Aim
The overarching aim of this work was to explore student nurses experiences of compassion fatigue using student authored reflective poems as a data source. It is important to understand students’ experiences of practice so that they can be supported appropriately both in clinical and academic settings. This has the potential to positively affect retention, promote the health and well-being of the student group and support effective patient care provision. Further, sharing experiences of practice can support development of the bond between the student and educator and helps develop constructive relationships, which are grounded in an enhanced understanding of the student’s lifeworld [20].
Design
I used an interpretive phenomenological approach to explore how our students described and understood compassion fatigue on a personal and professional level. This style of phenomenology is based on the belief that the way to understanding is through interpretation, which in turn is based on our history, or, what has happened to us in the past [17]. Heidegger [17] stated that our ‘being in the world’ is covered up, and phenomenology is required to uncover what is happening to us. Phenomenology is not merely concerned with the description of thoughts and feelings but is an attempt to uncover the meaning behind what is actually said [30]. Naturally, the interpretation will rely on the researcher’s interpretative lens and as Finlay [11] suggests, the research is a combined product of the data and also the relationship between the informants and researcher. This leads to a combined interpretive ‘truth’ based on words and feelings. This style of phenomenology is in contrast to the Husserlian approach, which seeks to find an untainted ‘truth’ which is free from the researcher’s previously held thoughts and assumptions about the subject being researched. Husserl, originally a mathematician, was concerned with truth which was free of presupposition [19]. However, there is great potential to reach different understandings of a phenomenon when we combine our own ‘prejudice’ about a subject with the thinking of another person. In this context, prejudice is used in a positive way, and leads to a new ways of understanding [14]. This process can lead us to discoveries which might never be made had we chosen to bracket out our previous thinking about the phenomenon. Dahlberg et al. [6] describes the interpretive process as ‘the whole-the parts-the whole’. As researchers we begin with the ‘whole’ of our initial understanding, which is then exposed to the ‘parts’, for example, lines of the students’ poems. Then, a new ‘whole’ is revealed based on what we knew already, combined with the informants thinking on the subject.
In keeping with this approach, it was important that I exposed my understanding of compassion fatigue to make it clear how my interpretation of the data was reached. This process adds to the credibility of the research, as the reader is exposed to the context surrounding the interpretation, as they are privy to the thoughts of the researcher [5]. Figley CR [10]) describes compassion fatigue as a sudden response accompanied by feelings of helplessness, confusion and isolation from others and I suggest that my own experience relates most closely to this description.
My prior experience
As a student nurse the most satisfaction I gained was through talking to patients and trying to make emotional connections with them. As a third year student nurse, during one clinical placement on a female medical ward, an elderly woman had been admitted following a myocardial infarction. She was accompanied by her husband and it seemed clear to me that their relationship was very loving and caring. He seemed devoted to her and the love between them was obvious. I came to know them well during her stay and when she recovered a date was set for discharge. However the day before she was due to be discharged she suffered a cardiac arrest and died. I was shocked and overwhelmed by this experience, not least because it seemed unexpected. What upset me most was the thought of her husband and after someone had broken the news to him, his face was that of a lost man, bewildered and confused. He came onto the main ward to see his wife and I was standing close by. I spontaneously gave him a hug and started to cry, something that was not accepted by my assigned educator, who suggested I went off the ward and got a drink for myself. I was coming to the end of my pre-registration education and was physically and mentally exhausted. Following this event I felt confused, helpless and heartbroken; I had not known what to do at that time, words seemed insufficient and I felt very distressed.
Poetry as data
Reflective poetry, written by student nurses, was used as data in this study. Poetry, both published and student authored, has been used in various ways and across many disciplines to explore students experiences, for example, Nursing [3, 25], Sports Coaching [48], Teacher Education [47] and Medicine [12]. Student authored poetry has been used as qualitative data in nursing research [20, 25] and when used in this way, supports our understanding of the individual lifeworld of another. Indeed Rolfe & Gardner [38] call for nursing research which values the individual nature of others and it is often the difference between informants’ stories which is interesting, rather than what is similar. Poetry is an effective way to tell unique stories of experiences and supports exploration of feelings, some of which might not usually be considered [47]. Some students might worry that they are not creative and find poetry writing a difficult task; it is important that educators do not judge the quality of the poems written and accept all as having value [48]. However poetry writing enables feelings to surface in ways, such as reading published poems, might not [20]. Poetry writing encourages the use of metaphor which enables students to explore ideas in ways they might not usually do [44]. It can support understanding of the patients point of view and help the writer see things in a more holistic way [7]. Further, it can support self-development and exploration [35] making it a helpful way to consider nursing values and how they relate to the self. Therefore when exploring the phenomenon of compassion fatigue, reflective poems were considered a rich source of data.
Sample
A cohort of 42 nursing students on the BSc (Hons) Adult Nursing programme at a UK university were asked to write and submit poems relating to the concept of compassion to the ‘Caring Words’ website in 2015. This was not related to their assessment but as part their directed study learning during the module. The website www.caringwords.mmu.ac.uk is a dedicated online community where students can read poems written about practice by their nursing peers, and post poems of their own. The community was developed to reduce the isolation students feel when exposed to difficult clinical practice issues. By reading the poems written by others, students feel less alone when they read that other students might be experiencing the same or similar feelings to themselves.
Minimal guidance about poetry writing was given to the students, although it was suggested that the poems could be written in first person or ‘from a distance’, using the voice of the patient, or as if telling a story as an observer. Students were given a period of 2 weeks to complete this exercise and this was preceded by a discussion of the benefits of expressive writing and the multiple creative ways in which nurses can reflect on practice issues. Some students became concerned about the quality of their poems although were reassured that the exercise was about the reflective process they followed during the writing of the poem, rather than the finished product. Viewing the poems on the website, written previously by their peers, supported them in writing their own work. After the 2 week period, the students meet and discuss their poems in a small group, facilitated by an experienced educator. This has been shown to be an effective way to explore and reflect upon practice issues.
On review of the work submitted, rather than focus on compassion, it was clear that some poems explored the difficulties of caring and I interpreted these works as reflecting the concept of compassion fatigue. This was not entirely an unexpected finding as I had not directed the student group in a particular way, therefore they were free to interpret the brief how they liked. I wanted to use poetry writing to uncover the realities of practice and it was clear that the students did not always experience compassion in positive ways. Some of the poems revealed stressful events and experiences relating to their practice as a student. For me as an educator, I felt it was beneficial to know about these experiences, based on the belief that if I can understand how students are feeling, I am better positioned to provide support and subsequent effective interventions. All four of the poems selected for this study were written by female students who were coming to the end of their first year of the undergraduate nursing programme. The poems were purposively chosen as they were the ones most representative of the concept of compassion fatigue. The students had been exposed to one clinical placement at the time of writing the poems. The age range of the sample was 18–30 years of age.
Analysis
As discussed earlier, it is often the differences between experiences which hold the most interest, rather than the similarities or themes which cut across all of the data. With this in mind, the poems were analysed as individual works rather than thematically. Fragmenting poems to ease the process of analysis, although tempting, would not do justice to the individual pieces and in agreement with Shapiro and Stein [44]: 176) might be considered ‘aesthetic murder’. Therefore the poems were individually analysed and in line with a phenomenological approach were considered using the hermeneutic circle. Heidegger [17] suggests that ‘In the circle is hidden a positive possibility of the most primordial kind of knowing’ and this form of analysis operates on multiple levels. For example, lines of a poem are considered against the backdrop of the whole piece of work, whole poems are analysed in relation to the parts, and this goes on in a back and forth motion until a different understanding of the phenomenon is reached. Often, perspectives can only be understood and interpreted against the backdrop of the whole situation. Therefore it is important to work in a circular motion, whole-parts-new whole, until understanding is gained.
