Introduction

The Bureau of Labor Statistics Employment Projections (2020) predict an additional 203,700 new registered nurses will be needed each year through 2026 [1]. Replenishing and sustaining the number of nurses needed to meet the demands of the United States healthcare system is an increasing struggle for nursing schools across the country. The national nurse educator shortage of 7.9% [2] has resulted in nursing schools being filled to capacity, requiring the remaining educators to continually extend themselves beyond normal working hours [3]. Although nurse educators are deeply committed to the students they mentor and serve [4], the increasing demands and responsibilities of the role may lead to symptoms of compassion fatigue.

The multifaceted role of classroom teacher, clinical instructor, mentor, role model, and adviser, creates a bond, and a culture of caring between faculty and students [5]. The process of offering effective advice and counsel to the diverse pool of students who are now entering into higher education can be challenging. Barr determined that 16% of students in higher education today suffer from anxiety, depression, or other behavioral problems [6]. Students often seek support and comfort from faculty as they work through the cumulative stresses of balancing work, studies, friends, and family life [6]. Offering support and counsel to struggling students is important for their academic development and emotional outcomes [7], but may be detrimental to the well-being of faculty.

Woo, et al. warn that faculty mentoring is correlated with high levels of burnout [8]. Nurse educators are a vital resource in identifying and addressing students in crisis, but may struggle with resilience from the emotional impact of counseling many difficult situations with a large number of students [7]. When the emotional and physical exhaustion from traumatic encounters prevents the health professional from having the energy to feel or care for others, the educator may be suffering from compassion fatigue [9].

Compassion fatigue is a well-documented issue among registered nurses working in highly stressful environments in healthcare settings [10-12]. Compassion fatigue can cause symptoms of physical and emotional exhaustion, feelings of being overwhelmed, loss of meaningfulness in work, and disconnection or isolation from work-related events [13]. Other frequently reported symptoms of compassion fatigue include: headaches, difficulty sleeping, mood swings, irritability, poor concentration, social withdrawal, and loss of the ability to feel empathy for those in need [4,13]. Compassion fatigue is evident in clinical nurses [11] and recognized in educators [14], but symptoms may go unnoticed unless one is aware of compassion fatigue and what the symptoms include. Investigating compassion fatigue in nurse educators on the intent-to-stay in academia may provide additional answers to the mounting nurse educator shortage.

Research Question

To what extent does compassion fatigue predict nurse educator intent-to-stay in academia?

Literature Review

Job satisfaction in the academic environment tends to be contradicting. Typically viewed as a highly stressful and demanding occupation, college professors ironically report feeling satisfied with their profession [12,15,16]. Nurse educators with strong personal attributes and high levels of resilience have a higher likelihood of experiencing compassion satisfaction when working in the role. Compassion satisfaction was described as the feeling of motivation, sense of purpose [17], personal fulfilment [6], enjoyment [18], gratification [19], and the pleasure derived from good and even difficult encounters at work. Resilient individuals experiencing compassion satisfaction handled stressful situations with ease [20], provided positive responses, and used healthier coping mechanisms to enhance meaningful relationships with others [17]. Pursuing higher levels of compassion satisfaction resulted in better mental and physical health outcomes for nurse educators [17]. When nurse educators experienced higher levels of compassion satisfaction, a natural response was to foster student success by providing a positive and supportive environment for students [14]. However, there were times when even professors with high compassion satisfaction burned out, and the emotional investment in students became too arduous. Quickly this compassion satisfaction can turn to fatigue; individuals experiencing compassion fatigue lose the ability to feel compassion for others, lack motivation and hope, and deplete the spirit and optimism for their work [21].

Educators experiencing symptoms of compassion fatigue can exacerbate feelings of job dissatisfaction. When assessing the factors that contributed to job dissatisfaction and burnout within the nurse educator role, four themes emerged: high workload [22], an unsupportive work environment [16,23], low compensation [24], and poor work-life balance [25,26]. The four factors identified are significant predictors of nurse educator intent-to-leave [27]; confirming that multiple, instead of one single factor contribute to the nurse educator shortage.

The possibility that compassion fatigue may be another factor contributing to the nurse educator shortage starts with the challenge of effectively managing the diverse student population entering higher education. Millennials, meaning those born between 1982 and 2002, changed the landscape of higher education and posed new challenges for nurse educators. The parents who raised millennial children were extremely attentive, many times giving unwarranted praise and creating a false sense of confidence [28,29]. Millennial students tend to be highly optimistic, but they lack the independent drive and motivation for academic work and tend to feel overwhelmed with the inability to balance school and social activities [30]. In addition, millennials have a sense of academic entitlement [31], viewing higher education as a right versus a privilege. This entitlement results in students putting in the least amount of effort to succeed, and often times put personal values ahead of educational goals [29]. Millennials’ expectations of the college environment include a high-quality education, but also assume faculty will take over the nurturing and caring role previously provided by their parents [32]. Although nurse educators are caring and nurturing by nature, they may feel unqualified to manage the complexity of the diverse students entering higher education.

Mental health problems in college students are on the rise as well, and create a complex environment for nurse educators to teach, mentor, and advise students [33]. Bruffaerts, et al. affirmed that one in three college students suffered from a mental health problem [33]. Since the average age for developing psychological issues such as: anxiety, clinical depression, substance abuse, and suicidal thoughts, become evident between 18 and 24 years old, the triggered responses from the intense academic and social demands of college can make these psychological issues more pronounced [34-36]. In a recent survey conducted with 79,266 college students, participants reported the following emotions in the last 12 months: feeling overwhelmed and exhausted (50%), sad (25%), lonely (24%), overwhelming anxiety (22%), hopeless (16%), and feeling too depressed to function (10%) [37]. Han, et al. pointed out the suicide rate among young adults rose from 6.1% to 8.3% from the year 2009 to 2015 [38]. The heavy emotions experienced by college students require the attention of trained professionals, but the number of students requiring crisis management has dramatically drained available resources [35]. The drained resources have resulted in unqualified faculty at the frontline to manage, identify, address, and evaluate the extent of student mental health problems [39]. Karr-Lilienthal, et al. surveyed 42 faculty members with student advising responsibilities and the common theme among the educators was that they felt ill-equipped and thrust into the role without proper training [40].

When educators are overworked, especially with issues they are unprepared and untrained for, compassion fatigue can be the result. This fatigue then results in losing the ability to express empathy for others afflicted by emotional pain and consists of two constructs: burnout and secondary traumatic stress [41]. Stamm described burnout as an overwhelming negative feeling preventing practitioners from effectively performing job duties [42]. Other researchers described burnout as losing interest in work [25], the physical and emotional exhaustion leading to poor work performance [43], and the combination of emotional exhaustion, having a cynical attitude, and viewing one’s work accomplishments negatively [44,45].

Individuals suffering from burnout have higher incidences of job dissatisfaction and work disengagement. Herman et al. measured 93% of teachers experienced high levels of occupational stress. Of the 121 teachers surveyed, 33% reported a lower ability to cope with higher levels of burnout [46]. The higher levels of stress experienced by teachers was corroborated by Barkhuizen, et al. who conducted a study investigating the effects of increased job demands on 595 academic staff members at South African universities. The researchers found that higher job demands significantly predicted higher levels of burnout, and individuals suffering from burnout reported higher levels of disengagement from work-related activities [47]. Similarly, Padilla and Thompson surveyed 1,439 university faculty members in the United States, and over 27% of participants had experienced symptoms of burnout associated with factors affecting work-life balance [48]. The strong connection between poor work-life balance and burnout threatens the sense of meaning and continued commitment to work, and creates a higher potential for individuals to leave their place of employment [20].

The second construct, secondary traumatic stress, happens when individuals suffer the negative consequences of helping others through traumatic or difficult events [42]. The symptoms of secondary traumatic stress include feelings of fear, helplessness, or shock [49]. Managing the stress and dealing with the strong emotions after any traumatic experience can cause recurrent memories of the event, difficulty sleeping or concentrating, and increased absenteeism from work [50]. Nurse educators evoke a nurturing and caring environment, and create a safe avenue for students to share personal and sometimes traumatic experiences. Vulnerable students often reveal distressing traumatic experiences to faculty mentors and looked for guidance of how to cope and manage stressful situations [51]. The continued exposure to student hardships or behaviors can be devastating for faculty, leaving them feeling helpless, especially with the limited authority to protect the student [52]. Consequently, the exposure to student hardships and behaviors combined with the inability to cope increases the risk for developing secondary traumatic stress and could result in faculty leaving their position or academia all together [52].

Methodology

Subjects and design

A quantitative cross-sectional correlational design with regression analyses was conducted to measure and predict nurse educators’ level of compassion fatigue on the intent-to-stay in academia. The population sample included nurse educators currently working in any level of an accredited nursing program, in an institution of higher education in the United States that had contact with students within the last 30 days. Participants were excluded if they were not employed as a nurse educator, if residence was outside of the United States, and if there had not been contact with students in over 30 days. The required sample for a medium effect size was 89 when using a G*Power of 0.95, and a significance level of 0.05. Anticipating a 20% response rate on the surveys, the target population for this study was 450 participants. After obtaining Institutional Review Board approval from all facilities, homogenous purposive sampling was used to recruit 146 participants via email from 20 randomly selected colleges/universities. The email indicated the purpose of the study was ‘…to research nurse educator compassion fatigue and intent to stay’ and that it would take approximately 15 minutes to complete. Participants provided written consent and were given an anonymous link to the Qualtrics survey without any incentive upon completion. The survey remained open for five weeks from December 2018 to January 2019.

Instrumentation

This study included two combined instruments as well as specific demographic questions chosen for their significance in the literature. The instruments included the Professional Quality of Life Scale version five (ProQOL5) and the Price Scale on Intent to Stay (PSIS).

The ProQOL5 was an instrument containing 30 items with three subscales, compassion satisfaction, burnout, and secondary traumatic stress and included a five-point Likert scale requiring participants to select a degree of how often each of the experiences happened in the last 30 days. The participants had a choice of answering never, rarely, sometimes, often, or very often (1=never; 5=very often). Each subscale consisted of ten questions. To determine nurse educators at risk for compassion fatigue, participants had to score high in both burnout and secondary traumatic stress. The ProQOL5 was found to be highly reliable (α=0.72).

The PSIS instrument included four items on a five-point Likert scale and required participants to indicate the degree of agreement or disagreement with each statement regarding their current place of employment. The participants had a choice of answering each item by indicating, strongly disagree, disagree, neutral, agree, and strongly agree (1=strongly disagree; 5=strongly agree). After organizing the scores into quartiles, the lower scores indicated a lower level of intent-to-stay and the scores greater than or equal to 14 indicated a high level of intent-to-stay. The PSIS was found to be highly reliable (α=0.85).

Data Collection and Analysis

Following the closure of the study, the data were downloaded from the Qualtrics program into an Excel spreadsheet for column organization, labeling, and data cleansing. The data were then uploaded into the Statistical Package for Social Sciences (SPSS) version 25 for statistical analysis. The five assumptions of normality, linearity, absence of auto-correlation, absence of multicollinearity, and homoscedasticity for violations were assessed. A parametric correlation and simple linear regression analysis method was used to assess the predictor variable (compassion fatigue) on the criterion variable (intent-to-stay). Statistical significance was accepted at p < 0.05.

Results

A total of 146 usable surveys were returned (response rate=15.6%) and met the required sample size of 89 participants when using a medium effect size with G*Power of 0.95, and a significance level of 0.05. The sociodemographic variables are presented in (see Table 1).

After uploading the data in SPSS, the data from the ProQOL5 instrument required reverse scoring for items [1,4,15,17,29]. The sums for compassion satisfaction, burnout, and secondary traumatic stress were computed and then converted from z scores to t scores. The t scores, described as percentages, were then compared against the cut scores provided from the published ProQOL5 manual [42]. If the cut score was above 57, the interpretation indicated the nurse educator exhibited a high level of compassion satisfaction. The cut score indicating a low risk for burnout was 43, and the score indicating a high risk for burnout was 56. The cut score indicating a low risk for secondary traumatic stress was 42, and the score indicating a high risk for secondary traumatic stress was 56. Nurse educators exhibiting compassion fatigue included the combination of high-risk scores for burnout and secondary traumatic stress [42]. Frequency analyses revealed in Table 2 show that 23.3% of the participants experienced high levels of burnout, and 21.9% experienced high levels of secondary traumatic stress. Participants scoring high in both burnout and secondary traumatic stress (13.7%) were determined to be the highest risk of suffering from compassion fatigue and were analyzed with the intent-to-stay.

The Price Scale on Intent to Stay was used to measure the criterion variable. Before summing the totals, question one required reverse scoring. The sum of the scores ranged from 4-20. After organizing the scores into quartiles, the lower scores indicated a lower level of intent-to-stay and the scores greater than or equal to 14 indicated a high level of intent-to-stay. Frequency analyses revealed in Table 3 show the nurse educator responses of intent-to-stay in quartiles by nurse educator participants with high-risk for compassion fatigue.

A Pearson’s correlational analysis was run to determine the relationship between nurse educator compassion fatigue and intent-to-stay in academia. The results revealed a significant, positive, but weak relationship, r=0.190, n=146, p=0.021. After revealing a relationship between compassion fatigue and intent-to-stay, a simple linear regression analysis was conducted to determine the predictability of the intent-to-stay by the predictor variable, compassion fatigue. As shown in Table 4, results show that compassion fatigue significantly predicted intent-to-stay (β=0.19, p=0.021). The R² value indicated that compassion fatigue explained 3.6% of the predicted variance of the intent-to-stay. The regression equation predicting the nurse educator intent-to-stay was y=10.754 + 1.94x, where compassion fatigue comprised of scores above 56 in both subscales of secondary traumatic stress and burnout. The data in the B coefficient column showed that nurse educator intent-to-stay increased by 1.94 with every one-unit of change in compassion fatigue scores, meaning that as compassion fatigue scores increased, so did the nurse educator intent-to-stay in their current position.

Conclusion

One of the most important determinants of this research was the identification that compassion fatigue exists among nurse educators. In the ProQOL5 instrument, compassion fatigue consisted of the two constructs of burnout and secondary traumatic stress, where nurse educators reported high scores for both. Some characteristics associated with burnout included symptoms of fatigue, irritation, resentment, and depression [42]. The characteristics associated with secondary traumatic stress included symptoms that surfaced after exposure to work-related, stressful, and negative experiences invoking a fear that compromised the professional work-life of educators and diminished the overall quality of life [42]. Researchers found evidence of compassion fatigue in other helping professions [9,53,54], but this was the first research study identifying compassion fatigue specifically in nurse educators.

In this study, the significant finding was nurse educators suffering from compassion fatigue were more likely to stay in their current workplace. However, the finding contradicted the evidence in the existing literature that individuals who suffered from compassion fatigue were more likely to leave their current place of employment. Sung, et al. asserted that compassion fatigue accounted for 29.6% of the variance for turnover intent [55]. Similarly, Sheppard reported an increase in absenteeism and higher turnover rates in individuals with unresolved compassion fatigue but also pointed out that it can significantly affect their health and impair job performance [56].

Despite suffering from the effects of compassion fatigue, participants in this study reported high organizational commitment. What should be of great concern is the effect compassion fatigue can have on job performance for individuals who stay. The effects can have a profound effect on the physical and mental health of faculty. Anitha and Sritharan determined 80% of professors over the age of 40 complained of high levels of stress causing physiological symptoms of headaches, fatigue, high blood pressure, and skin problems [57]. The inability to tolerate high stress in the workplace triggered emotions of anger, irritability, mood swings, suicidal tendencies [58] and often caused individuals to self-medicate to escape the intense feelings of distress [56]. The inability to cope with personal stressors can be inadvertently displaced onto students potentially resulting in uncivil behavior.

Nurse educators suffering from symptoms of compassion fatigue may not have awareness of how the negative behaviors are impacting students. Masoumpoor, et al. conducted a qualitative study with 13 clinical nursing students that uncovered the effects that uncivil behaviors of clinical instructors had on student satisfaction [59]. Poor communication and disrespectful comments from faculty resulted in students’ feeling humiliated, disrespected, and unsupported. Students’ felt threatened and intimidated to disclose their emotions to the educators that were supposed to be their mentor and guide [59]. Educators who allowed and honored students’ release of positive and negative feelings produced a venue of disclosure, encouraged constructive channeling of emotions, and strengthened the trust in the educator/student relationship [60]. However, if educators lack self-awareness when suffering from the symptoms of compassion fatigue, judgement may be clouded and reactions may be aggravated potentially resulting in uncivil behaviors.

To be fully effective in understanding the sensitivity of others, a practitioner needs great awareness and sensitivity to their own personal feelings [61]. Gustin and Wagner pointed out when practitioners were not sensitive to their own personal needs and feelings, a sense of bitterness developed and made it difficult to feel compassion for others [56,62,63]. Itzhaki, et al. conducted a quantitative study of 283 practitioners to measure the relationship between compassion fatigue, burnout, and caring for self [63]. The study supported the notion that practitioners were able to lower their risk for compassion fatigue when they remained focused on self-care, even when working in environments of highrisk. O’Neal, et al. conducted a study implementing strategies to increase self-care with 48 educators. The educators showed significant improvement in levels of self-care after receiving two days of training on multiple self-care techniques including stress and anxiety reduction, anger management, and self-care [64]. Nurse educators who take measures to understand and decrease the symptoms of compassion fatigue can have a positive influence on the students they teach.

In education, when nurse educators created meaningful relationships with students and emphasized a positive learning environment, the teaching encounter became significant to both parties [61,62,65]. As previously described, Masoumpoor, et al. was a prime example of how the negative verbal and nonverbal communication of instructors damaged the students’ experience and self-esteem [59]. Communication between nurse educators and students must contain an equal balance of honest but constructive communication. Mikkonen, et al. recognized when nurse educators modeled empathic teaching to students, seeing the emphatic behaviors created a positive impact on students becoming an empathetic nurse [66]. Students reported the empathetic behaviors witnessed and experienced with the nurse educators helped demonstrate how to deliver the same kind of care to patients [66]. If nurse educators are teaching without compassion, it may directly affect how students treat and care for future patients.

Nurse educators suffering from symptoms of compassion fatigue may be experiencing a loss in the meaningfulness of work, losing empathy for students, distancing themselves from work related events, or having difficulty doing their job effectively [13]. Nursing leaders have the opportunity to acknowledge and understand the needs of their nurse educators, drawing specific attention to areas that require strengthening and support necessary to sustain a challenging work environment. Taking care of the physical and mental well-being of nurse educators can yield positive outcomes of increased student success, job satisfaction, and retention of faculty.

Limitations

Due to the cross-sectional nature of this study, participants were limited to those working during the specific semester of data collection. In addition, the homogenous sampling method and the limited data collection period occurred during major holidays and may not have included all faculty views, decreasing the generalizability of this study to the greater population.

Recommendations for Future Research

To add to this current study, a more extensive and qualitative analysis of nurse educators experiencing symptoms of compassion fatigue or high levels of burnout may provide an understanding about why nurse educators stay in their current position. Further exploration of compassion fatigue in nurse educators in a longitudinal study would give insight into whether nurse educators experience heightened levels of compassion fatigue at different times or throughout the duration of the academic year. Understanding times of heightened stress in faculty may provide nursing leadership the critical period to offer additional resources.

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