Relationships between nurses’ empathy, self-compassion and dimensions of professional quality of life: A cross-sectional study
Introduction
Empathy is a central aspect of healthcare, and has been associated with positive outcomes not only for the patient (e.g., Blatt et al., 2010, Hojat et al., 2011, Rakel et al., 2011) but also for the healthcare professional (Shanafelt et al., 2005, Thomas et al., 2007).
However, given the constant exposure to highly distressing situations, such as illness, suffering and death, healthcare professionals are particularly vulnerable to the development of professional stress and compassion fatigue, especially if they are not able to effectively regulate their capacity to empathize and their empathic feelings (Decety et al., 2010).
Job stress and burnout are common in healthcare professionals (e.g., McCray et al., 2008) and in nurses in particular (Dominguez-Gomez and Rutledge, 2009, Sermeus et al., 2011). Several studies have reported that stress and burnout in healthcare professionals are associated with several physical and mental health problems, such as depression, anxiety and low self-esteem (e.g., Maslach et al., 2001, Schulz et al., 2011). Stress and burnout also impact on professional effectiveness and has been associated with suboptimal patient care (Shanafelt et al., 2002), and self-reported medical errors (West et al., 2006).
In addition to objective errors in care, stress and burnout may decrease compassion in the caregiver (Neumann et al., 2011, Nunes et al., 2011, Wilson et al., 2012), and impact on their relationship with patients (Ratanawongsa et al., 2008). Thus, it is not surprising that burnout has been associated with decreased patient satisfaction, suboptimal self-reported patient care, and longer patient-reported recovery times (Shanafelt et al., 2002, Shapiro et al., 2005, Vahey et al., 2004). A survey of intensive care unit nurses and physicians in Europe and Israel indicates that one fourth of those surveyed report providing less than optimal care (Hand, 2011).
Apart from the heavy workload and lack of resources that are important risk factors for burnout (Maslach et al., 2001), healthcare providers are also confronted daily with emotionally stressful situations associated with illness, suffering and dying, which require empathic abilities.
There have been many definitions of empathy (see Batson, 2009). In general, empathy is activated when observing or imagining another person's affective state triggers an isomorphic affective response, and requires some differentiation of one's own and the other's emotional states (see Batson, 2009, Singer and Leiberg, 2009). Current approaches converge to consider empathy not as a single ability but a complex socio-emotional competency that encompasses different but interacting components (e.g., Decety and Svetlova, 2012).
Having an idea of the other person's thoughts, feelings and motives can be considered the cognitive component of empathy. There are two main categories of affective empathy responses to observing another person in pain. Self-oriented responses are feelings of distress and anxiety when witnessing another's negative state (personal distress), whereas other-focused responses are feelings that focus on the well-being of the other person (empathic concern; Davis, 1983). These two types of affective responses can have different motivational tendencies. Self-oriented feelings will motivate the observer to reduce his/her own distress, whereas other-focused feelings will motivate the observer to focus on the needs of the other and to provide care (Batson et al., 1987).
Empathy is particularly important in healthcare provider–patient relations, and is associated with improved patient satisfaction and compliance with recommended treatment (Epstein et al., 2007).
However, there can be costs associated with empathy (Hodges and Biswas-Diener, 2007). Literature suggests that being overly sensitive to others’ suffering in the course of caring for patients experiencing trauma or pain can lead to deleterious effects, such as burnout or compassion fatigue (Aigley, 2002, Aigley, 2012). However, there are few empirical studies to date directly exploring such hypothesis.
While empathy can be a seen as double-edge sword, facilitating care but at the same time leaving the healthcare provider vulnerable to compassion fatigue, compassion may instead be a protective factor (Boellinghaus et al., 2012). Compassion appears to buffer the effects of stress on well-being (Poulin et al., 2013). Also, the other-oriented focus of the compassionate response may allow the observer to empathize with the other's suffering but without identifying with it, providing a self-other distinction which is essential to regulate personal distress feelings and to provide adequate care to the sufferer (Klimecki and Singer, 2012).
Research suggests that compassion can also be important for the successful treatment of patients. For example, in one study watching 40 s of compassionate communication from a provider on videotape was sufficient to reduce anxiety in breast cancer patients (Fogarty et al., 1999).
Several studies have suggested that compassion for others is closely linked to self-compassion (Lindsay and Creswell, 2014, Neff and Pommier, 2013, Welp and Brown, 2014). Self-compassion is simply compassion directed inward, relating to oneself as the object of care and concern when faced with the experience of suffering (Neff, 2003a).
Self-compassion, therefore, involves being touched by and open to one's own suffering, not avoiding or disconnecting from it, generating the desire to alleviate one's suffering and to heal oneself with kindness. Self-compassion also involves a non-judgmental understanding of one's pain, inadequacies and failures, so that one's experience is seen as part of the larger human experience (Neff, 2003a). The research literature consistently suggests that self-compassion is associated with fewer psychological symptoms and with indices of psychological well-being (MacBeth and Gumley, 2012). Self-compassionate people seem to have a more adaptive psychological profile, which may explain such findings. For example, self-compassion has been associated with lower levels of rumination (Johnson and O’Brien, 2013, Odou and Brinker, 2014, Raes, 2010), avoidance (Krieger et al., 2013), suppression of unwanted thoughts and emotions, and with emotional validation skills (Leary et al., 2007, Neff et al., 2005). Self-compassion is also associated with positive psychological characteristics such as emotional intelligence, wisdom, life satisfaction, well-being and feelings of social connectedness (Neff et al., 2007a, Neff et al., 2007b, Neely et al., 2009). Experimental studies confirmed some of these findings (e.g., Adams and Leary, 2007, Leary et al., 2007) and suggest that self-compassion can be enhanced and contribute to well-being and less psychological distress.
Moreover, self-compassion has been shown to improve interpersonal functioning. It is linked to such traits as more empathic concern, altruism, perspective-taking, and forgiveness of others (Neff and Pommier, 2013).
Self-compassion could be helpful to healthcare professionals, and nurses in particular, because it may play an important role in maintaining their mental health and because of the emerging evidence that self-compassion is associated with compassion for others, which has been shown to have a significant impact on patient outcomes. Thus, developing self-compassion may be vital for preventing compassion fatigue and promoting compassionate care (Gustin and Wagner, 2013).
Although recent review papers argued for the importance of exploring self-compassion in healthcare professionals (Mills et al., 2015, Raab, 2014), so far no empirical studies have been published.
The concept of compassion fatigue was first introduced by Joinson (1992) to describe a state of reduced capacity for compassion as a consequence of being exhausted from dealing with the suffering of others (Aigley, 2002, Aigley, 2012, Sabo, 2006). The term compassion fatigue has been used interchangeably with secondary traumatic stress. It has been suggested that empathy for patients may be at the very root of compassion fatigue (Aigley, 2002, Schulz et al., 2007). Nurses may be at particular risk for compassion fatigue because compassion and empathy are at the core of their work (Aigley, 1995, Stebnicki, 2002).
Although healthcare providers are at risk of developing compassion fatigue, many do not. Rather, some healthcare providers are motivated by a sense of satisfaction derived from helping others also known as compassion satisfaction (Stamm, 2010), which enables them to engage in meaningful interactions with patients rather than withdrawing from them. Compassion fatigue and compassion satisfaction are opposite results from helping others and are intrinsic properties of healthcare providers’ professional quality of life.
In this study we aim to address issues and gaps in previous research by exploring the relations between self-compassion and empathy, and three aspects of quality of life: compassion satisfaction, burnout and compassion fatigue. The literature has been pointing that empathy is vital for the work of healthcare professionals. However, it has also been suggested that empathy may also be a vulnerability factor for the development of compassion fatigue. Thus, we hypothesize that empathic feelings will be negatively associated with burnout but positively associated with compassion fatigue and compassion satisfaction (Hypothesis 1a). Regarding the other empathy components, we hypothesize that perspective taking will be positively associated with compassion satisfaction and negatively associated with burnout and compassion fatigue (Hypothesis 1b), and personal distress will be negatively associated with compassion satisfaction and positively associated with burnout and compassion fatigue (Hypothesis 1c). Based on previous research on the relation between self-compassion and mental health, it is hypothesized that self-compassionate individuals (i.e., high levels of self-kindness, mindfulness and common humanity, and low levels of self-judgment, over-identification and isolation) experience less burnout and compassion fatigue symptoms and more compassion satisfaction (Hypothesis 2). Finally, we wanted to explore the finding that empathic emotions are associated with compassion fatigue, and the role of self-compassion in this relationship. We hypothesize that self-compassion may mediate and/or moderate the relationship between empathy and compassion fatigue (Hypothesis 3). We used a cross-sectional design to test these hypotheses.
Section snippets
Participants and procedures
Participants were recruited from four public hospitals from Portugal's north and center regions, between February 2014 and February 2015. This was a convenience sample of hospitals. After approval of the hospitals’ ethics committees, department chief nurses were directly contacted by the researcher who explained the study aims and the importance of participation. Department chief nurses were asked to advertise the study among the nurses in their services and to deliver and receive the
Sample profile
A total of 280 registered nurses from different clinical services in Portugal participated in the study. This sample had a mean age of 37.66 (SD = 9.34), ranging between 22 and 60; the majority of participants were female (n = 227; 81.1%) and married (n = 160; 57.1%). Also, the mean years of schooling was 15.90 (SD = 2.14) indicating that the average education level is university. Participants reported a mean years of practice of 14.74 (SD = 9.30).
Descriptive statistics
Descriptive statistics for the study variables are
Discussion
Repeated exposure to the suffering of others in healthcare professionals may be associated with the adverse consequences of personal distress, burnout and compassion fatigue, which are detrimental to their well-being. By the very nature of their work, healthcare professionals encounter people with various injuries and suffering in their everyday practice. In this case, being overly sensitive to others’ suffering and pain may be detrimental and cause several negative effects, such as compassion
Conclusion
Nurses face the challenge of finding the balance that allows them to resonate with patients’ suffering without becoming emotionally overinvolved in a way that might lead to burnout and compassion fatigue. This study's findings suggest that teaching self-compassion and self-care skills, i.e., a tendency to be kind and understanding toward oneself, to feel interconnected with other people and to hold negative experiences with mindful awareness, may be an important feature in nursing educational
Acknowledgments
This research was supported by the first author's Ph.D. Grant (SFRH/BD/81416/2011), sponsored by the Foundation for Science and Technology (FCT), Portugal.
The authors gratefully acknowledge the institutional boards for approving the recruitment of participants in their hospitals.
Conflict of interest. None declared.
Funding. The research was supported by the first author's Ph.D. Grant (SFRH/BD/81416/2011), sponsored by FCT (Foundation for Science and Technology), Portugal, and co–sponsored by ESF
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