Compassion fatigue among nurses working on an adult emergency and urgent care unit

Objective to assess compassion fatigue levels among nurses and its variation according socio-demographic and professional characteristics. Method quantitative, descriptive and cross-sectional study, with 87 nurses from an emergency and urgent care unit for adults from a university hospital. A socio-demographic and professional questionnaire, along with the Professional Quality of Life Scale 5 were used. Data analysis was performed using descriptive and inferential statistics. Results compassion satisfaction presents the highest means, followed by burnout and secondary traumatic stress. Among the participants, 51% presented a high level of compassion satisfaction, 54% a high level of burnout, and 59% a high level of secondary traumatic stress. Older participants presented higher score of compassion satisfaction, and younger nurses, women, nurses having less job experience and nurses without leisure activities showed higher means of secondary traumatic stress. Conclusion we found compassion fatigue, expressed in the large percentage of nurses with high levels of burnout and secondary traumatic stress. Fatigue is related to individual factors such as age, gender, job experience and leisure activities. Doing research and understanding this phenomenon allow the development of health promotion strategies at work.


Introduction
Health, safety, and well-being of health professionals are the focus of worldwide attention, due emotional demands of their task and the importance they have on the productivity, competitiveness and sustainability of organizations (1)(2)(3) .
Compassion fatigue, which is considered one of the greatest threats to the mental health of health professionals (4)(5)(6)(7) , is defined as "the natural, consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other -the stress resulting from helping or wanting to help a traumatized or suffering person" (8) . Lately, the Professional Quality of Life model describes compassion fatigue as the combination of high burnout, secondary traumatic stress and low compassion satisfaction (9) .
Different factors contribute to compassion fatigue, with emphasis on personality, education, job experience, personal quality of life and, at the organizational level, the specificity of the tasks and the changes of the health system (6,10) . Due to the considerable demand and frequent contact with traumatic situations, nursing work in emergency and urgent care makes nurses susceptible to feel the pain of their patients, increasing compassion fatigue (11)(12)(13) .
The expressions of compassion fatigue are varied and have not always been valorized. They develop over time and compromise not only the physical, psychological, cognitive and spiritual health of professionals, but also their personal, social and professional life, with a negative impact on their well-being and quality of life, as well as on the health institutions and on the quality of care provided (4)(5)(14)(15)(16) . Considering that nurses have emotionally demanding tasks and work under stressful conditions (17)(18)(19)(20) , this study aimed to assess compassion fatigue levels among nurses and its variation according socio-demographic and professional characteristics.

Method
This is a quantitative, descriptive and cross-sectional study conducted from May to July 2017, with Portuguese nurses from an emergency and urgent care unit from a university hospital in the city of Porto, Portugal. The inclusion criterion was being a nurse with job experience more than 6 months. A convenience sample from a population of 93 nurses was selected, participating 87 nurses, which represents a 94% adhesion rate.
The data was collected through a self-reporting instrument containing socio-demographic questions (gender, age, marital status, children, academic qualification and leisure activities), job questions (years of job experience, work contract, working schedule, presence of dependents, monthly income, and a question asking if they considered their work stressful), and the Professional Quality of Life Scale (ProQOL5), translated and adapted for the Portuguese population (9,21) . This author (9) were followed. The raw scores of the subscales compassion satisfaction, burnout and secondary traumatic stress were converted in Z scores and these in t-scores. The forced conversion of raw scores to obtain M=50 and SD=10 makes it possible to compare the score of the three dimensions and to compare the results with other studies.  (9) and in the Portuguese version (21) , which had score of 0.88; 0.75; 0.81 and 0.86; 0.71; 0.83, respectively.

Regarding
The analysis of the dimensions of professional quality of life reveals that compassion satisfaction has the highest mean score, followed by burnout. Secondary traumatic stress has the lowest score (Table 1).
Correlation analysis between dimensions revealed that the correlation between compassion satisfaction and burnout is negative and strong, between compassionate satisfaction and secondary traumatic stress it is negative but weak, and between burnout and secondary traumatic stress is positive but weak (Table 1).  gender, job experience and leisure activities (Table 3).
Regarding the age, nurses aged 36 years or older presented higher means of compassion satisfaction and lower burnout. Younger nurses, women, and with 11 years or less of job experience showed higher score of secondary traumatic stress. The nurses who did not engage in leisure activities presented higher score of burnout and secondary traumatic stress.

Discussion
The mean score found through the raw scores of the subscales compassion satisfaction, burnout, and secondary traumatic stress are similar to those of other investigations (22)(23) . The same was found for the score of compassion satisfaction, burnout, and secondary traumatic stress regarding cut-off points (4,9,21) . In general, the results of this study demonstrate, as did the aforementioned studies, the predisposition of nurses to develop high levels of compassion fatigue. Several studies have shown the emotional costs of caring for people in distress, emphasizing the association between compassion fatigue and job stress, especially when stress is chronic and becomes burnout (18,(24)(25)(26) , as well as when situations are emotionally draining and lead to primary post-traumatic stress (10,(14)(15)20,27) . In fact, the possibility of nurses being affected by their experiences, associated with the altruistic character and the empathic concern that characterizes the professional relationship established with the patients, represent risk factors for the development of compassion fatigue and, consequently, are a threat to the mental health and well-being of these professionals (6)(7) .
Regarding the variation of compassion fatigue according to socio-demographic and job characteristics, these data corroborate studies suggesting that women present higher score of secondary traumatic stress than men. This might be related to the empathic ability of women to connect with their patients and feel their fears and traumas (9) . However, the same does not occur with age, that in other studies did not reveal a significant difference (9,(21)(22) , whereas in this study nurses aged 36 years and older presented higher score of compassion satisfaction, but lower score of secondary traumatic stress. Moreover, younger professionals presented lower score of compassion satisfaction and higher score of secondary traumatic stress, results similar to those of other researches (28) . Maybe this is due to a strong ability to adapt to situations, as well as the healthy worker effect, that is, nurses who are effectively suffering from psychological distress do not volunteer to participate in studies or may have abandoned their profession.
It was also verified that older nurses, especially women, present higher levels of compassion satisfaction, which corroborates the results of other studies (22) and suggests that women have a higher prevalence of compassion satisfaction and greater ability to take care of those who suffer. Nurses with job experience less than 11 years presented higher score of secondary traumatic stress, which is probably because they are less experienced and identify themselves with patients more easily. This leads to the belief that compassion fatigue decreases with years of job experience (7,29) , and that it may be related to an adaptive ability that is not yet so noticeable in less experienced nurses. Nurses who do not have leisure activities are more exposed to burnout a phenomenon that has been increasingly considered as a threat to the nurses' mental health (5,7) . Thus, it is possible to alert nurses and hospital managers about the importance of monitoring the mental health of health professionals, and try to ensure that their emotional and psychological state is not much affected by the care they provide to patients, so that they can continue to provide an optimal level of care.

Conclusion
The study revealed the presence of medium and high levels of compassion satisfaction, burnout and secondary traumatic stress in the sample studied.
In addition, the results show that compassion fatigue is related to personal factors such as age, gender, professional experience and leisure activities.
We believe that the research and knowledge of