The Imperative of Proactivity

A first step in being proactive is understanding compassion fatigue, burnout, secondary traumatic stress, PTSD, and moral injury, which are similar concepts. First defined in nursing by Joinson,⁵  compassion fatigue is “a state where the compassionate energy that is expended by nurses has surpassed their restorative processes with recovery being lost.”^6(p237) This concept was pioneered in the helping professions by Dr Charles Figley⁷  and Dr Beth Hudnall Stamm.⁸  In the Professional Quality of Life model, compassion fatigue comprises burnout and secondary traumatic stress, each of which are influenced by an individual’s work environment, population served, and personal characteristics.⁸ 

Burnout is a cumulative stress response experienced in the workplace and resulting from chronic exposure to work-related stressors that develop gradually.^8,9  In contrast, secondary traumatic stress develops suddenly as a consequence of witnessing another’s, often a patient’s, stressful or traumatic event, experiencing the aftermath of that event, or by directly experiencing the event.^8,10–12  Nurses may also acutely develop PTSD after exposure to an event that is beyond what would be considered a normal stressor.^13,14  Hallmarks of PTSD include persistent intrusive symptoms; avoidance of situations similar to the causative event; alterations in mood, cognition, arousal, and reactivity; and impaired functioning.^13,14 

Signs and symptoms of burnout, secondary traumatic stress, and PTSD intersect and may lead to dysfunction in other areas of nurses’ lives. The overlapping signs of these conditions include depersonalization, frustration, exhaustion, intrusive imagery, anxiety, powerlessness, and anger.^9,15,16 

Moral injury is another risk of caregiving, first identified in the military. The emotional, psychological, behavioral, spiritual, and social effects of being exposed to situations in which nurses’ moral beliefs are transgressed can result in moral injury.¹⁷  When experiencing moral injury, nurses may show signs of anger, guilt, and shame.^18,19  In extreme cases, moral injury can progress to changes in worldview; loss of empathy; and even mental health conditions such as depression, anxiety, and PTSD.^18,19 

As nurses and leaders, we can act to prevent the potential negative outcomes of nursing work described above. We need to understand and foster the positive aspects of nursing, including compassion satisfaction and moral resilience. Many nurses are drawn to nursing as a “calling,” and some are fulfilled by the joy, hope, and gratification they feel from providing patient care.²⁰  The result of these feelings is compassion satisfaction, defined as the positive feelings that a nurse gains as a result of caregiving.^8,20  Compassion satisfaction is also influenced by the work environment, patient population served, and personal factors.⁸  Stamm⁸  postulated that a balance between compassion satisfaction and compassion fatigue supports a caregiver’s professional quality of life.

Moral resilience is described as the ability to resume a state of stability and restore one’s integrity in response to situations that cause moral injury, moral outrage, or moral distress.²¹  Key to this definition is nurses’ integrity; when their integrity is compromised, nurses may experience apathy or disengagement, and, in extreme instances, moral distress.¹⁶  Rushton¹⁶  noted that there are modifiable factors that organizations can address to prevent compromised integrity and essentially foster moral resilience.

When embracing an imperative of proactivity, both compassion satisfaction and moral resilience can be promoted. In a proactive environment, structures are in place to prevent the negative aspects of nursing and to promote the positive aspects.^4,16,22  One method to doing so is implementing the American Association of Critical-Care Nurses healthy work environment standards, as measured by the Healthy Work Environment Assessment Tool.²³  Researchers have found that there are relationships between the healthy work environment standards and components of professional quality of life, as measured by the Professional Quality of Life scale (see Table).^15,24–26 

On the basis of the findings presented in the Table, in a proactive environment, in which interventions are developed and implemented to improve the nursing work environment, there may be incremental improvements to nurses’ professional quality of life, limiting compassion fatigue while promoting compassion satisfaction. Further research and quality improvement projects are necessary to test and evaluate such interventions.

A proactive response can also support nurses’ wellness, a responsibility of organizations to their employees and a responsibility we have to ourselves and one another. Wellness support may include attending to psychological safety and mental health, implementation of wellness programs and dedicated wellness officers, and enactment of policies on workplace violence and caring for individuals affected by violence.

Although we may not be able to insulate nurses from the these risks of nursing entirely, positively reframing the approach and moving to proactivity may produce positive change.⁴  In addition, ongoing professional development in disaster preparedness and caring for those who have experienced violence are imperative. Heeding lessons from our military colleagues may also be fruitful. To support our readers’ knowledge on these topics, Critical Care Nurse is pleased to announce a special issue on enhancing critical care through military, trauma, and disaster nursing in October 2024. As a guest editor for that issue, it is my hope that it may be one step in helping our readers to be more prepared for future emergency and disaster responses, a proactive strategy in a reactive world.