Compassion Fatigue in Critical Care Nurses in Saudi Arabia and its Impact on Nurse-Sensitive Patient Outcome: A mixed methods study

Abstract

<p>Compassion in the context of healthcare provision refers to the health professional’s internal feelings and emotions, which drive them to help others. Sometimes described as the ‘essence’ of nursing, compassion is acknowledged as integral to the provision of good nursing care and patient satisfaction within the care process. Compassion fatigue (CF) refers to accumulated negative feelings such as emotional exhaustion and disinterest in the care process, which may result from the continuous demands of providing care. A number of factors may have a role in the onset of this type of fatigue, including the nature of the care environment; the relationship the carer has with patients; and general caregiving activities. These factors can in turn lead the nurse or other caregiver to experience reduced capacity for empathy, or interest in being empathic. Indeed, CF is generally linked to nurses who provide direct, intimate care to patients with complex care needs, especially critical care nurses (CCNs) who are often required to provide care to individuals with life-threatening conditions. CF is also known to affect the wellbeing of nurses and patient safety outcomes.</p> <p>The aim of this study was to examine the relationship between nurse demographic characteristics and the development of CF as indicated by level of compassion satisfaction (CS), burnout (BO) and secondary traumatic stress, in CCNs in Saudi Arabia. This was achieved by addressing five research questions. Firstly, what is the current level of CF among CCNs in Saudi Arabia? Secondly, what are the demographic factors that affect CF and BO in CCNs in Saudi Arabia? Thirdly, what are the predictors of CF among CCNs practising in Saudi Arabia? Fourthly, what are the nurse-sensitive indicators that show the relationship between CF and patient safety? Finally, what strategies can be employed to mitigate the effects of CF, promote higher levels of compassion and decrease the sense of BO among CCNs in Saudi Arabia? To address these questions, a mixed methods study was conducted. A survey using a crosssectional design consisting of three tools was administered to CCNs (<i>n</i> = 321) in four Saudi public hospitals. Focus group interviews were then conducted with CCNs and their nurse managers. The survey instruments included the <i>Professional Quality of Life Scale</i>, which aimed to simultaneously measure CF and CS among the nurse participants; the<i>Coping Strategy Indicator</i> questionnaire, to tap into the ‘common denominators of coping’ strategies by the nurse participants; and the <i>Connor–Davidson Resilience Scale</i> questionnaire to measure the level of resilience of the participants.</p> <p>This research study also sought to identify a relationship between the occurrence of three nurse-sensitive indicators—namely, pressure injuries, patient falls and medication errors—and the level of CF among CCNs. A non-experimental descriptive research design was adopted to collect and analyse data on these three nurse-sensitive indicators. The three indicators were selected because they are linked to critical care wards and reflect the broader issues of quality of patient care in a health organisation that is dependent on the level of personal attention in a critical care unit. The two data collection phases (survey and focus group interviews) were conducted concurrently in this study.</p> <p>Based on the quantitative data, this study found that male CCNs reported higher levels of stress than female nurses, while female nurses scored significantly higher for avoidance and problem solving behaviours. Years of experience was also found to significantly influence avoidance behaviours: nurses with 16–20 years of experience achieved higher mean scores than all other groups. Nationality was also found to be important, with Saudi nurses reporting significantly higher levels of CS, as well as higher levels of stress than non-Saudi nurses. In addition, non-Saudi nurses were found to score significantly higher than Saudi CCNs for avoidance and problem solving behaviours. In terms of work setting, nurses working in coronary care, intensive care and neonatal intensive care units reported the highest levels of CS, whereas nurses working in burns units reported the lowest levels of CS. Last, nurses with a diploma qualification reported significantly lower CS than nurses with other degrees, and nurses working on 8-hour shifts reported lower CS than those on 12-hour shifts.</p> <p>From the qualitative data generated through the focus group interviews, the three main issues arising were nationality-based treatment as a major source of BO and stress; career opportunities associated with the level of stress and BO; and management practices associated with stress and BO. In terms of the relationship between the occurrence of the three nurse-sensitive indicators and the level of CF among CCNs, the study found that the most prevalent nurse-sensitive indicator across all four hospital settings was pressure injuries. In addition, the relationship between CF, CS and BO, and nurse-sensitive indicators revealed that workplace culture had a significant impact on wellbeing and rates of CF within Saudi hospitals. In particular, this study found that there were significant challenges in communication between management and staff based on nationality and position. This outcome led to a negative workplace culture in terms of promotion prospects, which in turn negatively affected motivation and workplace satisfaction. </p> <p>Further, a number of implications emerged from the findings for CCNs and critical care work environments in Saudi Arabia, spanning four key domains: the physical state of the nurse; the emotional state of the nurse; the working conditions in the unit; and the systems in place to overcome/prevent CF. Firstly, the findings point to the importance of CCNs’ monitoring practices and ability to manage their work patterns to reduce the risk of the onset of CF. In addition, it is apparent that nurse managers can play an important role in reducing the onset of CF and BO among CCNs on the ward. Specifically, this thesis recommends that nurse managers consider changing their approach to managing nurses in these settings by adopting more open, flexible and participatory models of management such as a shared governance model where nurses are central to decision-making processes, particularly in terms of addressing cultural bias in the workplace.</p>