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Differences in Compassion Satisfaction, Compassion Fatigue, and Work Environment Factors by Hospital Registered Nurse Type

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Lisa Lisle, MSN, RN, CEN
Karen Gabel Speroni, PhD, RN, BSN, MHSA
Wynne Aroom, MSN, RN-BC, CDE
Lynn Crouch, MSN, RNC-OB
Hope Honigsberg, CRNP, RN, CNOR

Abstract

Patients and families desire compassionate care from healthcare providers. In today’s healthcare environment, challenges exist for all providers, including nurses, with balancing the delivery of consistent, compassionate care and maintaining a professional quality of life (QOL) that incorporates overall wellness and a healthy work environment. A literature review indicated no available research related to compassion satisfaction and fatigue and work environment by RN type. The aims of this study were to quantify differences in compassion satisfaction (CS) and compassion fatigue (CF) scores, including burnout and secondary traumatic stress (STS), by four registered nurse (RN) employment-types and to study work environment factors. Our methods included a survey of a random sample (n = 208) of RNs by type. Study results indicated that significant differences existed by RN type for CF (burnout and STS) scores; nurse leaders had the most CF and other nurses the least. Significant differences also existed for some shared governance activities and workplace violence measures. Our discussion concludes that opportunities exist for evaluation of interventions for healthier work environments, particularly for nurse leaders, including supporting shared governance activities for all RN types, as well as zero-tolerance for workplace violence.

Citation: Lisle, L., Speroni, K.G., Aroom, W., Crouch, L., Honigsberg, H., (August 26, 2020) "Differences in Compassion Satisfaction, Compassion Fatigue, and Work Environment Factors by Hospital Registered Nurse Type" OJIN: The Online Journal of Issues in Nursing Vol. 25, No. 3.

DOI: 10.3912/OJIN.Vol25No03PPT44

Key Words: compassion fatigue, compassion satisfaction, burnout, secondary traumatic stress, healthy work environment, shared governance, nursing satisfaction, retention, nursing management, workplace violence, lateral violence, clinical nurse, nurse manager, nurse leader

Professional quality of life incorporates positive and negative aspects Patients and families desire compassionate care from healthcare providers. In today’s healthcare environment, challenges exist for all providers, including nurses, with balancing the delivery of consistent, compassionate care and maintaining a professional quality of life (QOL) that incorporates overall wellness and a healthy work environment.

Professional QOL incorporates positive and negative aspects (Stamm, 2010). An important positive aspect is compassion satisfaction (CS) and a negative aspect is compassion fatigue (CF). CS is the pleasure a nurse derives from performing his/her work well, such as the pleasure of helping others with their work. Nurses may experience positive feelings toward colleagues about their ability to contribute to the work setting or even the greater good of society. CF addresses two parts, with the first being exhaustion, frustration, anger and depression typical of burnout, and the second being secondary traumatic stress (STS), a negative feeling driven by fear and work-related trauma.

Healthcare providers are exposed to traumatic incidents that create immediate and/or delayed stress reactions that impact overall wellnessHealthcare providers are exposed to traumatic incidents that create immediate and/or delayed stress reactions that impact overall wellness (Griner, Shirk, Brown, & Hain, 2017). As CF can negatively affect nurses' well-being, the authors, all registered nurses (RNs), conducted a literature review that focused on RN employment-type groups, specifically, clinical nurses, nurse managers, nurse leaders, and other nurses. In our research, we assessed differences in CS and CF potentially related to work environment factors.

Literature Review

We followed conventional methods for a literature review, searching the Cumulative Index of Nursing and Allied health Literature (CINAHL), PubMed, and MEDLINE databases. Search terms included compassion satisfaction, compassion fatigue, secondary traumatic stress, burnout, clinical nurses, nurse managers, nurse leaders, shared governance, nursing satisfaction, leadership changes, workplace violence and lateral violence.

...researchers reported that the physical, emotional, social, and spiritual health of healthcare providers is impaired by cumulative stress related to work.In a 90-study meta-narrative review of CF in healthcare providers, researchers reported that the physical, emotional, social, and spiritual health of healthcare providers is impaired by cumulative stress related to work. This stress can impact healthcare service delivery (Sinclair, Raffin-Burnoutuchal, Venturato, & Mijovic-Knodejewski, 2017). Empirical studies primarily measured CF using the Professional Quality of Life (ProQOL) scale (Sinclair et al., 2017).

In a 2016 integrative literature review of 43 articles regarding CF in healthcare providers, researchers addressed the prevalence, risk factors, prevention measures, and CF symptoms, as well as the manner in which these areas affect the quality of healthcare providers’ personal and work lives (Sorenson, Burnoutlick, Wright, & Hamilton, 2016). The authors found that CF affected a vast number of healthcare professionals within many different specialties. However, there is limited research regarding the effect on advanced practice registered nurses (APRNs) and therapists (e.g., respiratory, physical and occupational), calling for, calling for additional research to evaluate the presence of CF in these provider populations.

In a systematic review of 71 articles that measured CF in healthcare providers using a validated instrument, CF was reported across all practitioner groups (Cavanagh et al., 2019). These researchers also reported variable CF prevalence and inconsistency related to years of experience and specialty. Further, there was variability in reporting ProQOL results.

In a correlative meta-analysis, 11 studies were evaluated on factors affecting CS, CF and burnout (Zhang, Zhang, Han, Li & Wang, 2018). Regarding nurses, these authors reported that stressful factors and negative affect promote CF and burnout, and positive affect is helpful for CS. They also found that demographic and professional factors were not significantly related to CS, CF or burnout.

...CF affected a vast number of healthcare professionals within many different specialties. The literature lacked information about the differences in CS and CF scores by RN types and specific work environment factors. Our research focused on selected study factors thought to affect the work environment, including nurse participation in shared governance-related activities; nursing satisfaction; leadership change; retention; and violence (workplace and lateral). Our study findings could then inform work environments for nurses by better understanding differences by RN type for the various environment factors as they relate to CS, secondary traumatic stress (STS), and burnout. Ideally, for RN types who experience the most STS and burnout, tailored interventions could be developed and tested to facilitate shared governance and /or nursing satisfaction activities; transition processes when leaders change; and improvements in workplace culture regarding violence.

Study Aims

The primary study aim was to quantify differences in CS and CF scores by RN type (i.e., clinical nurses, nurse managers, nurse leaders, and other nurses). The secondary aim was to quantify, by RN type, differences in work environment factors such as participation in shared governance activities; nurse satisfaction levels; experiencing changes in management; intent to stay/retention; and incidents in workplace and lateral violence.

Methods

Study Design and Setting
This survey study was initiated by nurse researchers from a rural, three-hospital system in the mid-Atlantic region of the United States. Each hospital has American Nurses Credentialing Center Magnet™ recognition. Of the three hospitals, one has 124 beds (104 licensed beds and 20 acute rehabilitation beds); the second has 42 licensed beds, which include 24 behavioral health beds; and the third has 21 licensed beds. The hospital system Institutional Review Board (IRB) reviewed the study protocol and approved the survey research in the category of exempt.

Study Population and Sample
We obtained a listing of the hospital systems RNs for each of the four RN type in our study population. The inclusion criterion was being an RN employee of one of the hospitals in the system. Agency and traveler RN employees were excluded. The sample goals were participation by at least 30% of RNs across the three-hospital system and representation by all RN types within each of the four groups being studied.

RN types were determined according to definitions provided for clinical nurse, nurse manager, and nurse leader...RN types were determined according to definitions provided for clinical nurse, nurse manager, and nurse leader, according to the American Nurses Credentialing Center (ANCC) Magnet Application Manual (ANCC, 2014). Clinical nurses spent the majority of their time providing direct patient care. Nurse managers were RNs who had 24-hour/7-day accountability for the supervision of all RN and other healthcare providers who deliver nursing care in an inpatient or outpatient area. Nurse leaders were RNs with line authority over multiple units that have RNs working clinically and nurse leaders who were positioned on the organizational chart between the nurse manager and the chief nursing officer. The other nurse group was comprised of Clinical Specialists, Infection Control Nurses, Nurse Educators, Clinical Nurse Coordinators, Nursing Supervisors, Admissions Coordinators, Nurse Navigators, and Care Coordinators. Within this hospital system, at the time the research was initiated, clinical nurses comprised 77.0% of total nurses, nurse managers were 2.8%, nurse leaders were 1.8%, and other nurses were 18.4%.

From this list, we drew a random sample of the four RN categories described above. Of the 653 RNs asked to participate, 208 completed the study (response rate = 31.9%).

Data Collection Tool
With permission, we collected data using the ProQOL, a validated survey tool that provides individual scales for measuring CS and CF (Stamm, 2010). This tool contains three subscales: one for CS and two for CF, which are burnout and STS. These three scales measure separate constructs. The CF scale is distinct. Inter-scale correlations have a 2% shared variance (r=.23; co‐σ = 5%; n=1187) with STS and 5% shared variance (r= .14; co‐σ = 2%; n=1187) with burnout. The shared variance between the burnout and STS scales was 34% (r=.58; co‐σ = 34%; 14; n=1187).

The ProQOL, a 71-item survey, has the following three parts. Part 1-Demographics/Work, contained nine investigator developed questions. Part 2-ProQOL contained the validated 30-item survey (Stamm, 2010). The ProQOL has good construct validity as reported by more than 200 publications. Part 3, which assessed Shared Governance Activities, Nurse Satisfaction, Management Changes, Retention, Violence (workplace and lateral), and Other, had 32 questions.

Regarding Part 3, shared-governance questions were derived from a 26-item tool rated for relevance and clarity, with an acceptable content validity index of 0.94 (Wilson, Speroni, Jones, & Daniel, 2014). Workplace violence questions were from a 34-item tool, rated for relevance and clarity with an acceptable content validity of 0.80, and a Cronbach α coefficient of 0.95 (Speroni, Fitch, Dawson, Dugan, & Atherton, 2014). Lateral violence questions included those from the 16-item Workplace Bullying Inventory by Hutchinson, Wilkes, Vickers, & Jackson (2008), which has a Cronbach α coefficient of 0.93 (Stagg, Sheridan, Jones, & Speroni, 2013). Also, there were four ‘other’ questions. One was “For the following categories, please rank, with 1 being the highest, that which provides the most compassion satisfaction to you in your RN position [1=most compassion satisfaction; 6=least compassion satisfaction]” by each of the work environment factors studied.

A parallel question for CF was also included, with rankings corresponding to CF. Two additional, open-ended questions were as follows: “Please provide any other comments regarding shared governance activities, nurse satisfaction, management changes, retention, and violence (workplace and lateral), related to compassion satisfaction,” and “Please provide any other comments regarding shared governance activities, nurse satisfaction, management changes, retention, and violence (workplace and lateral), related to compassion fatigue.” For these two questions and any which included an ‘other’ option and/or ‘specify’ option, qualitative analysis was completed when participants provided a response.

We used the following definitions: workplace violence was defined as “a nonfatal violence (rape/sexual assault, robbery, and aggravated and simple assault) against employed persons age 16 or older that occurred while they were at work or on duty” (Bureau of Justice Statistics [BJS], 2019, para. 1). Lateral violence (i.e., workplace bullying) was defined as: Workplace bullying was defined as repetitive, inappropriate behavior, direct or indirect, whether verbal, physical or otherwise, carried out by one or more persons against another or others, at the workplace and/or in the course of employment, which undermines the individual’s right to dignity at work (Center for American Nurses, 2008). 

Data Collection Process
The survey was piloted by members of the hospital system’s Nursing Research Council prior to initiating the study. There were no incentives offered to participants for completing the study. Nurses selected by the random sample received a recruitment email that included a link to the ICF. Participants accessed an online, informed consent form (ICF) prior to continuing the online survey. The ICF was completed in Survey Monkey and described the study purpose, participation duration, and investigator information. Participants who clicked on the 'agree' link within the ICF were then taken to the study survey.

Analysis
Descriptive statistics, including mean (M) or median and standard deviations (SD) were used for continuous variables, and frequency and percentage for categorical variables. Chi-square and analysis of variance were used to determine differences amongst the four RN types.

The median score was used for ProQOL analysis. For CS, we used the following scale scores: low = ≤22, average = 23-41, and high = ≥42. For the CF scale - burnout, the scale scores were: low = ≤22, average = 23-41, and high = ≥42; and for the CF scale - STS, a low score = ≤22, average = 23-41, and high = ≥42(1).

Statistically significant findings were reported at p<0.05. Statistical analysis was completed in SPSS, version 13.0. Statistical test conducted and significance testing are reported on each table.

Conventional content analysis was completed for the open-ended survey questions (Hsieh & Shannon, 2005). Participant response data were coded separately by two nurse researchers and consensus was reached for all final codes with two other nurse researchers. Codes were identified and aggregated into categories, which are reported below as primary themes.

Results

Of the 232 RNs entering the survey, 208 completed it (clinical nurses, n =142 or 68.3%; nurse managers, n =13 or 6.2%; nurse leaders = 6 or 2.9%; and other nurses, n = 47 or 22.6%). Most nurses specified a baccalaureate degree as their highest nursing degree (n = 85 or 40.9%), and most were 41 years of age or older (n = 157 or 75.4%). The most frequent work areas were the emergency department (n = 37 or 17.8%) and the medical/surgical area (n = 3 or 17.8%). Most worked 36-40 hours per week (n = 123 or 59.1%), and on average had 21.1 years of experience. Nurses were represented from each of the three hospitals by the four RN types, except for nurse leaders (two of the three hospitals had nurse leader participation).

Nurses were represented from each of the three hospitals by the four RN types, except for nurse leaders...The tables below report findings for the primary aim, showing the median ProQOL CS and CF (burnout and STS) scores by RN type (Table 1); and the secondary aim, showing work environment factors by the four RN types and overall (Tables 2 and 3).

Compassion Satisfaction and Compassion Fatigue (Burnout and STS)
Table 1 provides the analysis of variance findings by CS and CF by RN type. There were statistically significant differences for both CF ProQOL scales, burnout (p<0.05) and STS (p<0.05), but there were no significant differences for CS (p=0.26). Nurse leaders demonstrated the highest median burnout score (24.2) and STS score (25.5). The other nurse group had the lowest burnout (20.7) and STS (21.2) scores.

Table 1: ProQOL Scores by RN Employment Type, Group and Overall

Scale,
(range)
[SD]

Clinical Nurses
N=142 (68.3%)

Nurse Managers
N=13
(6.2%)

Nurse Leaders
N=6
(2.9%)

Other
Nurses
N=47
(22.6%)

Overall
All RNs
N=208

Significance Test+

Median CS Score*

40.1 (26-50) [6.5]

42.0 (39-45) [2.7]

40.9 (31-50) [5.7]

42.1 (28-50) [5.3]

40.7 (26-50)
[6.2]

F-stat=1.35  p=0.26

Median CF Score for Burnout**

21.1 (14-29) [3.5]

22.8 (19-27) [3.3]

24.2 (19-31) [4.0]

20.7 (15-30) [2.8]

21.3 (14-31)
[3.5]

F-stat=4.2  p<0.05

Median CF Score for STS***

21.8 (11-37) [5.1]

24.3 (18-33) [5.1]

25.5 (14-35) [6.3]

21.2 (12-34)
[5.1]

22.0 (11-37)
[5.3]

F-stat=2.75  p<0.05

*CS: <22=Low; 23-41=Average; >42=High
**Burnout scores: <22=Low; 23-41=Average; >42 High
***STSscores: <22=Low; 23-41=Average; >42=High
+ Analysis of variance reported with F-statistic

In another survey question, nurses were asked to rank categories which provided the most CS [1=most CS; 6=least CS] to them in their RN position. Overall nurse rankings for providing the most CS to the least were as follows: 1) having a high level of nursing satisfaction (M = 2.5, SD = 1.6); 2) intending to stay in current position for one year from now (M = 3.3, SD=1.7); 3) having no lateral violence (M = 3.5, SD=1.6); 4) having the same nurse leader to report to/no change in leadership (M = 3.6, SD=1.7); 5) having no workplace violence (M = 3.7, SD=1.5); and 6) participating in shared governance activities (M = 4.4, SD=1.6).

Content analysis was completed for the open-ended question, which asked: “Please provide any other comments regarding shared governance activities, nurse satisfaction, management changes, retention, and violence (workplace and lateral), related to CS.” A total of 33 (15.9%) nurses commented. Top CS-related themes were: 1) having nurse satisfaction (e.g., trust in leadership; good morale; respectful work environment; resources for safe practice and patient care) (n = 14 or 42.4%); 2) having no lateral violence (n = 10 or 30.3%); and 3) having good manager/leaders (e.g., supportive; visible; accessible; fair; properly trained; effective communicators), (n = 8 or 24.2%). Nurses stated:

  • Having a manager that connects when things go wrong, calls, stops by or just sits in the background being supportive.
  • Stable leadership is important to overall health of an organization.
  • Lateral violence (bullying) is a significant issue. I believe it is related to staff perceptions and egos. Behaviors that I find difficult to work with are incompetence, elitist, and bigotry. These behaviors have a great impact on my compassion. I do not enjoy working with nurses that have the above behaviors.

Another survey question asked nurses to rank the categories which provided the most CF [1=most CF; 6=least CF] to them in their RN position. Overall nurse rankings for those providing the most CF were 1) having low level of nursing satisfaction (M =2.4, SD = 1.6); 2) having lateral violence (M = 3.3, SD=1.7); 3) having workplace violence (M =3.4, SD=1.6); 4) having no intent to stay in current position for one year from now (M =3.7, SD=1.4); 5) not having the same leader to report to/change in nurse leadership (M = 3.8, SD=1.6); and 6) having no participation in shared governance activities (M = 4.5, SD=1.7).

Themes for the open-ended question: “Please provide any other comments regarding shared governance activities, nurse satisfaction, management changes, retention, and violence (workplace and lateral), related to CF,” (n = 19 or 9.1%) were: 1) not having nurse satisfaction (n = 11 or 57.9%); 2) having workplace violence (n = 7 or 36.8%); and 3) having lateral violence (n = 4 or 21.1%). Nurses stated:

  • Other factors that lead to compassion fatigue are related to long hours, stress of meeting the needs of others (other managers, leaders, staff and patients), feeling of being overwhelmed due to multiple responsibilities, desire to do more (focus on other things i.e. research, using available data to make improvements in patient outcomes via patient education or staff development - but not enough time).
  • You will lose amazing hardworking nurses because of workplace/lateral violence, bullying.

Shared Governance-Related Activities, Nurse Satisfaction, Management Changes, and Retention
Table 2 provides the analysis of the study variables: shared governance-related activities, nurse satisfaction, management changes and retention, by RN type and overall.

Table 2: Nurse Participation in Shared Governance-Related Activities, Nursing Satisfaction, Management Changes, and Retention by RN Employment Type, Group and Overall

Variables

Clinical Nurses
N=142

Nurse
Managers
N=13

Nurse Leaders
N=6

Other Nurses
N=47

Overall
All RNs
N=208

Significance Test+

Activity Type RN Participated in Over Last Year, # (%)*

 

 

 

 

 

 

Oriented new RNs

82 (57.7%)

9 (69.2%)

4 (66.6%)

31 (65.9%)

126 (60.6%)

∑2=1.5  
p=0.93

Participated in unit-based shared governance council

60 (42.3%)

11 (84.6%)

1 (16.6%)

24 (51.1%)

96 (46.2%)

∑2=5.22 p=0.56

Participated in hospital-based nursing council/committee

50 (35.2%)

11 (84.6%)

4 (66.6%)

27 (57.4%)

92 (44.2%)

∑2=17.8 p<0.001

Provided staff development education (includes in-services, lunch-n-learn, continuing education etc.)

48 (33.8%)

9 (69.2%)

5 (83.3%)

29 (61.7%)

91 (43.8%)

∑2=19.1 p<0.001

Participated in unit-based quality improvement project

46 (32.3%)

9 (69.2%)

1 (16.6%)

21 (44.7%)

77 (37.0%)

∑2=11.2 p<0.05

Participated in hospital-based interdisciplinary council/committee

22 (15.5%)

12 (92.3%)

5 (83.3%)

23 (48.9%)

62 (29.8%)

∑2=54.6 p<0.001

Created and designed unit bulletin boards

30 (21.1%)

3 (23.1%)

2 (33.3%)

20 (42.5%)

55 (26.4%)

∑2=8.6
p<0.05

Developed/revised patient education material

22 (15.5%)

5 (38.5%)

5 (83.3%)

23 (48.9%)

55 (26.4%)

∑2=31.9 p<0.001

Participated in unit-based evidence-based practice project

27 (19.0%)

6 (46.2%)

2 (33.3%)

10 (21.3%)

45 (21.6%)

∑2=5.7
p=0.13

Participated in unit-based research project

14 (9.9%)

2 (15.3%)

1 (16.6%)

2 (4.3%)

19 (9.1%)

∑2=2.5
p=0.41

Participated in the unit journal club

9 (6.3%)

1 (7.7%)

 0

3 (6.4%)

13 (6.3%)

∑2=0.454 p=0.41

None – I have not participated in any activities

25 (17.6%)

1 (7.7%)

 0

2 (4.3%)

28 (13.5%)

∑2=6.6
p=0.08

Average Overall RN Satisfaction Level (0=Not at all satisfied; 10=Very Satisfied), # (range) [s.d.]

7.1 (2-10) [1.9]

7.3 (5-10) [1.6]

7.7 (6-9) [0.9]

7.7 (4-10) [1.5]

7.3 (2-10) [1.8]

∑2=16.5 p=0.74

Change in Nursing Management for Nurse Position in Last Year, # (%)

N=141

N=13

N=6

N=47

N=207

∑2=13.3 p=0.15

   Yes

58 (41.1%)

5 (38.5%)

0

20 (42.6%)

83 (40.1%)

 

    No

82 (58.2%)

8 (61.5%)

5 (83.3%)

25 (53.2%)

120 (58.0%)

 

    Not applicable, do not report to an RN

1 (0.7%)

0

1 (16.7%)

2 (4.3%)

4 (1.9%)

 

Intent to Be in Current Position in One Year [Retention], # (%)

N=141

N=13

N=6

N=47

N=207

∑2=0.58 p=0.99

   Yes

115 (81.6%)

11 (84.6%)

5 (83.3%)

38 (80.9%)

169 (81.6%)

 

    No

26 (18.4%)

2 (15.4%)

1 (16.7%)

9 (19.1%)

38 (18.4%)

 

*Not mutually exclusive
+Statistical testing by RN employment type group; Chi-Square represented by ∑2

To measure shared governance, nurses were asked “Please check all of the activities that you have participated in during the last year.” Of the 11 shared governance activities evaluated by Chi-Square, most (n = 6 or 54.5%) had statistically significant differences (p<0.05) for participation rates by RN type. Most activities reported by nurse managers included hospital committees, interdisciplinary committees, and quality improvement activity; those reported by nurse leaders included staff development education, and patient education development. Most common activities for all nurses’ participation over the last year were orienting new nurses (n = 126 or 60.6%); unit-based shared governance councils (n = 96 or 46.2%); hospital-based nursing councils or committees (n = 92 or 44.2%); and providing staff development education (n = 91 or 43.8%). Nurses who responded to other activities reported community and education-related activities most frequently.

Most activities reported by nurse managers included hospital committees, interdisciplinary committees, and quality improvement activity; those reported by nurse leaders included staff development education, and patient education development.Nurse satisfaction was measured by the question “Please select the value between 0-10 that best represents your average overall satisfaction level as a RN in your position in the last year" (0 = Not at all satisfied; 10 = Very satisfied). There were no statistically significant differences by RN type (M =7.3; SD = 1.8; 0 = not at all satisfied; 10 = very satisfied). The 'other' nurse type had the highest satisfaction rating (7.72, s.d. =1.5).

Nursing management changes were measured by the question, “Please specify if you have had a change in nursing management for your position in the last year [nursing management change is defined as either a change in nurse manager or nurse leader within the last year.” There were no significant differences by nurses experiencing a change. Most nurses (n = 120 or 58.0%) had no change in their nurse management over the previous year; for those reporting a change, clinical nurses had the greatest (n = 58 or 41.1%) number of nursing management changes.

Retention was measured by the question “Do you intend to be in your current position one year from now?” There were no significant differences by RN type. Overall, most nurses (n = 169 or 81.6%) intended to be in their position in one year. For those who did not intend to be in their position in one year, a total of 39 nurses specified why, for which primary themes included: 1) a change of position within the hospital (n = 11 or 28%); 2) professional advancement (n= 8 or 21%); and 3) lack of nursing satisfaction (e.g., stress, lack of support, workload, unhappy, overwhelmed, lack of recognition, lack of staffing, turnover, lack of trust in senior leadership) (n = 7 or 18%). Nurses commented:

  • Unsure of if the current role is for me as working short staffed and being worked to the bone with no recognition is not going over well. May want to be in a different position out of staffing if possible or try a different department.
  • …too much work, lack of support, long hours.

Violence (Workplace and Lateral)
Being shouted/yelled at or sworn/cursed at had the highest number of incidents within the last year... Table 3 provides the analysis for violence. For the 207 nurses who responded to the verbal violence question, 107 (51.7%) reported ≥1 verbal violence incident(s) in the last year by patients or patient visitors. More than half of clinical nurses, nurse managers, and nurse leaders reported verbal violence within the last year. Being shouted/yelled at (M = 23.8; SD = 80.7) or sworn/cursed at (M = 21.7, SD=79.3) had the highest number of incidents within the last year, or approximately twice per month. 


Table 3: Incidents of Workplace and Lateral Violence by RN Employment Type, Group and Overall

Violence Variables

Clinical
Nurses
N=142
(68.3%)

Nurse Managers
N=13
(6.2%)

Nurse Leaders
N=6
(2.9%)

Other
Nurses
N=47 (22.6%)

Overall
All RNs
N=208

Significance Test

Experienced Verbal Workplace Violence Incidents by Patients or Patient Visitors in The Last Year, # (%)

N=141

N=13

N=6

N=47

N=207

∑2=5.2
p=0.5

   Yes

72 (51.1%)

10 (76.9%)

4 (75.0%)

21 (44.7%)

107 (51.7%)

 

   No

69 (48.9%)

3 (23.1%)

2 (25.0%)

26 (55.3%)

100 (48.3%)

 

Mean Number of Verbal Violence Incidents in Last Year, # (range) [s.d.]

N=72

N=10

N=4

N=21

N=107

 

Shouted or yelled at

30.8 (0-735) [96.7]

15.0 (2-100) [30.1]

7.8 (2-20) [8.3]

6.7 (0-49)
[11.0]

23.8 (0-735) [80.7]

F-stat=0.57 
p=0.63

Sworn or cursed at

27.8 (0-735) [95.6]

15.7 (0-100) [30.2]

6.0 (1-15) [6.2]

6.5 (1-49)
[10.7]

21.7 (0-735) [79.3]

F-stat=0.45 
p=0.72

Called names/something derogatory

13.1 (0-294) [39.3]

6.8 (0-50)
[15.3]

0.8 (0-2) [1.0]

5.8 (0-49)
[12.3]

10.6 (0-294) [32.9]

F-stat=0.43 
p=0.73

Ridiculed or humiliated

7.9 (0-245) [32.3]

7.0 (0-60)
[18.7]

0

0.7 (0-4)
[1.2]

6.1 (0-245) [27.0]

F-stat=0.43 
p=0.73

Threatened with physical assault

7.8 (0-100) [19.8]

3.7 (0-25) [7.6]

1.0 (0-3) [1.4]

3.8 (0-49)
[10.8]

6.3 (0-100) [17.1]

F-stat=0.51 
p=0.67

Experienced Physical Workplace Violence Incidents in Last Year, # (%)

N=140

N=13

N=6

N=47

N=206

∑2=3.7
p=0.72

   Yes

38 (27.1%)

3 (23.1%)

0

10 (21.3%)

51 (24.8%)

 

   No

102 (72.9%)

10 (76.9%)

6 (100.0%)

37 (78.7%)

155 (75.2%)

 

Mean Number of Physical Workplace Violence Incidents by Patients or Patient Visitors in The Last Year, # (range) [s.d.]

N=38

N=3

N=0

N=10

N=51

 

Grabbed

4.1 (0-38) [7.1]

5.5 (1-10) [6.4]

0

2.2 (0-10)
[3.4]

3.8 (0-38) [6.4]

F-stat=0.42 
p=0.66

Scratched

2.7 (0-38) [6.5]

3.0 (1-5)
[2.8]

0

0.8 (1-3)
[1.0]

2.3 (0-38)
[5.7]

F-stat=0.42 
p=0.65

Kicked

1.8 (0-10) [3.5]

1.0 (0-2)
[1.4]

0

0.9 (0-5)
[1.6]

1.6 (0-10)
[2.8]

F-stat=0.44 
p=0.64

Pinched

2.4 (0-38) [7.0]

0

0

0.5 (0-2)
[0.8]

1.9 (0-38)
[6.1]

F-stat=0.47 
p=0.62

Pushed/shoved

6.0 (0-175) [29.1]

8.0 (1-15)
[9.9]

0

0.8 (0-5)
[1.6]

5.0 (0-175)
[25.2]

F-stat=0.17 
p=0.84

Spat on

1.5 (0-38)
[6.3]

1.0 (0-2) [1.4]

0

0.6 (0-5)
[1.6]

1.3 (0-38)
[5.5]

F-stat=0.1 
p=0.9

Punched

0.8 (0-8)
[1.6]

0.5 (0-1)
[1.4]

0

0.1 (0-1)
[0.3]

0.6 (0-8)
[1.4]

F-stat=0.8 
p=0.16

Slapped

1.1 (0-20)
[3.5]

0

0

0.6 (0-5)
[1.6]

0.9 (0-20)
[3.1]

F-stat=0.18
p=0.84

Arm twisted

0.2 (0-2)
[0.5]

2.5 (0-5)
[0.7]

0

0.1 (0-1)
[0.3]

0.3 (0-5)
[0.8]

F-stat=9.8 
p<0.001

Hit by thrown object

0.5 (0-4)
[1.0]

1.0 (0-2) [1.4]

0

0.1 (0-1)
[0.3]

0.4 (0-4)
[0.9]

F-stat=1.2 
p=0.31

Bitten

0.2 (0-5)
[0.9]

0

0

0.1 (0-1)
[0.3]

0.2 (0-5)
[0.8]

F-stat=0.1 
p=0.9

Urinated on

1.2 (0-38)
[6.2]

0

0

4.9 (0-49)
[15.5]

1.9 (0-49)
[8.8]

F-stat=0.74 
p=0.83

Hair pulled

0.1 (0-3)
[0.5]

0

0

0.1 (0-1)
[0.3]

0.1 (0-3)
[0.5]

F-stat=0.05 
p=0.95

Slammed against wall/hard surface

0.1 (0-1)
[0.4]

0

0

0.1 (0-1)
[0.3]

0.1 (0-1)
[0.3]

F-stat=0.14 
p=0.87

Personal property deliberately destroyed

0.1 (0-2)
[0.4]

0

0

0

0.1 (0-2)
[0.4]

F-stat=0.29 
p=0.74

Experienced Lateral Violence Incidents by Other Nurses in Last Year, # (%)

N=137

N=12

N=6

N=47

N=202

∑2=9.6
p=0.14

   Yes

98 (71.5%)

9 (75.0%)

2 (33.3%)

27 (57.4%)

136 (67.3%)

 

   No

39 (28.5%)

3 (25.0%)

4 (66.7%)

20 (42.6%)

66 (32.6%)

 

Experienced Lateral Violence Incidents by Other Healthcare Professionals in Last Year, # (%)

N=137

N=12

N=6

N=47

N=202

∑2=11.8
p=0.6

   Yes

114 (83.2%)

9 (75.0%)

3 (50.0%)

31 (66.0%)

157 (77.7%)

 

   No

23 (16.8%)

3 (25.0%)

3 (50.0%)

16 (34.0%)

45 (22.3%)

 

+ Statistical testing by RN employment type group; Chi-Square represented by ∑2; Analysis of variance represented by F-statistic

Fewer nurses (n = 51 or 24.8%) reported physical violence by patients or patient visitors (i.e., ≥1 incident(s), in the last year). Nurse leaders reported no incidents, while the other three RN types reported incidents (clinical nurses, n = 38 or 27.1%; nurse managers, n = 3 or 23.1%; and other nurses, n = 10 or 21.3%). Of the 15 physical workplace violence measures evaluated, one (arm twisting in the last year) had statistically significant differences by RN type, with managers having the most incidents in last year (M = 2.5, SD = 0.7; p<0.001). Being pushed/shoved (M = 5.0, SD=25.2) and grabbed (M = 3.8, SD=6.4) were reported most frequently overall.

Nurse leaders reported no incidents, while the other three RN types reported incidents... To measure lateral violence, participants were asked two questions, “Have you experienced lateral violence incidences by other nurses in the last year?" and “Have you experienced lateral violence incidences by healthcare professionals [other than nurses] in the last year?” Overall, more lateral violence to nurses was reported from other healthcare professionals (n = 157 or 77.7%), than by other nurses (n = 136 or 67.3%). Nurse managers had the greatest percentage (75.0%) of lateral violence occurring by both nurses and other healthcare professionals. Nurse leaders reported the least lateral violence by other nurses (33.3%), and other healthcare professionals (50.0%).

Discussion

Overall, more lateral violence to nurses was reported from other healthcare professionals than by other nurses This research presents new findings by RN type with significant differences in CF scores, but not for CS scores. Nurse leaders had the highest CF scores, followed by nurse managers, clinical nurses and other nurses (p<0.05). Further, the findings highlighted the need for understanding by all RNs that CF varies by RN type. The literature supports the assertion that the physical, emotional, social and spiritual health of healthcare providers is impaired by cumulative stress related to work and can impact healthcare service delivery (Sinclair et al., 2017).

...the findings highlighted the need for understanding by all RNs that CF varies by RN type. New findings also reported by RN type were the work environment factors that do (shared governance and workplace violence) and do not have significant differences. Notably, opportunities exist to facilitate shared governance activity participation for all RN types. The ability of nurses to participate in shared governance and to have shared decision making is also important. These structures aim to empower nurses to have control over their practice, to develop collaborative and supportive working relationships, and to establish trust (Berger, Polivka, Smoot, & Owens, 2015). The concept of shared governance is also important for nurses to provide innovative, quality-based nursing care (Wilson et al., 2014).

Findings from this study also highlighted opportunities to reduce violence in the workplace. Incidents of violence in this study were similar overall to those previously published (Stagg et al., 2013). New findings are incidents experienced by RN type. Unfortunately, more than half of clinical nurses, nurse managers and nurse leaders surveyed in this study have experienced verbal violence in the last year. Of these, clinical nurses, nurse managers, and other nurses all reported at least one incident of workplace violence in the last year. Best practices for an effective, zero-tolerance for workplace violence are needed for healthier work environments.

Limitations
As this research was completed within a rural healthcare system, findings may not be generalizable to other healthcare setting types. Also, there were not equal survey participation rates by RN type in this study (as expected, with most nurses being of the clinical type and the least in the nurse leader type). It is noted that there was comparable survey participation by RN type to the hospital system’s overall RN type at the time the research was initiated. Inherent with survey research is also the limitation of self-selection sample bias. Additional research is warranted with comparable samples from each of the four RN types.

Implications for Practice and Research
When evaluating best practices for a healthier work environment, one is encouraged to consider varied strategic approaches by RN type for clinical, manager, leaders, and other nurses. It is important to recognize that we all have varying levels of compassion fatigue and compassion satisfaction, which may or may not, either be in our control and/or work related. Nurses are encouraged to strategize with peers and administrators in management to determine methods to enculturate an open environment where RNs feel they can safely communicate needs based on these variances.

Nurses are encouraged to strategize with peers and administrators... Implications for practice include tailored interventions for RN for healthier work environments to decrease CF, particularly for nurse leaders. These could include additional leadership courses, mentoring, and education about conflict management/resolution, which facilitate more effective coping strategies in a complex work environment. Ensuring that non-working breaks and meal times are afforded, healthy foods are available for all shifts, and initiatives to promote easy access health and wellness options for all nurse types may significantly decrease CF and increase CS. Additionally, opportunities exist for supporting shared governance activities for all RN types, and for supporting zero-tolerance for workplace violence. Further research is warranted regarding evidence-based interventions to improve the work environment for each RN type, whether clinical nurses, nurse managers, nurse leaders, or nurses that work in other roles.

Conclusion

Practice implications from this study can... help nurses to better balance the obligation to provide a high level of compassionate care with their own professional quality of life.New findings from this study were the identification of significant differences by RN type for CF (burnout and STS), with nurse leaders having the highest CF scores and 'other' nurses having the lowest CF scores. Significant differences existed by RN type for two of the six work environment factors evaluated (i.e., most of the shared governance activities measured, and one workplace violence measure, which was arm twisting for nurse managers). Practice implications from this study can address the complex challenges in the current healthcare environment and help nurses to better balance the obligation to provide a high level of compassionate care with their own professional quality of life. Continued research in this area will contribute additional knowledge about how to best provide a healthy work environment for providers with an emphasis on professional wellness.

Authors

Lisa Lisle, MSN, RN, CEN
Email: llisle@umm.edu

Lisa Lisle has 12 years of emergency nursing experience. She has functioned in the role of staff nurse, clinical nurse coordinator, and nurse research intern. She is currently the Clinical Nurse Coordinator at the University of Maryland Shore Emergency Center at Queenstown, a rural, freestanding emergency department.

Karen Gabel Speroni, PhD, RN, BSN, MHSA
Email: Karen.speroni@outlook.com

Dr. Speroni is the Chair of the Nursing Research Council at University of Maryland Shore Regional Health. She is a Nursing Research Consultant, providing research infrastructure and process consultation for hospitals and health systems. She has over 30 years of experience in biomedical research, including leading hospital-based research programs, publishing, presenting, serving on Institutional Review Boards, and research-related university teaching.

Wynne Aroom, MSN, RN-BC, CDE
Email: waroom@umm.edu

Wynne Aroom is a Patient Educational Specialist at the University of Maryland Shore Regional Health. Wynne has 38 years of experience as a bedside nurse, 25 years as a nurse educator for various nursing programs, and 20 years of experience as a certified diabetes educator. She currently oversees all patient education for a three-rural- hospital system

Lynn Crouch, MSN, RNC-OB
Email: lcrouch@umm.edu

Lynn Crouch has 46 years of nursing experience in perinatology and education. She has made podium and poster presentations for the Maryland Nurses Association and has published research in the Journal of Obstetric Gynecology and Neonatal Nursing. Currently, she is the unit nurse educator for Women's and Children's Services, University of Maryland Shore Regional Health, responsible for patient, family and staff education

Hope Honigsberg, CRNP, RN, CNOR
Email: Hope.honigsberg@umm.edu

Hope Honigsberg is the Orthopedic Nurse Navigator for the University of Maryland Shore Regional Health. She has multiple years of experience as a staff nurse in the operating room and has been the Orthopedic Nurse Navigator since 2017. She has published research in the Association of periOperative Registered Nurses (AORN) Journal.

References

American Nurses Credentialing Center (ANCC). 2014 Magnet application manual. Silver Spring, MD: ANCC; 2013

Berger, J., Polivka, B., Smoot, E.A., & Owens, H. (2015). Compassion fatigue in pediatric nurses. Journal of Pediatric Nursing, 30(6), e11-e17. doi: 10.1016/j.pedn.2015.02.005

Bureau of Justice Statistics (BJS). (2019). Workplace. Retrieved from: https://www.bjs.gov/index.cfm?ty=tp&tid=446.

Cavanagh, N., Crockett, G., Heinrich, C., Doig, L., Fiest, K., Guichon, J.R., Page, S., Mitchell, I., & Doig, C.J. (2019). Compassion fatigue in healthcare providers: A systematic review and meta-analysis. Nursing Ethics, 27(3), 639-665. doi: 10.1177/0969733019889400.

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Sinclair, S., Raffin-Burnoutuchal, S., Venturato, L., & Mijovic-Knodejewski, J. (2017). Compassion fatigue: A meta-narrative review of the healthcare literature. International Journal of Nursing Studies, 69, 9-24. doi: 10.1016/j.ijnurstu.2017.01.003

Sorenson, C., Burnoutlick, B., Wright, K., & Hamilton, R. (2016). Understanding compassion fatigue in healthcare providers: A review of current literature. Journal of Nursing Scholarship, 48(5), 456-465. doi: 10.1111/jnu.12229

Speroni, K.G., Fitch, T., Dawson, E., Dugan, L., & Atherton, M. (2014). Incidence and cost of workplace violence perpetrated by hospital patients or hospital visitors. Journal of Emergency Nursing, 40(3), 1-11. doi:10.1016/j.jen.2013.05.014

Stagg, S., Sheridan, D., Jones, R., & Speroni, K.G. (2013). Workplace bullying: The effectiveness of a workplace program. Workplace Health & Safety, 61(8), 333-338. doi: 10.3928/21650799-20130716-03

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© 2020 OJIN: The Online Journal of Issues in Nursing
Article published August 26, 2020


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