Psychological Distress and Compassion Fatigue among Hospice Nurses: The Mediating Role of Self-Esteem and Negative Affect

Abstract

Background:

Compassion fatigue among health care professionals has negative effects on patient care. Providing end-of-life care, hospice nurses may be particularly at risk for compassion fatigue.

Objective:

The purpose of this study was to investigate self-esteem and affect as mediators between psychological distress and compassion fatigue among hospice nurses (N = 90).

Design and Measurements:

Hospice nurses working in a health care setting were recruited to complete a survey. Multiple mediation analysis was used to explore associations between variables of interest.

Results:

Psychological distress was associated with greater compassion fatigue and had an indirect effect on compassion fatigue through lower self-esteem and higher negative affect, but not through positive affect.

Conclusion:

Among hospice nurses, psychological distress may reduce self-esteem and create negative feelings, thereby increasing the risk of compassion fatigue. Interventions that target both the cognitive and affective links between psychological distress and compassion fatigue may be most effective.

Introduction

Hospice care supports individuals approaching the end of life with expert medical care and provides emotional and spiritual support to those individuals and their families.¹ One risk of such emotionally demanding work is compassion fatigue, which is the physical and mental exhaustion resulting from exposure to a traumatized individual over an extended period of time.² Compassion fatigue occurs when individuals exhaust and are unable to restore their compassionate energy and has negative effects on patient care.^3–5 Hospice nurses, who are frequently exposed to death, are especially at risk for compassion fatigue.⁶ Psychological distress—anxious and depressive symptoms—has been linked with compassion fatigue among nurses,⁷ hospice workers,⁸ and hospice nurses.⁶ In this study, we investigated cognitive self-evaluations (i.e., self-esteem) and affect (i.e., positive and negative affect) as mediators between psychological distress and compassion fatigue among hospice nurses.

Self-esteem, positive affect, and negative affect

Self-esteem is the cognitive evaluation that we have of ourselves, and it is associated with greater psychological well-being and lower psychological distress.^9,10 Self-esteem has an important role in hospice care and influences personal identity and professional qualities.¹¹ Affect refers to subjective experience that is expressed through emotional states.¹² Positive affect is characterized by feeling enthusiastic and active, whereas negative affect is characterized by unpleasurable engagement and aversive mood states.¹³ Positive affect has been linked with psychological health¹⁴ and lower levels of depression¹⁵ and stress.¹⁶ Negative affect has been associated with psychological distress and compassion fatigue among nurses.¹⁷

Current study

The purpose of this study was to investigate self-esteem and affect as mediators between psychological distress and compassion fatigue among hospice nurses. We hypothesized (H₁) that psychological distress would be associated with higher compassion fatigue. Nurses experiencing psychological distress may evaluate themselves more negatively, and this diminished self-esteem may deplete their endurance levels.³ It is also possible that nurses experiencing psychological distress may lack the positive feelings and be burdened with negative feelings, which then contribute to compassion fatigue. Thus, we hypothesized that psychological distress would have a positive indirect effect on compassion fatigue through (H₂) lower self-esteem, (H₃) lower positive affect, and (H₄) higher negative affect.

Methods

Participants

Hospice nurses (n = 90; 94.4% female) aged 22–70 years (M = 43.00, SD = 12.11) working in hospice centers, hospitals, nursing homes, and other long-term care facilities, and home healthcare in the southern United States were recruited at staff meetings and hospice nursing conventions. Regarding ethnicity, 58 (64.4%) identified as white, 12 (13.3%) as African American, 6 (6.7%) as Hispanic, 12 (13.3%) as Asian/Pacific Islander, and 2 (2.2%) as another ethnicity. The average number of years of experience as a hospice nurse was 17.30.

Procedure

This study was approved by the university's committee for the protection of human subjects. Participants completed the survey online and were entered into a drawing for gift cards.

Measures

Psychological distress

The Depression Anxiety and Stress Scale¹⁸ consists of 21 items on a 4-point Likert-type scale. All items—those measuring depression, anxiety, and stress—were summed so that a higher score indicated a higher level of psychological distress (Cronbach's α = 0.91).

Compassion fatigue

The Compassion Fatigue Short-Scale¹⁹ consists of 13 items on a 10-point Likert-type scale that were summed so that higher scores indicate higher levels of compassion fatigue (Cronbach's α = 0.85).

Self-esteem

The Rosenberg Self-Esteem Scale²⁰ consists of 10 items using a 4-point Likert-type scale, which were summed so that higher scores indicate higher levels of self-esteem (α = 0.83).

Positive and negative affect

The International Positive and Negative Affect Schedule—Short Form²¹ consists of two five-item scales using a five-point response scale, which were summed so that higher scores indicated higher levels of positive affect (Cronbach's α = 0.73) and negative affect (α = 0.73).

Results

Bivariate correlations between and descriptive statistics for all variables of interest are displayed in Table 1. Multiple mediation was assessed with a bootstrapping procedure²² in which 95% confidence intervals were used and 10,000 bootstrapping resamples were run. For ease of interpretation, we converted confidence intervals into p values. Results are displayed in Figure 1. Psychological distress explained 37.4% of the variance in compassion fatigue. Psychological distress had an indirect effect on compassion fatigue through self-esteem (β = 0.18, 95% CI [0.06– 0.39]) and negative affect (β = 0.21, 95% CI [0.01–0.44]) but not positive affect. Together, psychological distress, self-esteem, positive affect, and negative affect explained 49.13% of the variance in compassion fatigue.

FIG. 1.

Multiple mediation model (n = 90; *p < 0.05; **p < 0.01; ***p < 0.001).

Table 1.

Descriptive Statistics and Bivariate Correlations for Study Variables (N = 90)

	M	SD	Possible range	1	2	3	4
1. Psychological distress	30.17	7.59	21–84
2. Self-esteem	33.60	3.99	10–40	−0.36^*
3. Positive affect	20.40	2.36	5–25	−0.43^*	0.38^*
4. Negative affect	11.53	2.48	5–25	0.50^*	−0.42^*	−0.47^*
5. Compassion fatigue	36.71	14.06	13–130	0.61^*	−0.49^*	0.52^*	0.52^*

p < 0.001.

Discussion

The purpose of this study was to investigate self-esteem and affect as mediators between psychological distress and compassion fatigue among hospice nurses. Consistent with previous research,⁶ psychological distress was associated with compassion fatigue, supporting H₁. We believed that this would be due to psychological distress lowering self-evaluations, depleting positive feelings, and amplifying negative feelings. Psychological distress had an indirect effect on compassion fatigue through lower self-esteem and higher negative affect, meaning that H₂ and H₄ were supported. This finding is consistent with previous research that has linked negative affect with compassion fatigue.¹⁷ Positive affect did not mediate the relationship, meaning that H₃ was not supported. Psychological distress may impact compassion fatigue through the effects of more negative self-evaluations and more negative feelings rather than depleting positive resources.

This study provides insight into the relationship between psychological distress and compassion fatigue among hospice nurses, yet it was limited in a few ways. The study utilized a cross-sectional design, limiting conclusions that can be drawn about causality and directionality of results. Participants were self-identified hospice nurses, and the sample size was small and drawn from a limited geographic area, limiting the generalizability of the results. Future studies could utilize larger samples to overcome these issues as well as explore whether similar mediation effects would be found across other job types.

Finally, we feel that this study has implications for hospice nursing. Psychological distress appears to be a risk factor for compassion fatigue among hospice nurses; thus, engaging in self-care and having access to mental health resources to promote psychological well-being may be effective primary prevention strategies for compassion fatigue. Beyond this, interventions intended to bolster self-esteem and reduce negative affect may be effective tertiary prevention strategies as these may minimize the effects of psychological distress on compassion fatigue.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

References

National Hospice and Palliative Care Organization (NHPCO): NHPCO's facts and figures: Hospice care in America.. Alexandria, VA:. 2017. Retrieved from https://www.nhpco.org/sites/default/files/public/Statistics_Research/2016_Facts_Figures.pdf (last accessed November 5, 2017).

Figley

: Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. New York: Brunner-Routledge, 1995.

Coetzee

, Klopper

: Compassion fatigue within nursing practice: A concept analysis. Nurs Health Sci, 2010; 12:235–243.

Boyle

: Countering compassion fatigue: A requisite nursing agenda. Online J Issues Nurs, 2011; 16:1.

Ledoux

: Understanding compassion fatigue: Understanding compassion. J Adv Nurs, 2015; 71:2041–2050.

Abendroth

, Flannery

: Predicting the risk of compassion fatigue: A study of hospice nurses. J Hosp Palliat Nurs, 2006; 8:346–356.

Hegney

, Cragie

, Hemsworth

, et al.: Compassion satisfaction, compassion fatigue, anxiety, depression and stress in registered nurses in Australia: Study 1 results. J Nurs Manag, 2014; 22:506–518.

Whitebird

, Asche

, Thompson

, et al.: Stress, burnout, compassion fatigue, and mental health in hospice workers in Minnesota. J Palliat Med, 2013; 16:1534–1539.

Neff

: Self-compassion, self-esteem, and well-being. Soc Pers Compass, 2011; 5:1–12.

10.

Pyszczynski

, Greenberg

, Solomon

, et al.: Why do people need self-esteem? A theoretical and empirical review. Psychol Bull, 2004; 130:435–468.

11.

Olthuis

, Leget

, Dekkers

: Why do hospice nurses need self-esteem?. Nurs Ethics, 2007; 14:62–71.

12.

Fredrickson

: The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions. Am Psychol, 2001; 56:218–226.

13.

Watson

, Clark

, Tellegen

: Development and validation of brief measures of positive and negative affect: The PANAS scales. J Pers Soc Psychol, 1988; 54:1063–1070.

14.

Denollet

, De Vries

: Positive and negative affect within the realm of depression, stress and fatigue: The two-factor distress model of the Global Mood Scale (GMS). J Affect Disord, 2006; 91:171–180.

15.

, Yu

, Xie

, et al.: Positive affect promotes well-being and alleviates depression: The mediating effect of attentional bias. Psychiatry Res, 2015; 228:482–487.

16.

Thian

JHM

, Kannusamy

, He

, et al.: Relationships among stress, positive affectivity, and work engagement among registered nurses. Psychology, 2015; 6:159–167.

17.

Craigie

, Osseiran-Moisson

, Hemsworth

, et al.: The influence of trait-negative affect and compassion satisfaction on compassion fatigue in Australian nurses. Psychol Trauma, 2016; 8:88–97.

18.

Antony

, Bieling

, Cox

, et al.: Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychol Assessment, 1998; 10:176–181.

19.

Adams

, Boscarino

, Figley

: Compassion fatigue and psychological distress among social workers: A validation study. Am J Orthopsychiatry, 2006; 76:103–108.

20.

Rosenberg

: Conceiving the Self. New York: Basic Books, 1979.

21.

Thompson

: Development and validation of an internationally reliable short-form of the positive and negative affect schedule (PANAS). J Cross-Cultur Psychol, 2007; 38:227–242.

22.

Hayes

: Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach. New York: Guilford Press, 2013.