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Authors: Marylou Andrea G. Candano and Mary Rose Ann M. Mancuyas (Philippine
Heart Center)

One of the core values of Philippine Heart Center is compassion. It entails healing and nurturing
response to the suffering of others. More often than not, nurses are not aware of the consequence
of negative things they absorb when interacting with patients and their family that eventually leads to
compassion fatigue. Extreme stressors include burnout and secondary traumatic stress that affect
efficient patient care.

To determine the level and factors associated with compassion fatigue such as burnout and
secondary stress among nurses at the Philippine Heart Center.

The study utilized a cross-sectional analytic design. Level of compassion was correlated with the
nurses’ age, gender, length of direct patient care, unit assignment, stress level, job fulfillment and
compassion satisfaction. Survey was conducted in all nursing units of the Philippine Heart
Center. Sample population (n=262) was determined through total enumeration. Workplace stress
level of staffs was measured through self-administered tool with 10-item questionnaire that was
pretested with a Cronbach’s alpha result of 0.97. Professional Quality of Life Scale Version 5
(PROQOL5) was utilized to determine the levels of compassion fatigue, compassion satisfaction,
burnout and secondary traumatic stress.

Findings revealed that higher level of work stress results to higher chance of secondary traumatic
stress among nurses at the Philippine Heart Center. While male nurses appeared more vulnerable
than female nurses, higher autonomy, professional development, empowerment, work environment
and fundamentals of quality nursing care all relate to burnout.
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More than just tired

Nurses, employers should work together to reduce fatigue, its effects

Years ago while driving home after working a 12-hour night shift in a busy emergency department, R.
John Repique was pulled over by a Baltimore police officer; he was told he had been swerving.
“Getting stopped that morning saved my life and possibly someone else’s,” said Repique, who realized
that feeling tired had become his norm. “That happened in the early 1990s, while I was rotating on
nights as a staff nurse. Ever since then I’ve been very passionate about the issue of fatigue and
drowsy driving because it can be fatal.”
Now chief executive officer of Friends Hospital in Philadelphia, Repique, MS, RN, NEA-BC, is one of 15
nurses who served on the steering committee of the American Nurses Association (ANA) Professional
Issues Panel on Nurse Fatigue, which developed a new position statement on this urgent issue.

John Repique

He emphasized that his former routine was not unlike that of his peers back then or now. Many nurses
work long shifts, sometimes at night, attend school to further their education, and juggle a whole host
of family and other responsibilities, according to Repique, an ANA member.

Further, insufficient sleep is so widespread in America that the Centers for Disease Control and
Prevention characterized it as a public health epidemic.
“Our society does not value adequate sleep, but rather, working long hours,” said Ann Rogers, PhD,
RN, FAAN, a steering committee co-chair, Georgia Nurses Association member and author of the 2004
groundbreaking study on nurses’ work hours and patient safety. “And nurses are a reflection of our

Ann Rogers

But fatigue among nurses is particularly vexing.

“It’s a big responsibility to take on the health and welfare of other people,” said critical care staff
nurse and stat (rapid response) team member Stephene Swift, BSN, RN, a Washington State Nurses
Association member. “I always want to be at the top of my game with my critical-thinking skills and
nursing judgment, because I am dealing with life or death situations. When you’re fatigued, you can’t
be 100 percent.”
Although Swift and other nurses successfully advocated for better staffing at her facility, she said
nurses as a whole are working more with less – a practice that contributes to fatigue.

Revising policy, ramping up efforts around rest

Over the years, ANA has worked with nurses across the nation to address fatigue by developing
evidence-based policies, advocating for practices to ensure a healthier work environment and
workforce, and providing educational and other resources for nurses that address this
multidimensional issue. ANA also has been committed to the overall health of nurses by promoting the
importance of self-care.
One of ANA’s most recent efforts is the updated position statement, “Addressing Nurse Fatigue to
Promote Safety and Health: Joint Responsibility of Registered Nurses and Employers to Reduce Risks,”
which also was developed with input from a 350-plus Advisory Committee and from a range of expert
and interested stakeholders. Another new offering is a four-part educational series, which covers the
impact of fatigue on a person’s mind and body, evidenced-based strategies to prevent and combat it,
and ways to evaluate one’s own role and the employer’s role in addressing nurse fatigue. The
educational modules reinforce the critical information detailed in the position statement.
Steering committee members say the ANA statement emphasizes the importance of nurses and
employers sharing the responsibility of preventing nurse fatigue.

Barbara Hobbs
“Taking steps and measures to reduce fatigue should not be an ‘us against them’ proposition,” said
Barbara Hobbs, PhD, RN, NEA-BC, a steering committee and South Dakota Nurses Association
member, as well as assistant dean and associate professor at South Dakota State University. “We’re
here for one thing – the patients. We need to work together to build an environment that keeps
patients safe and nurses healthy.” Continuing, Hobbs said, “When people are up for many hours, they
lose the ability to determine their level of alertness.”
That holds true for nurses who often push through longer shifts on adrenaline, she said. In addition to
the increased risk of making errors because of decreased alertness or the potential harm caused by
drowsy driving, repeatedly working long hours without adequate rest can affect nurses’ long-term
health – diabetes, musculoskeletal problems and obesity, for example.
Beyond detailing the risks, the new position statement also recommends strategies that nurses and
employers can implement. One key measure involves scheduling practices, which is generally
enmeshed in staffing.
The position statement calls on nurses to work no more than 12 hours a day and no more than 40
hours in seven days, and urges employers to support these limits. Further, ANA recommends
establishing at least 10 consecutive hours a day of protected time off so nurses can get seven to nine
hours of sleep, among other rest break strategies.
Research has shown that working more than 12 hours a day or more than 40 hours a week poses a
greater risk to nurses, patients and to society, if for example, a fatigued nurse gets into an accident
on the way home, said Rogers, director of the graduate program at Emory University’s Nell Hodgson
Woodruff School of Nursing and board certified in sleep medicine.
“Managers should also make sure nurses have time for rest breaks, so they can stay alert through
their entire shift,” Rogers said. Night nurses, in particular, should be allowed and encouraged to nap
or rest in the middle of their shift, so they are not fighting their circadian rhythms.
Among its many recommendations for nurses and employers, the ANA statement calls for nurses to
make sure they have adequate rest before they start a shift and to consider the length of the
commute before applying for a job. Others speak to enacting formal policy that allows nurses to reject
an assignment if they are fatigued and to prevent the use of mandatory overtime as a staffing
Meeting the challenge in Illinois
When planners at Rush University Medical Center in Chicago were creating a new state-of-the-art
hospital, they wanted to ensure its design supported their desire to provide the highest quality of care.
“Being a nurse is a tough job, so we want to do what we can to prevent fatigue and stress,” said Patty
Nedved, MSN, RN, CENP, associate vice president, professional nursing practice at Rush. To that end,
Rush offers nurses the ability to self-schedule, training on mindfulness and lectures on work-life
balance, among other activities.
And then there is the creation of respite rooms. Rush first transformed a vacant room into a respite
room in 2009 at the suggestion of nurses and based on research that showed the benefits of naps,
Nedved said.
“Then when we designed the new building (which opened in January 2012), we made sure each unit
had access to a respite room so staff could take a nap or just rest during their break or before driving
home,” Nedved said. Nurses and other staff do take advantage of the rooms, which have fully-
reclining chairs and low-level lighting.
In terms of scheduling, Rush offers varied shifts based on the unit, including four, eight, 10- and 12-
hour shifts, she added.
In Washington State
To address staffing shortages and fatigue at her hospital, Swift, another staff nurse and a nursing
supervisor made a formal presentation to their hospital board. They presented “assignment despite
objection” forms that tracked the number of times nurses were working in conditions they felt were
unsafe. They also talked about the reasons behind the rising number of nurse vacancies.
“Globally, many nurses were leaving because they were stressed out, fatigued and felt powerless that
anything would change,” Swift said. “As nurses, we are more apt to speak out for our patients, but not
for ourselves.”
But that reluctance to be self-advocates may be changing, because fatigue is such a big issue for
many nurses, according to Swift. As a result of the WSNA nurses’ advocacy, the hospital filled a
number of vacancies and added some traveling nurses.
“We had positive outcomes because we spoke out,” said Swift, “and I hope it continues.”
In South Dakota
Hobbs routinely presents on “strategies for surviving shiftwork” through her university-affiliated
hospital nurse residency program; it’s an early intervention in the battle against fatigue.
Hobbs specifically talks with new graduate RNs about smart scheduling practices; recognizing fatigue
in oneself and in peers; the undesired effects of fatigue on nurses and patients; and strategies to
improve sleep.
For those already ensconced in fatigue-inducing practices, Hobbs said that some of the
recommendations included in the ANA statement would require a culture change and a behavioral
Added Repique, “How we address fatigue should not be politicized. We have decades of research
showing that working fatigued has many negative effects. It should be all about health and safety.”
— Susan Trossman is the senior reporter for The American Nurse.
ANA resources
• Full position statement on fatigue
• New ANA CE Course: Your Mind and Body on Fatigue
• Webinar: Navigating Shiftwork: 5 Tips for Managing Fatigue
• Interview of ANA President Pam Cipriano and renowned nurse researcher Linda Aiken.