Final Research Paper
Final Research Paper
Jane G. Watson
I pledge: JGW
AN INTEGRATIVE REVIEW 2
Abstract
The purpose of this integrative review is to gain a better understanding of how nurses who care
for chronically ill patients perceive the effects of compassionate care while treating patients who
are at the end of life. There is currently a nursing shortage. Due to improvements in medical
technology that allow people to live longer and the fact that the baby boomer generation is
getting older, the need for nurses to care for patients with chronic illness will most likely
increase over the next few years. Therefore, it is important to understand the needs of these
nurses and equip them for success. Databases such a PubMed and Google Scholar were utilized
to obtain relevant studies. The searches yielded well over 1,000 articles. After refining the
search several times, the researcher chose five articles that fulfilled requirements set for this
topic. Although the researcher specifically sought studies that offered contrasting points of view,
the researcher was only able to locate studies within the past five years that supported the
relationship with their patients. Providing compassionate care can be beneficial to both the nurse
as well as the patient. However, nurses “working in the landscape of death and dying frequently
are exposed to existential issues, psychological challenges, and emotional distress associated
with care at the end of life” (Sansó, Galiana, Oliver, Pascual & Sinclair, 2015). In 1992, Carla
Joinson coined the term compassion fatigue (CF) as a type of professional burnout specific to
caregivers who continually provide support to trauma patients. In the context of this literary
review, the “American Psychiatric Association’s definition of trauma will be used which refers
to a traumatic stressor as any event that may cause or threaten death” (Sacco, Ciurzynski,
Harvey, & Ingersoll, 2015). Therefore, nurses who routinely work with a chronically ill patient
population may be at a greater risk for developing CF. The purpose of this integrative review is
to analyze pertinent research information obtained from reliable medical journals that provide
relevant information regarding the researcher’s PICOT question, how do nurses who care for
chronically ill patients perceive the effects of compassionate care for patients nearing the end of
life? The researcher is interested in this topic as she is currently a nursing student.
This integrative review analyzes five studies that are relevant to the researcher’s PICOT
question. Two databases, PubMed and Google Scholar, were retrieved through the researcher’s
remote library access via Open Athens. Key terms used in the searches included: compassion,
nursing, healthcare, chronic, terminal, and long-term. The criteria were further refined to peer
AN INTEGRATIVE REVIEW 4
reviewed, academic journals published in English between 2012 and 2017 with full text
accessibility. The research method was limited to either quantitative or qualitative. The
researcher was able to find a significant amount of studies pertaining to the PICOT question,
how do nurses who care for chronically ill patients perceive the effects of compassionate care for
patients nearing the end of life? For the purpose of this review, two qualitative and three
The findings and results of the research articles clearly reveal a correlation between the
additional stress of caring for chronically ill patients and the risk of developing compassion
fatigue (CF). A summary of the studies selected for this integrative review is provided in Table
1 and can be found following the reference page. Four of the articles investigate compassionate
care from a healthcare provider’s point of view. One article utilizes the perception of
compassionate care through the eyes of the family members of patients that died as a result of
having dementia. Although this particular article does not directly answer the researcher’s
PICOT question, it does provide relevant information for future recommendations regarding
compassionate care in nursing. Each study was conducted by well qualified researchers and
credentials were provided. Each study obtained appropriate sample sizes for the type of study,
ethical considerations for all participants was addressed, and proper research approval was
This integrative review is based on the following categories that emerged as recurring
themes throughout the analysis: compassionate care, compassion fatigue, and coping strategies.
AN INTEGRATIVE REVIEW 5
Compassionate Care
As previously mentioned, caring is a fundamental part of the nursing role. Three of the
articles utilized for this integrative review mention some sort of personal fulfillment nurses
achieve by offering compassionate care. “Most palliative professionals report high levels of
satisfaction and meaning in their work and acknowledge that caring for patients facing the end of
life can be an enriching and beneficial experience” (Sansó et al., 2015, p. 201). “Although all of
the nurses interviewed indicated that providing hospice and palliative care was a privilege, each
had experienced some of the symptoms of professional compassion fatigue (PCF)” (Melvin,
2012, p. 608). “Although nurses obtain professional satisfaction from their work, their repeated
exposure to the aftermath of critical illness puts them at a high risk for compassion fatigue”
Compassion Fatigue
In this integrative review, two qualitative studies utilized in-depth interviews to gather
data. Each of the interviews lasted between 30 and 80 minutes, were recorded, and then
transcribed verbatim. In the study by Crowther, Wilson, Horton & Lloyd-Williams (2015), 40
mourning family members of deceased patients who suffered from dementia were analyzed by
unstructured narrative interviews with a grounded theory, allowing for personal experiences to
dictate the direction of the interview. Each participant was asked to rate their perceived level of
compassionate care that was provided to their family member by the nursing staff. A perception
of little compassion was noted as the staff was viewed as distant and unaffected by the
The second qualitative study evaluated in this integrative review was by Melvin who
semi-structured interview of six female palliative care nurses with at least 10 years of experience
in their field of nursing. The data was analyzed using a constant comparison analysis. An
inductive approach was used to develop codes, categories and patterns. “Each of the nurses
recognized the risk of professional compassion fatigue (PCF), while one of the nurses was
clearly showing signs and symptoms of PCF at the time of the interview” (Melvin, 2012, p. 610).
This participant was not rebounding from work stressors like she used to. “This finding is
consistent with previous research which suggested that when health professionals suffer with
PCF they become physically, mentally, and spiritually exhausted, yet they continue to provide
fatigue and turnover intention for nurses working in high stress areas of Korean hospitals. One
hundred and forty-two nurses were recruited by sampling who worked for tertiary hospitals with
500 beds or more. PASW 19.0 program which included one-way ANOVA, independent t-tests,
“Compassion fatigue and burnout were significantly correlated and they were tested as predictive
variables for turnover intention” (Sung, Seo, & Kim, 2012). Therefore, the study suggests that
gaining insight regarding compassion fatigue and providing appropriate interventions can reduce
Coping Strategies
Of the five studies included in this integrative review, one quantitative and two
qualitative studies explore the effects of coping strategies on the perception of providing
compassionate care for chronically ill patients nearing the end of life. In the quantitative study
by Sansó, Oliver, Pascual, Sinclair & Benito (2015), 385 healthcare professionals from 13
AN INTEGRATIVE REVIEW 7
associations belonging to the largest palliative care association in Spain were assessed based on
an adapted version of the Kearney’s awareness model of self-care. The study was conducted by
gathering data from emailed surveys. Three variables of self-care that were evaluated by Sansó et
al. included physical self-care (maintaining a healthy body), inner self-care (maintaining a
healthy mind), and social self-care (maintaining healthy relationships outside of work). The
variable of awareness was measured “with the validated Spanish version of the Mindful
Attention Awareness Scale, a 15-item instrument that measures the general tendency to be aware
and conscious of one’s own experiences of daily life” (Sansó et al., 2015). The variable of
coping with death was “measured with the Coping with Death Scale, a questionnaire that
preparedness for death” (Sansó et al., 2015). Data aligned with the estimated model and
supported the hypothesis that “self-care and awareness positively predicted professionals’
competence in coping with death and negatively predicted compassion fatigue and burnout”
In the cross-sectional quantitative study by Sacco et al., data was gathered via electronic
survey and analyzed by ProQOL, version 5, of 221 voluntary participants solicited through the
University of Rochester medical center. After thorough investigation of the participants grouped
by education level (associate, bachelors, and masters), gender (male/female), and age ranges per
decade (20s, 30s, 40s, and 50+), the overall finding of the study revealed that in general “nurses
that achieve a balance of compassion satisfaction to off-set the effects of compassion fatigue,
experience a higher professional quality of life and are less likely to leave their position” (Sacco,
2015, p. 40).
AN INTEGRATIVE REVIEW 8
In Melvin’s qualitative study, “the overarching theme that emerged was that without
adequate coping strategies, the participants were at risk of developing PCF” (Melvin, 2012, p.
608). Melvin’s coping strategies included internal personal choices such as setting professional
boundaries and exercise, as well as external support from supervisors who recognize signs of CF
and offer appropriate and timely interventions that may include a periodic change in roles
In regard to the researcher’s PICOT question, how do nurses who care for chronically ill
patients perceive the effects of compassionate care for patients nearing the end of life, the results
from this integrative review support the fact that compassionate care can mutually benefit the
patient as well as the nurse as long as the nurse employs positive coping strategies that facilitate
self-preservation. “Most palliative professionals report high levels of satisfaction and meaning
in their work and acknowledge that caring for patients facing the end of life can be an enriching
and beneficial experience” (Sansó et al., 2015, p. 201). However, in order for those nurses to
provide compassionate care to chronically ill patients day after day, they must have appropriate
coping skills. These coping skills will assist the nurse in renewing the level of compassionate
care he or she is able to provide. “Each of the participants described the need to set professional
boundaries in order to maintain their ability to work in end-of-life care” (Melvin, 2012, p. 609).
“Palliative care professionals are privileged and challenged to find ways of using their selves
simultaneously providing a means for health care professionals to cope when facing frequent
losses. Palliative care professionals function as a powerful but vulnerable tool in the caring
A few limitations should be noted regarding this integrative review. First, the
researcher’s lack of experience in performing integrative reviews may skew the information
represented. Additionally, all of the studies utilized in this integrative review represent the same
point of view. Contrasting points of view were found, however the research was conducted prior
to the 5-year inclusion criteria for this assignment and therefore disregarded.
In conclusion, caring for the chronically ill can be a tremendously satisfying career. As
the average age of our population continues to increase as a result of the baby boomer generation
diseases. Thus, the demand for medical services has increased rapidly, and the demand for
nurses has also increased consistently” (Sung et al., 2012, p. 1087). “Compassion fatigue has
emerged as a natural consequence of caring” (Crowther et al., 2013, p. 492). This integrative
review suggests that there appears to be a compassion threshold in nursing. Nurses perceive
compassionate care as beneficial up to a point. However, the stress of continually providing care
to patients that are at the end of life can become overwhelming, especially if nurses are not
utilizing positive coping strategies on a regular basis. Nurses who utilize positive coping
strategies are better equipped to handle the additional stress that caring for chronically ill patients
can present. Therefore, this integrative review supports the need to continually monitor the
compassion threshold of nurses who care for the chronically ill and support appropriate coping
strategies to enable sustainable compassionate care and decrease the risk of burnout or turnover.
AN INTEGRATIVE REVIEW 10
References
Crowther, J., Wilson, K. C. M., Horton, S., & Lloyd-Williams, M. (2013). Compassion in
healthcare-Lessons from a qualitative study of the end of life care of people with
10.1177/0141076813503593
Melvin, C. S. (2012). Professional compassion fatigue: What is the true cost of nurses caring for
doi: 10.12968/ijpn.2012.18.12.606
Sacco, T. L., Ciurzynski, S. M., Harvey, M. E., & Ingersoll, G. L. (2015). Compassion
satisfaction and compassion fatigue among critical care nurses. Critical Care Nurse,
Sansó, N., Galiana, L., Oliver, A., Pascual, A., Sinclair, S., & Benito, E. (2015). Palliative care
professionals’ inner life: Exploring the relationships among awareness, self-care, and
compassion satisfaction and fatigue, burnout and coping with death. Journal of Pain and
Sung, K., Seo, Y., & Kim, J. (2012). Relationships between compassion fatigue, burnout, and
Measurement Tool/Data Unstructured narrative interview allowed participants to guide the conversation
Collection Method Interviews lasted between 30 and 80 minutes
Recorded digitally then transcribed verbatim
Participants approved transcription (p. 493)
Data Analysis Grounded theory reflecting personal experiences (p. 493)
Findings/Discussion Kindness, compassion and humane were frequently used words by participants
Caring domain is from birth to death (womb to tomb) while the medical domain is purely the
science of saving life (p. 494)
Appraisal/Worth to practice Nurses who constantly work with dying patients can view it as routine and experience compassion
fatigue
Bereaved family offer great insight on the perceptions of compassionate care
Target driven care is important but family perceptions are just as important (p. 496)
AN INTEGRATIVE REVIEW Article #2 Evaluation Table 12
First Author • Sanso, PhD (2015) Department of Methodology for the Behavioral Sciences, University of
(Year)/Qualifications Valencia (p. 200)
Background/Problem • The researchers’ aim was to investigate the extent to which data from a nationwide survey of
Statement Spanish palliative care professionals supported Kearney and Weininger’s model on the
relationships among awareness, self-care, CS, CF, burnout and coping with death (p. 204)
Conceptual/theoretical • Based on previous research from Kearney and colleagues which suggests that self-awareness
Framework promotes compassion satisfaction and prevents compassion fatigue and burnout (p. 201)
Design/ • Quantitative online survey
Method/Philosophical • Included measurements of satisfaction, compassion fatigue, awareness, death exposure,
Underpinnings coping with death, and burnout (p. 201)
Sample/ Setting/Ethical • 385 healthcare professionals from 13 associations belonging to the largest palliative care
Considerations association in Spain (SECPAL)
• Inclusion criteria: currently working in palliative care setting and at least 18 yrs old (p. 202)
Major Variables Studied (and • Self-Care: physical (exercise) inner (emotional care of the mind), social (friendship)
their definition), if • Awareness: conscious of daily experiences
appropriate • Coping with death: 30 items concerning preparedness
• Professional Quality of Life: Balance of compassion satisfaction and compassion fatigue (p.
202)
Measurement Tool/Data • Due to the several variables being measured, the researchers chose path analysis instead of
Collection Method regression analysis in order to distinguish effects of one variable on another (p. 203)
Data Analysis • Path analysis was estimated using Satorra-Bentler robust corrections for standard errors and
fit indices implemented in the EQS 6.1 program for ordinal and non-normal data (p. 203)
First Author • Melvin (2012) Clinical Associate Professor, Department of Nursing, University of Vermont
(Year)/Qualifications (p. 606)
Background/Problem • Nurses who routinely care for dying patients are at an increased risk of developing
Statement professional compassion fatigue (PCF)- the cumulative impact of caring
• Compassion and empathy are core values of nursing (p 606-607)
Conceptual/theoretical • The researcher acknowledged that nurses are at a risk of compassion fatigue because
Framework compassion and empathy are core values of nursing and nurses who continually work with a
dying population are at an even greater risk of compassion fatigue (p. 606)
Design/ • Descriptive qualitative study
Method/Philosophical • Phenomenology (real life situations)
Underpinnings • Semi-structured interview (p. 607)
Sample/ Setting/Ethical • All participants were informed and assured anonymity
Considerations • Six female nurses purposefully selected with at least 10 yrs experience in palliative or end-
of-life care
• Experience ranged from 11-33 years
• Study was approved by the University of Vermont Human Subjects Research Com. (p. 607)
Major Variables Studied (and • Healthy coping strategies- exercise, good nutrition, relaxation, supportive supervisors, work-
their definition), if life balance
appropriate • The need to change roles periodically (p. 610)
Measurement Tool/Data • Semi-structured interview
Collection Method • Audiotaped- approximately one hour (p. 608)
Data Analysis • Audiotaped interview was transcribed verbatim
• Line-by-line process using themes generated in literature (p. 608)
Findings/Discussion • Emerging themes 1. Risk for PCF 2. Physical and Emotional Cost of Caring 3. Setting
boundaries/Healthy Coping Strategies
• Each participant had experienced some degree of PCF- One was actively in PCF (p. 608)
Appraisal/Worth to practice • The intensity from the needs of patients experiencing the end of life increases the risk of
professional compassion fatigue (PCF). This study explores the effects of PCF as well as
coping strategies adopted by nurses
• With an aging population, the demand for end-of-life care will increase (p. 610)
AN INTEGRATIVE REVIEW Article #4 Evaluation Table 14
First Author • Sung (2012) College of Nursing/Catholic University of Daega, Department of Nursing
(Year)/Qualifications Kyonbuk/Science College Chilgok-gun and Department of Med Technology
Background/Problem • Nursing is stressful. There is a worldwide shortage of nurses. Nurses who experience
Statement compassion fatigue may leave their position for a nonclinical role
Conceptual/theoretical • This research investigated relationships between compassion fatigue as a predictive variable
Framework for turnover intention
Design/ • Quantitative
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical • 142 nurses who worked for tertiary hospitals with 500 beds or more recruited by sampling
Considerations • Participants signed written agreements and were assured the information would not be used
for any other purpose
• Research was supported by the Research Grant funded by Kangwon National University.
An Ethics Committee was not discussed
Major Variables Studied (and • Compassion Fatigue: stress caused by repeatedly helping others in need
their definition), if • Burn-out: manifested symptoms of anxiety, impulsive behavior, and substance abuse
appropriate • Turnover Intention: expressed desire to leave the unit
Measurement Tool/Data • PASW 19.0 program which included one-way ANOVA, independent t-tests, Pearson’s
Collection Method correlation coefficient, and hierarchical analysis
Data Analysis • Hierarchical regression analysis used to determine if compassion fatigue was a predictive
variable for turnover intention among hospital nurses
Findings/Discussion • Positive correlation between compassion fatigue and burn out (r=0.37, p < 0.001)
• Positive correlation between compassion fatigue and turnover intension (r= 0.55 < p 0.001)
Appraisal/Worth to practice • Gaining insight regarding compassion fatigue can reduce nurse turn-over and increase
retention
AN INTEGRATIVE REVIEW Article #5 Evaluation Table 15
First Author • Sacco, RN, MS, CCRN, AGNS-BC, ACCSN-AG (2015) St. John Fisher College
(Year)/Qualifications
Background/Problem • “Compassion fatigue has been studied in other populations. This research examined the
Statement effects of compassion fatigue on nurses in a critical care setting” p. 34)
Conceptual/theoretical • “The primary purpose was to establish the prevalence of compassion satisfaction and
Framework compassion fatigue in critical care nurses in an academic medical center in western New
York State” (p. 38)
Design/ • Quantitative
Method/Philosophical • Cross-sectional study; Electronic survey emailed (p. 34)
Underpinnings
Sample/ Setting/Ethical • “221 Voluntary participants
Considerations • Anonymity granted with no participant identifiers
• Approved by the Medical Center’s Institutional Review Board” (p. 35)
Major Variables Studied (and • “Compassion satisfaction- positive feelings from helping others during traumatic situations
their definition), if • Compassion fatigue- cumulative state of frustration with a person’s work environment that
appropriate develops over a long period of time
• Professional Quality of Life - Cumulative experience of both (compassion satisfaction and
compassion fatigue)” (p. 33)
Measurement Tool/Data • “Data was grouped by participants’ education level (associate, bachelors, masters), gender
Collection Method (male/female), and age grouped by decade (20s, 30s, 40s, and 50+)
• Therefore, an effective balance in the ProQOL was achieved” (p. 38)
Findings/Discussion • “The most significant finding was the high levels of compassion satisfaction (73%) in nurses
50 years and older than among their younger colleagues (34-42%)” (p. 36)
Appraisal/Worth to practice • Nurses who achieve a balance of compassion satisfaction and compassion fatigue
experience a professional quality of life and are less likely to leave their position