Providing compassionate care to those who are sick and suffering is considered by many nurses not only as a privilege, but also as an incredibly rewarding experience. Unfortunately, this emotionally, physically and intellectually demanding work can overwhelm a nurses’ psychological resilience to tolerate a patients’ distress (Gilbert, 2009), making them more vulnerable to Compassion Fatigue (CF).
 
The term CF was first used by Joinson (1992) who observed that nurses who are empathetic, caring individuals, may, due to repeated exposure to patient trauma, absorb the traumatic stress of those they are caring for. Secondary Traumatic Stress (STS) is often used interchangeably with the term CF (Sabin, 2013).
 
The symptoms of CF can take the same form of those associated with Post-traumatic Stress Disorder (PTSD) and include ‘intrusion’, ‘avoidance’ and ‘hyperarousal’ (Bride, et al, 2007), but the symptoms develop through exposure to a person suffering the effects of trauma (Figley, 1995; Baird and Kracen, 2006; Dominguez-Gomez and Rutledge, 2009), rather than to the traumatic event itself (Sabo, 2006).
 
The effect of CF is multifaceted, with symptoms including anxiety, intrusive thoughts, irritability, avoidance, numbness, persistent arousal, sleep disturbances, depression, weight gain, increased blood pressure, fatigue and not least, a loss of compassion (Joinson, 1992; Figley, 1995; Aycock and Boyle, 2009; Dominguez-Gomez and Rutledge, 2009; Quinal et al, 2009; Hooper et al, 2010; Boyle, 2011).

CF not only takes its toll on nurses on a personal level, but also on patients and the workplace itself, through more sick days, decreased staff retention, reduction in productivity (Pfifferling and Gilley, 2000), changes in job performance, poor professional judgment, an increase in mistakes and ultimately, dissatisfied patients (Schwam, 1998; Bride et al, 2007; Burtson and Stichler, 2010; Potter et al, 2010).
 
As ‘sustained responders’, nurses are particularly vulnerable to CF (Bush, 2009), which, if not addressed in its earliest stages, can permanently change the caregiver’s ability to provide compassionate care (Boyle, 2011). In order to self-manage the emotional and physical symptoms of CF, nurses may adopt maladaptive coping strategies, such as withdrawal, emotional numbing and avoidance. These psychological changes can have a direct, negative impact on the safety and quality of patient care, a situation coined the ‘cost of caring’ (Showalter, 2010).
 
A number of factors have been identified as influencing a nurses’ distress and vulnerability to CF. One such factor is the conflict between a nurses’ desire to provide high quality, compassionate patient care and the frustrating reality of being unable to meet these ideals, a dilemma that can lead to feelings of inadequacy (Smith et al, 1999; Upton, 2018). Studies indicate that age and years of nursing experience have a significant impact on a nurse’s CF level, with higher levels being found in younger nurses (Hunsaker et al, 2014; Kelly et al, 2015; Sacco et al, 2015; Von Rueden et al, 2010; Yoder, 2010; Upton, 2018) due to their inexperience (Delaney, 2003). Higher levels of CF have also been found in those who are in their 40s and older (Upton, 2018), since at this stage of life a nurse may have to meet new challenges in their lives, such as increased pressures from changes in family dynamics (Leggett, 2007), health problems and reduced stamina associated with the ageing process (Wray et al, 2006; Bennett et al, 2007; Storey et al, 2009), and managers who fail to value their experience (Wray et al, 2006; Storey et al, 2009).

Other factors that can lead to a nurse developing CF include work that is protocol and target driven (Bevan and Hood, 2006; Crawford et al, 2010; Upton, 2018), feelings of being overwhelmed and undervalued by the unrealistic expectations of patients, nurse managers and the employing organisation (Upton, 2018), as well as negative media coverage, such as ‘The Francis Report’ (2013), that has contributed to an atmosphere of individual blame, rather than one where wider concerns are explored (Marrin, 2009).
 
Today’s NHS nursing workforce is more varied in age than ever before, being made up of four different generations, each with different expectations, values, motivations and unique needs (Guthrie, 2009). Strategies need to be developed that take into account the age profile of the nurses employed by the organisation in order to protect them from the challenges and stresses of delivering patient care and the consequential risk of developing CF (Upton, 2018). It is crucial that the NHS and its leaders acknowledge that patient care is provided in the context of organisations, not in isolation. If compassionate care and relationships are to flourish, the design of the care environment and, the processes and culture of patient care, need to recognise the existence of CF and minimise its development by encouraging the well-being of their nursing staff and enhancing their ability to be resilient to CF (Upton, 2018). 

Within compassionate organisations nurses can be given a better opportunity to provide the authentic compassionate patient care that is both expected of their profession and which they seek to deliver (Upton, 2018).