion, they experience positive emotions like a sense of self-worth and professional accomplishment, which is in line with the results of this study. In addition, Berg et al. [ 31] interviewed trauma group members and the results of the study also showed that they would be motivated to work initially, further supporting the findings of this study. For this stage, we can fully explore its positive factors to actively maintain the experience during this period. Klein et al. [ 5] conducted a study implementing a resilience program focused on education about compassion fatigue, hoping to develop an ongoing self-care practice to prevent compassion fatigue. In other words, clinical nurses can preserve the period of compassion by utilizing their individual psychological resources (e.g., psychological resilience, self-compassion, and optimism).

With the increase in workload and lack of rest time, nurses will feel physically exhausted. Coupled with the fact that their emotional commitment is not understood by patients and families, nurses will feel aggrieved, thus entering a period of compassion decrement. This is in accordance with the findings of a previous study on the emotional experience of compassion fatigue in emergency department nurses [ 32]. In this period, the patients' and family members' lack of understanding will diminish the nurse's compassion experience due to the increased workload and lack of rest time. At this time, the key point of intervention is to consider seeking social support from society, hospitals, and families. At the hospital level, we can consider a rational allocation of human resources and a moderate reduction of work intensity; at the family level, family and friends can give more support and assistance; at the social level, we are actively guiding through the media to create a positive professional atmosphere for nurses.

Following failed treatment of patients, nurses go through a time of compassion discomfort brought on by psychological guilt and self-blame, emotions of helplessness, intense emotional misery, and unseen moral suffering. Studies have found that when nurses become overly empathically devoted to their patients, the slight discomfort or distress of patients can elicit a strong response from the nurse due to excessive emotional and responsible involvement [ 7, 33]. During times of compassion discomfort, clinical nurses generally feel moral distress and self-doubt. The self-efficacy theory of Bandura contends that behavior and self-efficacy are strongly related [ 34]. At this point, nurses have self-doubt about their competence, so increasing self-efficacy might improve their psychological well-being and consequently, their behavior. Verbal encouragement, alternative experiences, and behavioral performance successes serve as the foundation for an individual's sense of self-efficacy [ 34]. Therefore, researchers can raise nurses' sense of self-efficacy through the power of role models, encouraging words, and feedback to pass through the compassion discomfort period among clinical nurses.

The emotional distress of clinical nurses is exhibited in the compassion distress phase. Nurses will repeatedly focus on and recall things related to the patient, and this repeated recall has disrupted the nurses' lives, disturbed them emotionally, and can create an underlying sense of anxiety and compulsion in their lives. In addition, this study found that nurses will socialize the comparison from the patient's events and will analogize the patient's condition and experience to themselves, to worry and fear, and occasionally experience fear of illness. During this time, nurses will be influenced by patients' emotional responses and may experience psychological pain. They may likely have anxiety and obsessive symptoms in life if they keep thinking about the patients' circumstances. The pivotal point of intervention at this stage can be considered to use cognitive restructuring, which transforms negative, self-defeating thinking into positive, self-affirming notion.

As negative emotions accumulate, nurses eventually encounter a phase of compassion fatigue. Numbness and emotional exhaustion in the emotional experience, avoidance and alienation from work behavior, and physical problems including sleep disorders all occur, which is corresponding with results from previous studies [ 2, 7]. If the nurse experiences physical problems, such as sleeping difficulties, they may seek medical assistance and prescription medications. The psychological effects of emotional exhaustion can be alleviated through active interventions including emotional catharsis, attention shifting, and focusing on a spiritual outlet (such as religious belief) to help recovery [ 7].

Relevance for clinical practice

Compassion fatigue in clinical nurses develops over time and is a dynamic process, which can shed light on a better understanding of the problem of nurses' compassion fatigue locally and globally. The findings contribute to nursing management and education in the field of solving compassion fatigue in clinical nurses. The implications for nursing management include that clinical nurses' experience of compassion fatigue is a cumulative process. Interventions for compassion fatigue in clinical nurses should be staged, targeted, and individualized to maintain the compassionate experience period, pass through the compassionate discomfort period, cope with the compassion fatigue period, and ultimately reduce psychosomatic damage among clinical nurses.

In terms of nursing education, these findings urge consider teaching nursing students and new nurses about the development of compassion fatigue so they may be prepared for the problems they may encounter in the future. The majority of the existing intervention programs are designed to help nurses who are already suffering from compassion fatigue. Instead, we should emphasize prevention more, and a cost-effective way to do this is by creating educational programs to raise clinical nurses' awareness of and knowledge about compassion fatigue.

Limitations

The shortcomings of this study include the following aspects. Firstly, due to the impact of COVID-19, the study subjects were interviewed by telephone or video, and there may be an inability to carefully observe the participants' body language and facial expressions during the interview process. However, throughout the study, the researcher deeply felt that the participants were more willing to confide their feelings through the long-distance interviews with electronic devices, providing a wealth of information that could help the researcher understand more deeply the emotional experience during the process of compassion fatigue. Secondly, all the interviewees were female, and there may be differences in the feelings of male nurses; however, most of the nurse population was female, and the results of this study may also inform the psychological experience of the developmental process of compassion fatigue for most nurses; thus, further studies conducted with male nurses are needed.

Conclusions

Clinical nurses who experience compassion fatigue may go through five stages that are stage-specific and predictable: compassion experience period, compassion decrement period, compassion discomfort period, compassion distress period, and compassion fatigue period. This study pointed out a noteworthy issue regarding the significance of tackling compassion fatigue based on the characteristics of different stages. The analysis showed that if prompt intervention is not given to clinical nurses during the early stages of compassion fatigue, such as the periods of compassion decrement, compassion discomfort, and compassion distress, they will eventually enter a period of compassion fatigue, which is especially harmful to the nursing profession building on compassion and caring. This study critically advocates for hospital administrators to better address this issue by creating customized, stage-appropriate intervention programs.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Acknowledgements

We are grateful to all of our participants for voluntarily sharing their insightful experiences and making the study possible.

Abbreviations

SRQR

Standards for reporting qualitative research

COVID-19

Corona virus disease 2019

Author contributions

Study design: Jingping Zhang, Jie Zhang, Jie Zou; Data collection: Jie Zhang, Jie Zou; Data analysis: Xiao Wang, Yaoyue Luo, Zhiyao Xiong; Study supervision: Jingping Zhang, Xiao Wang; Manuscript writing: Jie Zhang, Jie Zou; Critical revisions for important intellectual content: Jin Zhang, Xiao Wang, Yaoyue Luo, Zhiyao Xiong.

Funding

Natural Science Foundation of Hunan Province(2021JJ30887) and the science and technology innovation Program of Hunan Province (2022WZ1030).

Data availability

Due to ethical concerns from the perspective of the participants, the datasets generated and/or analyzed during the current study are not publically available, but they are available from the corresponding author upon justifiable request.

Declarations

Ethics approval

All methods were carried out in accordance with relevant guidelines and regulations, such as the Declaration of Helsinki [ 35]. The study received ethical approval from the Behavioral Medicine and Nursing Research Ethics Review Committee of Central South University (No. E202027). Before starting data collection, written informed consent was obtained. Names were not used in interviews, and the audio and transcript files were tagged with a numbered scheme that was only known to the researcher.

Consent for publication

Non applicable.

Conflict of interest

All authors declare that they have no conflicts of interest.

Footnotes

Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Jie Zhang and Jie Zou are all first authors.

References

11. Figley CR. Compassion fatigue as secondary traumatic stress disorder: an overview. New York; 1995.

18. Charmaz K. Constructing grounded theory. 2nd ed. SAGE Publications; 2014.

21. Stamm BH. The Concise ProQOL Manual: The concise manual for the Professional Quality of Life Scale, 2 nd Edition. 2010.

23. B CTCO AWJ, C HH, D FF ELJ. A ZL, A LM: Factors associated with compassion satisfaction, burnout, and secondary traumatic stress among Chinese nurses in tertiary hospitals: a cross-sectional study - ScienceDirect. Int J Nurs Stud, 102. [DOI] [PubMed]

28. Hays DG, Mckibben WB. Promoting Rigorous Research: generalizability and qualitative research. J Couns Dev 2021, 99(2).

35. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. J Int Bioethique. 2004;15(1):124-9. [PubMed] [Google Scholar]

Associated Data
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Supplementary Materials

Data Availability Statement

Due to ethical concerns from the perspective of the participants, the datasets generated and/or analyzed during the current study are not publically available, but they are available from the corresponding author upon justifiable request.

Articles from BMC Nursing are provided here courtesy of BMC

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Clinical nurses' compassion fatigue psychological experience process: a constructivist grounded theory study

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Clinical nurses are susceptible to compassion fatigue when exposed to various types of traumatic events in patients for extended periods of time. However, the developmental process, staging, and psychological responses distinct to each stage of ...

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