Nurses are leaving the profession at an alarming rate [1]. Like soldiers on the battlefield, many nurses post pandemic are left alive but injured, with a catalogue of emotional experiences to wrestle with. Using Stamm’s [2] breakdown, Compassion fatigue (CF) can be understood as the combination burnout and secondary trauma. While often confused as simply burnout, CF is a distinctly different phenomenon that derives from the nurse-patient relationship [3]. Burnout is thought to stem from the employer-employee relationship and can occur in any setting or profession whereas CF is unique to caregiving professions such as nursing [4]. Daily exposure to the trauma of others differentiates CF from burnout and has serious implications for the nursing profession [5]. Conceptual confusion has served to hold back the understanding, awareness, and action required to combat CF. Terms such as secondary trauma, vicarious traumatization, empathetic distress, moral distress, compassion, caring, burnout, while alike in many ways, are different and confound the ability to understand the phenomena described as CF.

The impacts of CF are well documented in individuals, professions, and organizations. Those suffering with CF are known to have increased rates of turnover, decreased retention, as well as provide a lower quality of patient care [6]. Nurses who work in trauma rich areas have been identified as high-risk for CF, as they walk through daily suffering patients ultimately becoming impacted themselves as a result. The daily exposure to the suffering of others impacts caregivers to their core [4]. Known to impact a nurse physically, spiritually, and psychologically there is nothing that CF does not touch. Signs and symptoms of CF often overlap with other conditions and include substance abuse, loss of purpose, heavy heart, avoidance, difficulty sleeping, difficulty concentrating, loss of motivation, and disengagement [7].  Nurses may not be able to put their finger on what is wrong, but they know that something has changed, and they no longer have that zest with which they first entered the profession.

Protective factors against CF are characterized as those that increase compassion satisfaction (CS). CS describes the positive moments, the affirming moments where a nurse is reminded that they have made a difference in a meaningful way in a patient’s journey [2]. It is likely that during the pandemic, nurses were hit hardest here as opportunities to meet patient families, share food, share gifts, and have times of connection were taken away. The ability for a patient to recognize their care team with baking or a treat, while seemingly trivial, represents an important exchange and validation for both patients and nurses. Out of necessity hospitals became sterile and, in many ways, so did the care nurses were able to provide. With opportunities for CS at a minimum combined with the stress, heavy workloads, and enhanced trauma of the pandemic, nurses are more vulnerable than ever to the effects of CF.

Understanding the immense threat that CF is to the nursing profession, begs the question of what can be done to prevent CF from occurring and help those for whom it is too late. A recent literature review by Collier et al. [8] set out to answer that question in the oncology setting. An in-depth search of the CINAHL, PubMed, Google Scholar, and Web of Science databases revealed 18 full text peer-reviewed articles published in the past ten years, that were examined. The results of this integrative review revealed some concerning findings. With just one Randomized Control Trial [9] the results were alarming as what was found is that despite undergoing an intervention aimed to decrease CF, nurses reported higher levels of CF post intervention. Explanations for this finding seemed to indicate that nurses are unaware of CF and through the intervention learned about the phenomena and thus self-identified their own struggle with it. This finding was further supported by Esplen et al. [10] who reported that nurses despite an average of over 15 years of nursing experience, were unaware of what CF was and their risk factors for it. A clear lack of understanding and acknowledgement for CF adds to the threat of this trojan horse among the nursing profession. It is difficult, if not impossible, to guard against threats that remain veiled and hidden. Until CF is called out for what it is, accepted as a risk factor, part of orientations to high risk areas, acknowledged by universities, it will remain dangerous. Nurses care everyday for their patients yet often they lack the skills and knowledge to care for themselves.

Strategies to prevent and treat CF identified by Collier et al. [8] were mindfulness based interventions, self-care interventions, and resiliency based interventions. Overall results from each of these intervention types were mixed, demonstrating promise while also demonstrating the difficulty of taking action against such a complex phenomenon. Key questions were raised regarding the timing of self-care and whether self-care employed after experiencing CF was perhaps better labelled as after care, and possibly less effective. The basic building blocks of health, diet, sleep, exercise, education, expressive arts are ideal for the prevention and maintenance of health, but possibly less effective when used as treatment. Mindfulness and resiliency based interventions showed promising results. The THRIVE © resiliency based intervention was able to demonstrate decreased turnover in nurses who participated in the program versus the national average, a finding with importance for nursing organizations [11].

The first step in addressing CF must be acknowledgment. Nurses must be aware of the threats that they are up against, and this responsibility lies with universities, health organizations, the nursing profession, and individual nurses. CF must be viewed like any other hazard in healthcare and structure must be created in organizations for how to safely deal with it. We would never throw a pack of gloves in a nursing unit and walk away assuming that the task was complete, and the unit was now safe. Proper use of personal protective equipment requires training, awareness, understanding, and a structure and culture that embeds safety as a top priority, CF must not be an exception. Staff turnover places a huge financial burden on organizations, CF is known to cause turnover, therefore in addressing CF not only will budgets be healthier, but more importantly so will nurses.