Advertisement

Trauma, Compassion Fatigue, and Burnout in Nurses

The Nurse Leader’s Response
      Within health care, trauma-informed care has become an embedded approach in caring for patients; however, nurse leaders are not always prepared to lead nurses with a background of trauma. Nurses’ past trauma, coupled with workplace stressors, may result in compassion fatigue, burnout, and secondary traumatic stress. Nurse leader engagement and trauma-informed leadership approaches are imperative to mitigate and mediate the effects of trauma in nurses as the COVID-19 pandemic recedes.
      Key Points:
      • 1.
        Nurses and healthcare professionals may be impacted by Adverse Childhood Events and trauma, both personally and professionally.
      • 2.
        Adverse Childhood Events and trauma play a role in compassion fatigue, burnout, secondary traumatic stress, and resilience in nurses.
      • 3.
        Trauma-informed approaches and self-care in nurse leaders are imperative for effective leadership.
      When I attended nursing school in the early 1990s, trauma-informed care was not a defined concept. I learned about trauma-informed care in 2017 as a nursing faculty member while participating in a colleague’s undergraduate course lecture. Although my own undergraduate education included instruction on empathy, compassion, and patient advocacy, I realized trauma-informed care was the link I had been missing in my approach to patients as both a faculty member and a practicing emergency department nurse. In recent discussions with other nurse leaders and colleagues, I have found that there are gaps in knowledge on trauma-informed care for those who attended nursing school more than 10-15 years ago. This article will give a synopsis of what I have learned about trauma-informed care, the impacts of trauma and trauma-informed care on nurses, and the development of resilience in nurses. As a new hospital-based nurse manager, I will also discuss how I am learning to translate trauma-informed care practices into the leadership role.

      What is Trauma-Informed Care?

      Trauma-informed care has emerged and evolved over the past 20 years as a response to the landmark Adverse Childhood Events (ACEs) study.
      • Wilson C.
      • Pence D.M.
      • Conradi L.
      Trauma-informed care.
      Felitti et al.
      • Felitti V.J.
      • Anda R.F.
      • Nordenberg D.
      • et al.
      Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study.
      defined ACEs as “childhood emotional, physical, or sexual abuse, and household dysfunction during childhood.” Household dysfunction was further delineated as witnessing violent acts against one’s mother, living with a family member who used illicit substances or alcohol, having a household family member who was imprisoned, or living with a family member who had a mental illness or who was suicidal.
      • Felitti V.J.
      • Anda R.F.
      • Nordenberg D.
      • et al.
      Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study.
      ACEs are pervasive, and it is estimated that 55%-90% of the current U.S. population has experienced at least one form of childhood trauma.
      • Fallot R.D.
      • Harris M.
      Creating Cultures of trauma-informed care (CCTIC): a self-Assessment and Planning Protocol.
      Of the 55%-90% who have experience childhood trauma, many have experienced as many as five traumatic events in their lifetime.
      • Fallot R.D.
      • Harris M.
      Creating Cultures of trauma-informed care (CCTIC): a self-Assessment and Planning Protocol.
      Long-term outcomes of ACEs are an increased risk of developing chronic illnesses such as cancer, ischemic heart disease, and chronic lung disease, as well as higher rates of depression, alcoholism, drug abuse, and suicide in trauma survivors.
      • Felitti V.J.
      • Anda R.F.
      • Nordenberg D.
      • et al.
      Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study.
      The Substance Abuse and Mental Health Services Administration established the National Center for Trauma-Informed Care in 2005 after recognizing a need for care delivery which includes a trauma-informed framework at its core.
      • Wilson C.
      • Pence D.M.
      • Conradi L.
      Trauma-informed care.
      This framework assists health care professionals in viewing patients and clients through the lens of past trauma, using the mindset and verbiage of “what has happened to you,” rather than “what is wrong with you.”
      • Beattie J.
      • Griffiths D.
      • Innes K.
      • Morphet J.
      Workplace violence perpetrated by clients of health care: a need for safety and trauma-informed care.
      A trauma-informed approach also allows the trauma survivor to define his/her own traumatic experience and resultant stress.
      • Wilson C.
      • Pence D.M.
      • Conradi L.
      Trauma-informed care.
      This shift in patient approach and health care provider mindset serves to decrease retraumatization of the patient and provide psychological safety in patient care.
      • Wilson C.
      • Pence D.M.
      • Conradi L.
      Trauma-informed care.

      How are Nurses Affected by Trauma and Trauma-Informed Care?

      Nurses and health care providers are not immune to ACEs, trauma, and traumatic stress. Current literature postulates that ACE scores among nurses mimic those of the population, with some studies suggesting that nurses may have higher rates of ACEs than the general population.
      • Cogan R.M.
      The relentless school nurse: ACEs impact nurses more than we realized! ACES in Education.
      ,
      • Girouard S.
      • Bailey N.
      ACEs implications for nurses, nursing education, and nursing practice.
      Nurses who have a history of childhood trauma and who work in high-acuity settings are at risk of being retraumatized through exposure to stressful situations, leading to anxiety, depression, post-traumatic stress disorder, compassion fatigue, and burnout.
      • Ying L.Y.
      • Ramoo V.
      • Ling L.W.
      • et al.
      Nursing practice environment, resilience, and intention to leave among critical care nurses.
      The implementation of trauma-informed care by nurses, particularly in patient populations with high levels of trauma, can also lead to compassion fatigue and burnout.
      • Sales J.M.
      • Piper K.
      • Riddick C.
      • Getachew B.
      • Colasanti J.
      • Kalokhe A.
      Low provider and staff self-care in a large safety-net HIV clinic in the southern United States: implications for the adoption of trauma-informed care.
      These feelings of compassion fatigue and burnout are associated with negative work performance, nurse turnover, increased financial burden for employers, decreased patient satisfaction, and worsened quality of care delivery.
      • Ying L.Y.
      • Ramoo V.
      • Ling L.W.
      • et al.
      Nursing practice environment, resilience, and intention to leave among critical care nurses.
      ,
      The Joint Commission
      Developing resilience to combat nurse burnout. Quick Saf.
      ,
      • Girard S.A.
      • Hoeksel R.
      • Vandermause R.
      • Eddy L.
      Experiences of RNs who voluntarily withdraw from their RN-to-BSN program.

      Compassion Fatigue

      Compassion fatigue is the “phenomenon of stress resulting from exposure to a traumatized individual rather than from exposure to the trauma itself.”
      • Cocker F.
      • Joss N.
      Compassion fatigue among healthcare, emergency and community service workers: a systematic review.
      (p1) Signs of compassion fatigue include physical and emotional exhaustion, increased anxiety, anger, irritability, intimacy issues, and irrational fears.
      • Cocker F.
      • Joss N.
      Compassion fatigue among healthcare, emergency and community service workers: a systematic review.
      ,
      • Powell S.K.
      Compassion fatigue.
      Nurses may display decreased sympathy and/or empathy toward patients and coworkers and may express dread in working with certain clients or patients.
      • Cocker F.
      • Joss N.
      Compassion fatigue among healthcare, emergency and community service workers: a systematic review.
      ,
      • Powell S.K.
      Compassion fatigue.
      Negative coping behaviors, including drug and alcohol abuse, may emerge along with decreased job satisfaction. Nurse leaders may notice that staff members demonstrate increased use of sick days and/or paid time off and higher rates of absenteeism.
      • Cocker F.
      • Joss N.
      Compassion fatigue among healthcare, emergency and community service workers: a systematic review.
      ,
      • Powell S.K.
      Compassion fatigue.
      In contrast to absenteeism, presenteeism is the physical presence of a nurse or health care provider on the job when they should not report for duty due to illness or job-related stressors.
      • Bouchard L.
      • Rainbow J.
      Compassion fatigue, presenteeism, adverse childhood experiences (ACES), and resiliency levels of Doctor of nursing practice (DNP) students.
      Nurses have the highest rates of presenteeism in the workforce, which is linked to poor patient outcomes and decreased patient safety.
      • Bouchard L.
      • Rainbow J.
      Compassion fatigue, presenteeism, adverse childhood experiences (ACES), and resiliency levels of Doctor of nursing practice (DNP) students.
      Health care providers at the highest risk of experiencing compassion fatigue are younger nurses and nurses with 2-5 years of experience.
      • Kelly L.
      • Todd M.
      Compassion fatigue and the healthy work environment.
      Compassion fatigue in younger or inexperienced nurses may lead to decreased retention, increased turnover, and the intent to leave the nursing profession entirely.
      • Kelly L.
      • Todd M.
      Compassion fatigue and the healthy work environment.
      Nurses who are exposed to chronic stressors and traumatic patient experiences are also at an increased risk for experiencing compassion fatigue, as are nurses who work in medical-surgical and pediatric inpatient departments, outpatient home health, and those who practice in rural settings.
      • Bleazard M.
      Compassion fatigue in nurses caring for medically complex children.
      • Slatten L.A.
      • Carson K.D.
      • Carson P.P.
      Compassion fatigue and burnout: what managers should know.
      • Sorenson C.
      • Bolick B.
      • Wright K.
      • Hamilton R.
      Understanding compassion fatigue in healthcare providers: a review of current literature.
      Workplace incivility and higher patient-to-nurse staffing ratios are also associated with higher rates of compassion fatigue and burnout in nurses.
      • Bleazard M.
      Compassion fatigue in nurses caring for medically complex children.

      Burnout

      Dr. Beth Hudnall Stamm’s original research on Professional Quality of Life proposed that burnout is a byproduct of compassion fatigue, yet the two are not synonymous.
      ProQOL
      Secondary trauma. ProQOL.
      Burnout tends to have a gradual onset, whereas compassion fatigue may present more rapidly or suddenly.
      • Hunsaker S.
      • Chen H.C.
      • Maughan D.
      • Heaston S.
      Factors that influence the development of compassion fatigue, burnout, and compassion satisfaction in emergency department nurses.
      Burnout, or burnout syndrome, is often characterized by feelings of hopelessness, emotional exhaustion, lack of self-efficacy, depersonalization, and decreased productivity in the workplace and is thought to be caused by prolonged exposure to workplace stressors and events.
      • Najib Kawar L.
      • Radovich P.
      • Valdez R.M.
      • Zuniga S.
      • Rondinelli J.
      Compassion fatigue and compassion satisfaction among multisite multisystem nurses.
      ,
      • Cavanagh N.
      • Cockett G.
      • Heinrich C.
      • et al.
      Compassion fatigue in healthcare providers: a systematic review and meta-analysis.
      Studies have demonstrated that burnout is present in as many as 40%-75% of health care professionals and is not isolated to nurses.
      • Powell S.K.
      Compassion fatigue.
      The literature estimates that as many as 12% of physicians suffering from burnout syndrome struggle with suicidal thoughts, and the rate of completed suicide among medical students is twice that of the general population.
      • Powell S.K.
      Compassion fatigue.
      Nurses at an increased risk for burnout are often those working in high-acuity, high-intensity environments such as critical care, oncology, and emergency nursing.
      • Kelly L.
      • Todd M.
      Compassion fatigue and the healthy work environment.
      ,
      • Al-Majid S.
      • Carlson N.
      • Kiyohara M.
      • Faith M.
      • Rakovski C.
      Assessing the degree of compassion satisfaction and compassion fatigue among critical care, oncology, and charge nurses.
      • Fahey D.M.
      • Glasofer A.
      An inverse relationship: compassion satisfaction, compassion fatigue, and critical care nurses.
      • Jakimowicz S.
      • Perry L.
      • Lewis J.
      Insights on compassion and patient-centred nursing in intensive care: a constructivist grounded theory.
      • Storm J.
      • Chen H.C.
      The relationships among alarm fatigue, compassion fatigue, burnout and compassion satisfaction in critical care and step-down nurses.
      Prior to the COVID-19 pandemic, The Joint Commission
      The Joint Commission
      Developing resilience to combat nurse burnout. Quick Saf.
      surveyed over 2000 nurses and found that 15.6 of those surveyed had feelings of burnout, with even higher rates among emergency room nurses. Charge nurses working in oncology and critical care also reported higher rates of burnout and secondary traumatic stress than staff nurses.
      • Al-Majid S.
      • Carlson N.
      • Kiyohara M.
      • Faith M.
      • Rakovski C.
      Assessing the degree of compassion satisfaction and compassion fatigue among critical care, oncology, and charge nurses.

      Secondary Traumatic Stress

      Secondary traumatic stress or secondary trauma, like burnout, is another outcome of untreated or unresolved compassion fatigue.
      ProQOL
      Secondary trauma. ProQOL.
      Secondary traumatic stress develops from exposure to patients with a significant history of trauma, similar to vicarious trauma.
      • Kelly L.
      • Todd M.
      Compassion fatigue and the healthy work environment.
      Secondary traumatic stress in nurses is associated with sleep disturbances, anxiety, intrusive thoughts, and avoidance behaviors around reminders of trauma suffered by patients.
      • Kelly L.
      • Todd M.
      Compassion fatigue and the healthy work environment.

      Resilience

      Resilience is thought to be a positive and protective mechanism for survivors of trauma,
      • Pletcher B.A.
      • O’Connor M.
      • Swift-Taylor M.E.
      • DallaPiazza M.
      Adverse childhood experiences: a case-based workshop introducing medical students to trauma-informed care.
      described as one’s ability to overcome, bounce back, or rebound from adversity.
      • Ying L.Y.
      • Ramoo V.
      • Ling L.W.
      • et al.
      Nursing practice environment, resilience, and intention to leave among critical care nurses.
      ,
      • Bouchard L.
      • Rainbow J.
      Compassion fatigue, presenteeism, adverse childhood experiences (ACES), and resiliency levels of Doctor of nursing practice (DNP) students.
      In nurses, resilience provides a buffer from the stressors and challenges of the workplace, increasing adaptability and ability to cope within the work environment.
      • Ying L.Y.
      • Ramoo V.
      • Ling L.W.
      • et al.
      Nursing practice environment, resilience, and intention to leave among critical care nurses.
      ,
      The Joint Commission
      Developing resilience to combat nurse burnout. Quick Saf.
      The first step for nurses in developing resilience is recognition of their own ACEs along with past trauma and stressors.
      • Girouard S.
      • Bailey N.
      ACEs implications for nurses, nursing education, and nursing practice.
      This may be facilitated by nurse leaders mindfully educating nurses on ACEs and trauma-informed care. Nurses must then provide consideration to the impact their own past trauma has on their knowledge, skills, and attitudes in patient interactions and care delivery.
      Resilience in nurses has become so crucial that the Future of Nursing 2020-2030 committee has included resilience in their work, recognizing that nurse well-being and resilience are vital parts of quality health care delivery.
      The National Academy of Medicine
      The Future of nursing 2020-2030. National Academy of medicine.
      Prior to the COVID-19 pandemic, The Joint Commission
      The Joint Commission
      Developing resilience to combat nurse burnout. Quick Saf.
      authored their safety brief, Developing Resilience to Combat Nurse Burnout, discussing that nurses often provide care to others at a high personal cost. Additionally, many nurses report feeling a lack of support by administration and health care systems in addressing effective methods to reduce burnout.
      The Joint Commission
      Developing resilience to combat nurse burnout. Quick Saf.
      The Joint Commission
      The Joint Commission
      Developing resilience to combat nurse burnout. Quick Saf.
      recommended the focus of organizational leadership move to that of developing and improving resilience in nurses to combat burnout.

      How Do We Translate Trauma-Informed Care Into Leadership?

      In a recent editorial, Dr. Rose Sherman recently challenged nurse leaders to consider the effects of primary and secondary trauma on nurses, instituting the same trauma-informed approach that nurses use when engaging patients and clients.
      • Sherman R.O.
      Using a trauma-informed leadership approach.
      This approach is demonstrated by viewing nurses’ attitudes and behaviors through the lens of “what has happened to you” instead of “what is wrong with you.”
      • Beattie J.
      • Griffiths D.
      • Innes K.
      • Morphet J.
      Workplace violence perpetrated by clients of health care: a need for safety and trauma-informed care.
      ,
      • Sherman R.O.
      Using a trauma-informed leadership approach.
      By implementing a trauma-informed leadership approach, the nurse leader has the opportunity to have a significant influence on nurse compassion fatigue and burnout.
      • Hunsaker S.
      • Chen H.C.
      • Maughan D.
      • Heaston S.
      Factors that influence the development of compassion fatigue, burnout, and compassion satisfaction in emergency department nurses.
      Research has demonstrated that low levels of nurse manager support are significant predictors of burnout and compassion fatigues.
      • Kelly L.
      • Todd M.
      Compassion fatigue and the healthy work environment.
      ,
      • Hunsaker S.
      • Chen H.C.
      • Maughan D.
      • Heaston S.
      Factors that influence the development of compassion fatigue, burnout, and compassion satisfaction in emergency department nurses.
      In contrast, authentic leadership, as exhibited through qualities of trustworthiness, compassion, reliability, and genuineness in nurse leaders and health care administrators, is associated with workplace satisfaction in nurses.
      • Kelly L.
      • Todd M.
      Compassion fatigue and the healthy work environment.
      ,
      • Hunsaker S.
      • Chen H.C.
      • Maughan D.
      • Heaston S.
      Factors that influence the development of compassion fatigue, burnout, and compassion satisfaction in emergency department nurses.
      Dr. Dawn Emerick recommends that nurse leaders view the COVID-19 pandemic as a form of trauma for frontline nurses and staff members.
      Work Wellness Institute
      Trauma informed leadership and change Management in support of work Wellness: thoughts to Inspire.
      I have observed that acute care nurses, now over two years into pandemic care, are exhibiting signs of compassion fatigue, burnout, and moral exhaustion, particularly after caring for COVID-19–positive patients who have had increased lengths of stay. Nurses are discussing moving out of high-acuity hospital settings, leaving their current place of employment for lucrative travel assignments, or even leaving the nursing profession entirely. A nurse who worked in the food service industry prior to graduating from nursing school told me that she missed her previous job and was picking up restaurant shifts during the pandemic, stating “At least when I work there, no one tries to die on me.”
      Nurse leaders must provide nurses and frontline staff encouragement and resources to help them process workplace stress and trauma and to engage in self-care. Recommended trauma-informed leadership approaches include the following:
      • Encourage staff participation self-care activities while at work (e.g., journaling, walking, mindfulness, meditation, and gratitude activities)
      • Invite a staff member to go on a walk at work and listen to his/her stories
      • If staff members volunteer information about their own past trauma and its subsequent effects, consider their story in interactions with them, particularly in those showing signs of compassion fatigue and burnout
      • Have crucial conversations with staff members who are exhibiting signs of compassion fatigue and burnout, offering a change of job duties or work assignment if possible
      • Diversify or decrease staff workload, particularly in dealing with patients experiencing traumatic events or those admitted with COVID-19
      • Support staff in having time off work, particularly on evenings, nights, and weekends, and have minimal work-related contact with staff on their days off
      • Allow staff to take vacations and use paid time off when possible
      • Encourage participation in debriefings after difficult or traumatic patient care experiences
      • Educate and encourage staff to have professional boundaries with patients and their families
      • Provide positive recognition of staff in ways that are personally meaningful to the individual staff members
      • Acknowledge and reward staff members who are loyal to the organization (e.g., retention bonuses, extra shift bonuses)
      • Encourage peer support, teamwork, and collaboration
      • Empower and encourage staff in pursuing education, training, and professional development
      • Support employee autonomy, shared decision-making, and sense of control in the workplace.
        • Bleazard M.
        Compassion fatigue in nurses caring for medically complex children.
        ,
        • Slatten L.A.
        • Carson K.D.
        • Carson P.P.
        Compassion fatigue and burnout: what managers should know.
        ,
        • Copeland D.
        Brief workplace interventions addressing burnout, compassion fatigue, and teamwork: a pilot study.
        ,
        • Chapman G.
        • White P.
        The 5 Languages of Appreciation in the Workplace. Northfield Publishing.

      Work-Related Injuries

      Compassion fatigue and burnout, if left untreated, may lead to long-term emotional trauma, depression, and suicide in health care providers.
      • Kelly L.
      Burnout, compassion fatigue, and secondary trauma in nurses: recognizing the occupational phenomenon and personal consequences of caregiving.
      Therefore, compassion fatigue, burnout, and secondary traumatic stress should be treated as on-the-job injuries or work-related injuries.
      • Slatten L.A.
      • Carson K.D.
      • Carson P.P.
      Compassion fatigue and burnout: what managers should know.
      ,
      • Copeland D.
      Brief workplace interventions addressing burnout, compassion fatigue, and teamwork: a pilot study.
      Nurse leaders should first attempt to mitigate the effects of compassion fatigue and burnout in employees by using approaches and strategies such as those listed earlier in the study.
      • Copeland D.
      Brief workplace interventions addressing burnout, compassion fatigue, and teamwork: a pilot study.
      If unable to mitigate, workplace mental health resources such as employee assistance programs should be instituted as soon as possible.
      • Copeland D.
      Brief workplace interventions addressing burnout, compassion fatigue, and teamwork: a pilot study.

      How Do I Deal With Trauma as a Leader?

      Nurse leaders must first acknowledge their own past trauma and its impact on their mental health and leadership style. Additionally, nurse leaders must take time for self-care and find a healthy work-life balance.
      • Kelly L.
      • Lefton C.
      • Fischer S.A.
      Nurse leader burnout, satisfaction, and work-life balance.
      I have found that walking 30 minutes each day, either on a treadmill or during breaks at work, has significantly improved my mindset and allows time for mental processing. Recognition of my own self-care deficit and work-life imbalance has served as a barometer in managing my compassion fatigue. Similarly, this same self-awareness in nurse leaders will help in recognizing signs and symptoms of compassion fatigue and burnout in staff members and other leaders, allowing for early intervention, offering of resources, and increased support.
      • Powell S.K.
      Compassion fatigue.

      Conclusion

      Many nurses have experienced trauma in their lives, including working through the COVID-19 pandemic. When previous trauma is combined with current workplace stressors, nurses are at risk of experiencing compassion fatigue and burnout, and the quality of patient care suffers. Hospital and health care leaders can positively affect nurse well-being through a trauma-informed leadership approach and by promoting practices to decrease compassion fatigue and improve employee resilience. Leadership behaviors that foster self-care and nursing resilience are imperative to maintain and strengthen the nursing workforce.
      The Joint Commission
      Developing resilience to combat nurse burnout. Quick Saf.

      References

        • Wilson C.
        • Pence D.M.
        • Conradi L.
        Trauma-informed care.
        Encycl Soc Work. 2013; : 1-23
        • Felitti V.J.
        • Anda R.F.
        • Nordenberg D.
        • et al.
        Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study.
        Am J Prev Med. 1998; 14: 245-258
        • Fallot R.D.
        • Harris M.
        Creating Cultures of trauma-informed care (CCTIC): a self-Assessment and Planning Protocol.
        Community Connections. 2009; : 1-18
        • Beattie J.
        • Griffiths D.
        • Innes K.
        • Morphet J.
        Workplace violence perpetrated by clients of health care: a need for safety and trauma-informed care.
        J Clin Nurs. 2019; 28: 116-124
        • Cogan R.M.
        The relentless school nurse: ACEs impact nurses more than we realized! ACES in Education.
        (Available at:)
        • Girouard S.
        • Bailey N.
        ACEs implications for nurses, nursing education, and nursing practice.
        Acad Pediatr. 2017; 17: S16-S17
        • Ying L.Y.
        • Ramoo V.
        • Ling L.W.
        • et al.
        Nursing practice environment, resilience, and intention to leave among critical care nurses.
        Nurs Crit Care. 2021; : 432-440
        • Sales J.M.
        • Piper K.
        • Riddick C.
        • Getachew B.
        • Colasanti J.
        • Kalokhe A.
        Low provider and staff self-care in a large safety-net HIV clinic in the southern United States: implications for the adoption of trauma-informed care.
        SAGE Open Med. 2019; 7: 1-11
        • The Joint Commission
        Developing resilience to combat nurse burnout. Quick Saf.
        (Available at:)
        • Girard S.A.
        • Hoeksel R.
        • Vandermause R.
        • Eddy L.
        Experiences of RNs who voluntarily withdraw from their RN-to-BSN program.
        J Nurs Educ. 2017; 56: 260-265
        • Cocker F.
        • Joss N.
        Compassion fatigue among healthcare, emergency and community service workers: a systematic review.
        Int J Environ Res Public Health. 2016; 13: 1-11
        • Powell S.K.
        Compassion fatigue.
        Prof Case Manag. 2020; 25: 53-55
        • Bouchard L.
        • Rainbow J.
        Compassion fatigue, presenteeism, adverse childhood experiences (ACES), and resiliency levels of Doctor of nursing practice (DNP) students.
        Nurse Educ Today. 2021; 100: 1-6
        • Kelly L.
        • Todd M.
        Compassion fatigue and the healthy work environment.
        AACN Adv Crit Care. 2017; 28: 351-358
        • Bleazard M.
        Compassion fatigue in nurses caring for medically complex children.
        J Hosp Palliat Nurs. 2020; 22: 473-478
        • Slatten L.A.
        • Carson K.D.
        • Carson P.P.
        Compassion fatigue and burnout: what managers should know.
        Health Care Manag. 2020; 39: 181-189
        • Sorenson C.
        • Bolick B.
        • Wright K.
        • Hamilton R.
        Understanding compassion fatigue in healthcare providers: a review of current literature.
        J Nurs Scholarsh. 2016; 48: 456-465
        • ProQOL
        Secondary trauma. ProQOL.
        (Available at:)
        https://proqol.org/secondary-trauma
        Date accessed: June 9, 2021
        • Hunsaker S.
        • Chen H.C.
        • Maughan D.
        • Heaston S.
        Factors that influence the development of compassion fatigue, burnout, and compassion satisfaction in emergency department nurses.
        J Nurs Scholarsh. 2015; 47: 186-194
        • Najib Kawar L.
        • Radovich P.
        • Valdez R.M.
        • Zuniga S.
        • Rondinelli J.
        Compassion fatigue and compassion satisfaction among multisite multisystem nurses.
        Nurs Adm Q. 2019; 43: 358-369
        • Cavanagh N.
        • Cockett G.
        • Heinrich C.
        • et al.
        Compassion fatigue in healthcare providers: a systematic review and meta-analysis.
        Nurs Ethics. 2020; 27: 639-665
        • Al-Majid S.
        • Carlson N.
        • Kiyohara M.
        • Faith M.
        • Rakovski C.
        Assessing the degree of compassion satisfaction and compassion fatigue among critical care, oncology, and charge nurses.
        J Nurs Adm. 2018; 48: 310-315
        • Fahey D.M.
        • Glasofer A.
        An inverse relationship: compassion satisfaction, compassion fatigue, and critical care nurses.
        Nurs Crit Care. 2016; 11: 30-35
        • Jakimowicz S.
        • Perry L.
        • Lewis J.
        Insights on compassion and patient-centred nursing in intensive care: a constructivist grounded theory.
        J Clin Nurs. 2018; 27: 1599-1611
        • Storm J.
        • Chen H.C.
        The relationships among alarm fatigue, compassion fatigue, burnout and compassion satisfaction in critical care and step-down nurses.
        J Clin Nurs. 2021; 30: 443-453
        • Pletcher B.A.
        • O’Connor M.
        • Swift-Taylor M.E.
        • DallaPiazza M.
        Adverse childhood experiences: a case-based workshop introducing medical students to trauma-informed care.
        J Teach Learn Resour. 2019; 15: 10803https://doi.org/10.15766/mep_2374-8265.10803
        • The National Academy of Medicine
        The Future of nursing 2020-2030. National Academy of medicine.
        (Available at:)
        https://nam.edu/publications/the-future-of-nursing-2020-2030/
        Date: 2020
        Date accessed: November 15, 2020
        • Sherman R.O.
        Using a trauma-informed leadership approach.
        Nurse Lead. 2021; 19: 321-322
        • Work Wellness Institute
        Trauma informed leadership and change Management in support of work Wellness: thoughts to Inspire.
        (Available at:)
        https://www.youtube.com/watch?v=7NhDLFDjOb0
        Date: 2021
        Date accessed: February 19, 2022
        • Copeland D.
        Brief workplace interventions addressing burnout, compassion fatigue, and teamwork: a pilot study.
        West J Nurs Res. 2021; 43: 130-137
        • Chapman G.
        • White P.
        The 5 Languages of Appreciation in the Workplace. Northfield Publishing.
        (Available at:)
        • Kelly L.
        Burnout, compassion fatigue, and secondary trauma in nurses: recognizing the occupational phenomenon and personal consequences of caregiving.
        Crit Care Nurs Q. 2020; 43: 73-80
        • Kelly L.
        • Lefton C.
        • Fischer S.A.
        Nurse leader burnout, satisfaction, and work-life balance.
        J Nurs Adm. 2019; 49: 404-410

      Biography