The meaning of compassion fatigue to student nurses: an interpretive phenomenological study

Compassion fatigue is a term associated with nursing practice and is a form of occupational stress which has been linked to burnout and vicarious traumatisation [43]. Nursing is a stressful occupation and the most common stressor is heavy workload, which means that nurses are unable to carry out their role in the way they would like [39]. Subsequently there is incongruence between the nurse’s ideal and the actual reality of nursing practice, leading to dissatisfaction and frustration with the role. As student nurses do not hold the same level of responsibility as qualified staff, it could be argued that they are not exposed to as much stress, although having student status is stressful in itself [37]. In the UK student nurses spend half of their programme experience in a clinical area and it is these placement experiences that can cause a huge amount of stress, which can sometimes lead to students discontinuing their programme of study [16]. The emotional nature of nursing can cause a large amount of stress to student nurses [21] and the socialisation process can have a particularly negative effect on their emotional well-being [32]. Student nurses suffer financial hardship which might be linked to the current bursary arrangements, which might lead some to feel the need to engage in part time work to supplement their income [40]. This situation can lead to less study time and more personal stress. The financial situation for UK student nurses might be set to worsen, due to the Department of Health (DH) announcement regarding the withdrawal of the student nursing bursary from 2017 [8]. The implications of this are as yet unclear although the change might have a negative outcome for student nurses [40]. In addition to finance, the amount of stress experienced might relate to the learning stage of the student. Rudman & Gustaffson [42] suggest that the second year is the most stressful for student nurses although the first clinical placement has also been identified as being particularly problematic, as students worry about making mistakes and causing harm to patients at this early stage of their learning [26]. The first clinical placement can cause high levels of stress which negatively impacts on learning [24].

Compared to stress the concept of compassion fatigue, described as one form of occupational stress, is more recent, and has been studied primarily in non-nursing groups [51]. Compassion fatigue was first described in a nursing context by Joinson [23] who suggests it is a response to the large amounts of stress, and occurs when nurses witness suffering, illness and trauma on an ongoing basis. She describes compassion fatigue as ‘emotionally devastating’ (p. 116), an unavoidable part of care giving, and the caregivers personality type can increase susceptibility to it. Figley CR [10]: 7) describes compassion fatigue as the ‘natural consequent behaviours and emotions resulting from knowing about a traumatising event experienced by a significant others-the stress resulting from helping or wanting to help, a traumatised or suffering person’. Sabo [43] describes a number of key triggers of compassion fatigue including, the nurses personal characteristics, previous exposure to traumatic events, response to the stressor and the work environment. There are many signs of compassion fatigue including sadness, avoidance, detachment and changes in beliefs and assumptions [43]. Based on these descriptions, it would seem that student nurses are susceptible to compassion fatigue during their educational experiences. This could potentially have a detrimental effect not only on the ability of the student nurse to learn in the clinical environment, but to their physical and psychological health.

It is important that student nurses have happy and positive learning experiences, not only for the sake of their own health but because a clear link has been identified between staff wellbeing and effective patient care [31]. If student nurses suffer from compassion fatigue then this could have negative implications not only for themselves but for others. Michalec et al. [34] suggest that being a student affords some protection against compassion fatigue although there is potential for it to develop following transition to qualified nurse. However, in the clinical area students still witness the same amount of trauma and suffering as qualified staff. Further, students might be required to provide more of the personal care and work more closely with the patient than other members of the team. Therefore it would seem that student nurses are at risk of suffering huge amounts of stress during their education although little is known about their experiences of compassion fatigue.

The themes were revealed in all of the data to some extent. Therefore the poems are presented entire, under their original headings and preceded by a discussion of the multiple themes located within.

The aim of this study was to explore student nurses experiences of compassion fatigue using poetry as a source of data. It was evident from the poems that the students do suffer from compassion fatigue, based on definitions of the concept suggested in a nursing context by Sabo [43] and in more generally by Figley CR [10].

The data suggests that students feel distressed in clinical practice. This is based on the events they witness and might be due to their novice status, in that they lack knowledge and ability to manage their feelings. Some of the data revealed a frustration that in spite of all of the studying and academic work, the situations still do not make sense to students. Feelings of incompetence can be extremely stressful for students [15] and can impact negatively on their learning. Students describe feelings of sadness and the need to become tougher in order to deal with the situations they encounter. Through the data it is evident that even though students do not have overall responsibility for the care of patients, lack of knowledge and inability to cope with situations is stressful in itself. Indeed some of the most common stressors reported among student nurses include having to watch suffering and the death of patients [4].

Some students referred to their personal characteristics when exploring the care they provided to others. Some of the data articulated the difference between the students ‘real’ face and their ‘professional’ one. At times the authors suggest that the caring was ‘real’, and not just because of wearing a ‘professional face’. At times it seemed that the students cared more for the patients than they did for themselves, as they became more and more involved in the challenging situations which led them to place high expectations on themselves. This occurred, for example, in practical ways, such as staying on a shift after it had finished and in emotional ways, such as displaying a ‘brave face’ in order to comfort a patient. Self-sacrificing behaviours have been shown to be a contributing factor to compassion fatigue [1] and attention needs to be given to enhance students’ wellbeing and resilience during their clinical placement [29]. The development of resilience might be beneficial in reducing the risk of compassion fatigue [22]. This might be supported through mindfulness techniques, which could be beneficial in increasing both resilience and self-care and serve as a protective factor [13].

The influences of the work environment and colleagues’ attitudes to students were reflected in some of the data. An example of this was when a student felt she was not being taken seriously, was not supernumerary and that other staff members were treating her in an inferior way. Student nurses are required to have supernumerary status during all practice learning in the UK [36] and if this does not happen then they do not have time, under direct supervision, to develop the skills and competence required to qualify as a nurse [49]. Educators in the practice setting are important ‘role models for learning to care’ and this is facilitated in ways such as reflective practice and sharing experiences ([46], p235). However educators might not have time for joint reflection and subsequent discussion, and can often be too busy to support students learning [33]. Students report that they are often belittled in clinical practice and made to feel like a nuisance to qualified staff [45]. Staff behaviours can leave students feelings helpless and isolated and a difficult environment, combined with lack of support from educators, can lead to students becoming at risk of compassion fatigue.

Apart from poor interpersonal relationships, which are stressful in themselves, the work environment can cause students problems in other ways. Some of the data in this study suggests a ‘cure over care’ ethos in the UK National Health Service (see for example, the poem ‘More’) which leads to feelings of stress in student nurses. Students do not feel able to discuss the reasons for the practices they witness or make suggestions for changes in the way care is delivered [18]. Completing tasks is important for learning although it has been suggested that a more task-orientated approach is favoured generally in nursing practice [50]. This can be problematic as students value the emotional connections they make with patients [21]. Students can be left feeling frustrated as the reality differs of clinical work differs markedly from what they had envisaged, indeed, students hopes are often challenged as early as their first clinical placement [2].

All of the poems in this sample were written in first person and utilised metaphor to assist in the description of feelings. Using metaphor can support the development of intuition as it reaches beyond the rational mind to enable us to make a broader meaning out of our experiences [9]. This has the potential to be beneficial to student nurses, and support them to make sense of traumatic events. Conversely writing in first person might lead to more negative outcomes such as depression [41]. Writing about events from a distance assists in processing what has happened in an abstract way and on the reason why the writer is feeling distress rather than what they are actually feeling [27]. This could support healthy coping, a reduction in stress and a potential protective effect against compassion fatigue. Discussing feelings which arise from relationships with patients and carers help nurses to understand they are not alone in their experiences, [28] and sharing poetry can provide a way to facilitate this emotional exploration [20].

The overarching aim of this work was to explore student nurses experiences of compassion fatigue during their clinical placement. There is a drive in the UK towards the development of a more compassionate workforce. However the negative and stressful effects of caring need to be understood, if students are going to be supported in this difficult aspect of their role. It is clear from this study that students feel vulnerable and psychologically distressed by what they witness and it is not always clear that they are supported in making sense of their experiences. One way to explore difficult practice issues might be through reflective poetry writing, which enables students and educators to share experiences in a meaningful way. In order to promote healthy coping, it is important that educators recognise student’s susceptibility to compassion fatigue and provide appropriate support.