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Change your life through journaling--The benefits of journaling for registered nurses


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Objective : The objective of this study was to determine the effect journaling had on the degree of compassion satisfaction (CS), burnout (BO), and trauma/compassion fatigue (TCF) present in registered nurses (RNs). A secondary objective of this study was to gain knowledge about participants’ experiences with journaling. Methods : This study was a pre-test, post-test quasi-experimental design with a qualitative component. A total of 66 registered nurses were recruited to participate in a journaling class. Each RN completed the Professional Quality of Life Scale Survey Revision IV (ProQOL R-IV) three times. In addition to the surveys, participants were asked to answer two open-ended questions. Results : CS, BO, and TCF all improved after taking the course. The overall change from Pre-survey to Post II-survey was statistically significant for compassion satisfaction ( p = .008); burnout ( p = .0001); and, trauma compassion fatigue ( p = .0001). During constant-comparative analysis three themes were identified as: 1) journaling allowed me to unleash my inner most feelings, 2) journaling helped me to articulate and understand my feelings concretely, and 3) journaling helped me make more reasonable decisions. Conclusions : This study provides valuable information about journaling having a positive effect over time on the ability of registered nurses to handle stress, increase CS, and decrease BO and TCF symptoms. While this information adds to the limited literature, further research needs to be conducted with a larger sample.
Content may be subject to copyright. Journal of Nursing Education and Practice 2017, Vol. 7, No. 2
Change your life through journaling–The benefits of
journaling for registered nurses
Lynda J. Dimitroff1, Linda Sliwoski2, Sue O’Brien3, Lynn W. Nichols4
1Nursing Department, Nazareth College, Rochester, United States
2Greater Rochester Independent Practice Association, Rochester, United States
3Physical Therapy Department, Nazareth College, Rochester, United States
4Department of Nursing Research & Evidence-Based Practice, Rochester General Hospital, Rochester, United States
Received: May 16, 2016 Accepted: September 17, 2016 Online Published: October 8, 2016
DOI: 10.5430/jnep.v7n2p90 URL:
The objective of this study was to determine the effect journaling had on the degree of compassion satisfaction (CS),
burnout (BO), and trauma/compassion fatigue (TCF) present in registered nurses (RNs). A secondary objective of this study was
to gain knowledge about participants’ experiences with journaling.
This study was a pre-test, post-test quasi-experimental design with a qualitative component. A total of 66 registered
nurses were recruited to participate in a journaling class. Each RN completed the Professional Quality of Life Scale Survey
Revision IV (ProQOL R-IV) three times. In addition to the surveys, participants were asked to answer two open-ended questions.
CS, BO, and TCF all improved after taking the course. The overall change from Pre-survey to Post II-survey was
statistically significant for compassion satisfaction (p= .008); burnout (p= .0001); and, trauma compassion fatigue (p= .0001).
During constant-comparative analysis three themes were identified as: 1) journaling allowed me to unleash my inner most feelings,
2) journaling helped me to articulate and understand my feelings concretely, and 3) journaling helped me make more reasonable
This study provides valuable information about journaling having a positive effect over time on the ability of
registered nurses to handle stress, increase CS, and decrease BO and TCF symptoms. While this information adds to the limited
literature, further research needs to be conducted with a larger sample.
Key Words: Journaling, Registered nurses, Compassion satisfaction, Burnout, Trauma/compassion fatigue
Writing and wellness are natural allies. When approached in
a purposeful and intentional way, journal writing can be an
agent for healing and change. Writing thoughts and feelings
in a journal develops insight, compassion for self, and body
awareness. Writing organizes cognition, articulates intuition,
and regulates emotion.[1]
Emotional exhaustion and burnout (BO) are costly to reg-
istered nurses (RNs) physically, emotionally, socially, and
spiritually, and, financially costly to health care organizations
in terms of nursing turnover. The overall health of our RNs
has a direct impact on health care organizations. Emotional
exhaustion and BO of nurses are detrimental to patient care
outcomes. The nursing profession must explore opportu-
nities to strengthen the current workforce; and incorporate
Lynda J. Dimitroff; Email:; Address: Nursing Department, Nazareth College, Rochester, United
90 ISSN 1925-4040 E-ISSN 1925-4059 Journal of Nursing Education and Practice 2017, Vol. 7, No. 2
the development of self-care strategies and self-development
into the busy lives of nurses.
There is an abundance of literature supporting the benefits
of journaling. Journaling encourages self-awareness, allows
for the opportunity to release emotions, and may assist in
making sense of complex situations.
The current study
explored the effects of journaling on reported symptoms of
CS, BO, and, TCF in RNs. The very nature of working in
the nursing profession lends itself to CS, BO, and TCF. Most
nurses have experienced some form of related symptoms in
their careers.[15]
As more technical and complex treatments emerge, the RN
is required to compassionately care for and give emotional
support to treat the patient. Compassionate care and emo-
tional support of patients puts the RN in a very vulnerable
position. The empathy and compassion that are necessary for
supportive patient care are also the main characteristics that
make nurses susceptible to TCF and BO. If RNs continually
neglect their own basic human needs for self-care, eventu-
ally, they will give way to symptoms of BO and TCF.
“. . .
Compassion fatigue can be emotionally devastating, result-
ing in impaired performance which makes the goal of quality
care almost impossible to accomplish”.
Exploring the
benefits of a structured journaling program for RNs may be
one strategy to reduce BO and TCF and encourage self-care.
investigated how writing about emotionally
upsetting experiences can affect a person’s thoughts, feelings,
and physical health. Parr, Haberstroh, and Kottler
that not disclosing personal thoughts and feelings can be un-
healthy. Francis & Pennebaker
concluded that journaling
reduced blood pressure, moods, and absenteeism in subjects.
Pennebaker’s work
also indicated that journaling about
meaningful topics improved the physical and emotional well-
being of individuals. Pennebaker
reported that there were
no differences in the benefits of writing related to personality,
culture, or language.
1.1 Literature review
Despite the literature confirming the benefits of journaling,
it remains underused as a means of self-care in nursing. No
published research was found that examined the relationship
between journaling and extent of symptoms of CS, BO, or
TCF expressed by RNs.
1.1.1 Journaling
Journaling is one resource shown to improve health. Jour-
naling is the act of writing down thoughts, perceptions and
feelings. Journaling about complex situations is a practical
way for the author to have a relationship with her/his own
mind. The written word often provides clarity to a situation.
Journaling is a method that encourages reflection and emo-
tional discharge. The literature is saturated with the benefits
of journaling including self-awareness; release of pent-up
emotions, record keeping–tracking your life experiences;
relationship healing; exploring inner guidance-accessing sub-
conscious and unconscious minds; and, improved health.
Examples of improved health include: lowered blood pres-
sure, enhanced immune function, and decreased depressive
symptoms.[3, 8–11, 13, 18, 20]
Journaling is a record of personal thoughts, daily events, and
evolving insights. By giving the author a voice, journaling
allows the opportunity for the author to release emotions
and make sense out of complex life experiences. Journal-
ing is a vehicle for self-understanding, self-guidance, ex-
panded creativity, and spiritual development.
The journal
allows authors to freely express themselves without judg-
ment, criticism or analysis. A scream, anger, whimper, sad-
ness, wail, and rage are all acceptable behaviors to the jour-
[2, 8–11, 13, 18, 20]
Journal writing is a form of self-expression
that can add dimension to the author’s life.
Progoff has been credited with being the father of modern
day journaling.
He has been recognized as the leader in un-
derstanding the personal value of journal writing for growth
and learning since 1966. Progoff
developed the Inten-
sive Journal Process Workshop, which is an instrument for
self-guidance to help people derive meaning of their unique
The review of the literature identified that journaling is an
effective tool to develop critical thinking in diverse fields of
education. Nurse educators have used journal entries, such
as general observations, questions, speculative statements,
expressions of self-awareness, statements of synthesis, revi-
sions of previously held ideas, and the accumulation of new
information, to develop critical thinking in nurses. The use of
a journal for clinical experiences can have the same benefits
as those received from personal journal writing. The student
can find meaning in life and the journal allows the student
to release feelings about the clinical experience. Empathy
develops with reflective thinking.
1.1.2 Compassion fatigue and compassion satisfaction
“Compassion fatigue (CF) also called secondary trauma . . .
is about your work-related, secondary exposure to extremely
stressful events”.
In contrast, “compassion satisfaction
is the sum of all the positive feelings a person derives from
helping others”.
The empathy that nurses provide to their
patients is life giving personally and professionally.[16, 23–25]
“Compassion satisfaction has been identified as a construct
that measures these affirmative experiences”.[25]
Published by Sciedu Press 91 Journal of Nursing Education and Practice 2017, Vol. 7, No. 2
CF is a specific type of BO unique to the helping professions
and was first identified and described in the nursing literature
by Joinson in the 1990s. RNs are especially at risk for de-
veloping CF due to the emotional and physical demands of
the profession. If the symptoms of CF are not identified and
preventive actions are not taken, several consequences may
result from these prolonged feelings, including the inability
to care for patients in a mutually satisfactory manner.
such situations, RNs may become more task-oriented and
less relationship-oriented.[27]
In some cases, the RN experiencing these symptoms over
time may choose to leave the nursing profession completely.
While all health care providers are at risk for CF, nurse lead-
ers need to understand and recognize that RNs are particu-
larly vulnerable. The stressors in nursing are related to close
patient and family relationships, the perceived lack of control
over disease outcome, and the deep involvement with death
and dying issues. RNs need help to recognize and cope with
these stressors. Some of the helping strategies may include
education, retreats, emotional expression, storytelling, and
CF began under the umbrella of Post-Traumatic Stress Syn-
drome (PTSS).
Early work in traumatology and the need
for early intervention for victims who were exposed to hor-
rific experiences grew in the late 1980s when it became evi-
dent that those providing assistance to victims of trauma
were experiencing adverse effects themselves outside of
[30, 31]
The care provider experienced symptoms that
mimicked those of the victims who were actually trauma-
tized. This phenomenon was called Secondary Traumatic
Stress Syndrome (STS). STS occurs when one is exposed to
extreme events which are directly experienced by another,
and is overwhelmed by this secondary exposure to trauma.
The historical development of the term CF came from the link
between PTSS and STS.
[29, 30, 32, 33]
Compassion fatigue has
been thought to be a combination of STS and BO precipitated
by the delivery of care that brings health care professionals
into contact with suffering.
[31, 34]
The concept of CF cited
in the nursing literature by Joinson
described nurses who
were exhausted and worn down by daily interactions with
patients, hospital emergences, “increasingly sophisticated
medical technology”,
and hospital emergencies. The RN
was exposed to a person or patient who had been trauma-
tized rather than having direct exposure to the trauma. This
differentiates CF from PTSS.[31]
Symptoms of CF share multiple traits with those of BO; there
are however, differences.
Burnout is associated with feelings of hopeless-
ness and difficulties in dealing with work or do-
ing your job effectively. These negative feelings
usually have a gradual onset. They can reflect
the feeling that your efforts make no difference,
or they can be associated with a very high work-
load or a non-supportive work environment.[22]
Compassion fatigue results from the consequence of caring
for people who are suffering, rather than a direct response to
the work environment.[23–25,35–39]
Compassion fatigue develops as a result of the care provider’s
exposure to the patient’s experiences combined with empa-
thy for the patient. Burnout is a gradual wearing down of
the caregiver, by one’s feelings of being overwhelmed by
one’s work and feeling incapable of effecting positive change.
These feelings produce emotional withdrawal and diminished
empathy. When symptoms of CF are present, the caregiver
tries to continue to give patient care but feels as though s/he
has failed at the profession.
[29, 40, 41]
Nurses experiencing CF
are left emotionally and psychologically unavailable to give
more to their patients and families.
suggested that empathy and emotional energy are
the underlying drivers in the development of CF. Those care
providers who have an enormous capacity for feeling and
expressing empathy tend to be more at risk.
[31, 42]
The profes-
sion of nursing puts the needs of patients first before tending
to its own needs. Caregivers in general, lack the attention
to their own personal, social and spiritual needs.
[26, 32]
order of priorities, coupled with the demand for caring for
more patients in less time and with fewer resources, produces
decreased morale, decreased patient and nurse satisfaction,
increased health care costs, and behavioral changes in staff
Statement of study aims, research question, and/or hypothe-
The objective of this study was to determine the effect jour-
naling had on the degree of CS, BO, and TCF present in RNs.
A secondary objective of this study was to gain knowledge
about participants’ experiences with journaling.
The study design was a pre/post-test quasi experimental de-
sign with a qualitative component. Descriptive and infer-
ential statistics including Friedman’s two-way analysis of
variance (ANOVA) by ranks, and pairwise comparisons were
chosen to analyze the responses to the Professional Quality
of Life Scale Survey Revision IV (ProQOL R-IV) which
measured CS, BO, and TCF. Friedman’s two-way ANOVA
by ranks is a non-parametric test similar to the one-way
ANOVA with repeated measures.
The Friedman test was
92 ISSN 1925-4040 E-ISSN 1925-4059 Journal of Nursing Education and Practice 2017, Vol. 7, No. 2
used to test the differences between groups across multiple
time periods (Pre-survey, Post I-survey, and Post II-survey)
with the ordinal variables (CS, BO, and TCF).
A descriptive qualitative method through constant-
comparative analysis was utilized to understand more about
the effects of journaling through responses participants gave
to the open-ended questions of the Post II-survey. The
purpose of descriptive qualitative research is to describe
experiences as they are lived. In this instance, a qualitative,
descriptive approach allowed for a deeper understanding of
the nurses’ experience with journaling.
Taylor[45] explained that
. . . the search for the nature of a phenomenon
begins with the people, in their place and time,
and it leads to an explication of the aspects of
a phenomenon. The nature of a phenomenon
is a reflection of the nature of people as human
beings . . .who are living and making sense of
their experiences.
In qualitative research, data analysis is an on-going pro-
cess of interpretation, coding, and re-coding. Following the
verbatim transcription of the written responses to the two
open-ended questions, the transcripts were read, coded, and
re-read. Two registered nurses (the Primary Investigator [PI]
and the Research Mentor) analyzing the data allowed for au-
diting categories and themes, thus ensuring the dependability
and confirmability components of trustworthiness.
Prior to data collection, Nursing Research Committee and
Institutional Review Board approvals were obtained from the
institution where the study took place.
Though there were minimal risks to the participants, there
was the potential of bringing unresolved issues to the surface
which could have led to temporary feelings of sadness or
depression. If temporary feelings of sadness or depression
persisted, the participant was encouraged to talk with a ther-
apist. Participants who were in therapy were encouraged
to review this research program with their therapist prior
to beginning the program. Participants were free to with-
draw from this study at any time. Any identifying personal
information was kept confidential.
Participation in this study was voluntary. The study was
categorized as minimal risk and involved approximately 15
hours over a six-week period. In addition, participants were
asked to complete homework assignments.
The sample consisted of 66 RNs who were employed in the
Rochester, NY area. Data were collected in three phases
which included the administration of the ProQOL Revision
IV three times: the Pre-survey (prior to the intervention),
Post I-survey (immediately following the intervention), and
Post II-survey, and two open-ended questions (two months
after the intervention).
The ProQOL R-IV instrument measured the self-reported
frequency of various characteristics that RNs experienced
related to their work experiences over a 30-day period.
2.1 Sample recruitment
At the beginning of the study, a brochure explaining the
study, informational meeting dates, class dates and times,
and the Primary Investigator (PI) contact information was
posted on nursing units and discussed in meetings at the hos-
pital where the study took place. In addition, eligible RNs
were contacted through the hospital and local professional
organizations via email and word of mouth. Interested RNs
received a letter about the research project and were invited
to attend a 1.5-hour informational meeting.
2.2 Pre-survey phase
During the Pre-survey Phase, (the informational meeting),
the study was explained, there was an opportunity to ask
questions about the study, and the forms (informed consent,
demographics, contact information, and the Pre-survey) were
completed. In order to maintain confidentiality, each partici-
pant was assigned a code which was recorded on the contact
information form and the surveys.
2.3 Intervention phase
The intervention was a six-week journaling program con-
sisting of six 2.5 hour journaling classes. Each participant
was asked to attend all six classes and complete a 1-3 hour
assignment after each class. Participants determined how
much time they wanted to spend on assignments.
At the first journaling class, each participant received, The
write way to wellness, a workbook written by Kathleen
This workbook was used throughout the six-week
journaling program. At no time during the journaling pro-
gram were the participants asked to hand in their workbook
or journaling assignments. There were optional opportuni-
ties at each session for the participant to verbally share their
journaling experiences and feelings.
In the event that a participant missed a journaling class, the
PI gave the RN the material covered in class and they were
asked to complete the work independently. If more than
one class was missed, the participant was invited to attend
the subsequent journaling classes, however, they were not
eligible to complete the Post I-survey, Post II-survey or open-
ended questions, receive CNE credits, or receive the Journal
to the self
gift book at the completion of the journaling
Published by Sciedu Press 93 Journal of Nursing Education and Practice 2017, Vol. 7, No. 2
2.4 Post I-survey
Following the completion of the six-week journaling pro-
gram, the participant completed the Post I-survey which took
approximately 15 minutes. Each participant received a sealed
envelope with their name on the outside of the envelope. The
survey inside contained their assigned code. After complet-
ing the Post I-survey, the participant placed the survey in a
blank envelope, sealed the envelope, and gave the envelope
to the PI. This was to ensure confidentiality was protected.
2.5 Post II-survey
Two months after the completed journaling program, each
participant was sent the Post II-survey and the two open-
ended questions (qualitative data) in the mail and asked to
complete each form. These forms included their assigned
code number.
The participant was asked to return the completed surveys in
the stamped, addressed envelope within two weeks of receipt
of the surveys. The participant received the CNE certificate
and the workbook, Journal to the self
after returning the
completed final two forms.
2.6 Instrument
The Professional Quality of Life Scale R-IV Survey (Pro-
QOL R-IV) The ProQOL R-IV was used in this study to
measure CS, BO, and TCF. This instrument is the renamed
third version of the Compassion Fatigue Self Test (CFST),
a survey that has been widely used in assessing CF. The
revisions addressed difficulties with separating BO and sec-
ondary/vicarious trauma and also reduced the participant
burden by shortening the test from 66 to 30 items. Each
subscale contained ten items: seven items from the previous
version and three new items.
The Cronbach alpha reliabilities for the scales are as follows:
compassion satisfaction alpha = 0.87; burnout alpha = 0.72;
and CF alpha = 0.80.
The construct validity has been
well established in over 200 articles noted in the peer review
literature. Early return on test-retest data suggested good
reliability across time. Factor analysis techniques have been
applied in CFST revision to the ProQOL R-IV version.
Participants in this study were enrolled from a convenience
sample of RNs who were employed at an acute-care fa-
cility in Rochester, NY. There were 66 matching surveys
for the three time points (pre-intervention/Time 1, Post I-
survey/Time 2, and two months after the intervention Post
II-survey/Time 3) and responses to the two opened-ended
qualitative questions. The Statistical Package for Social Sci-
ences for Windows, Version 23.0
was utilized for data
analysis. Statistical significance was detected using an alpha
level of 0.05.
Descriptive statistics were used to describe the sample and
included an analysis of age, gender, race, education, years
in nursing, position, and expertise in journal writing and are
displayed in Table 1 characteristics of sample. Inconsistent
normality was found therefore, non-parametric tests were
used to test for difference across three time periods. Post hoc
testing was calculated to determine where significance was
between the three points in time.
CS, BO, and TCF all improved after taking the course. The
overall change from Pre-survey to Post II-survey was sta-
tistically significant for compassion satisfaction (p= .008);
burnout (p= .0001); and, trauma compassion fatigue (p=
Results were maintained (statistically significant) at the two
month period for BO (p= .0001) and TCF (p= .001) and
were not maintained for CS (p= 1.0).
These statistically significant results on all three scale means
indicate a trend for a positive impact of the journaling inter-
vention classes.
3.1 Quantitative
The quantitative results of this study were as follows:
Journaling was statistically significant, increasing com-
passion satisfaction (p= .008).
Journaling was statistically significant in reducing
burnout (p= .0001).
Journaling was statistically significant in reducing
trauma/compassion fatigue (p= .0001).
3.2 Qualitative
Constant-comparative analysis was completed of the written
responses to the two open-ended questions in the Post II-
survey. To ensure credibility, the analysis was completed by
both the PI and Research Mentor. Analysis was completed
individually and then individual results were compared to
safeguard the accurate representation of the participants’ re-
sponses and researchers’ construction of themes.
Saturation was reached by coding the written response to the
open-ended questions. Once the categories became repetitive,
themes were identified and the analysis process ceased. Dur-
ing the analysis three themes were identified as: 1) journaling
allowed me to unleash my inner most feelings,
2) journaling
helped me to articulate and understand my feelings con-
cretely, and 3) journaling helped me make more reasonable
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Table 1. Characteristics of sample (N = 66)
Characteristic n %
Age category
American Indian or Alaska Native
Hispanic or Latino
Native Hawaiian or Pacific Islander
RN-Diploma or Associate’s
RN-MSN or higher
Years in nursing
26 or more
Adult only
Home care
Pediatric only
More than one specialty
Administration or Management
Staff RN
More than one position
Rate expertise in journal writing
Theme I: Journaling allowed me to unleash my inner most
The journaling intervention helped the participant’s stress
at work because they had the ability to channel their inner
emotions onto paper. This released “the pressure valve” of
emotions as one participant stated.
One nurse said, “This by far was the best experience for me
as a person. It allowed me to unleash my inner thoughts. ..
Another said, “I use this journaling experience as a valve to
release pressure.
One of the RNs expressed this by writing,
The journaling experience has been an invigo-
rating cathartic extension of my journey. I have
never felt more connected or comfortable on
knowing that this was where I was supposed to
be. Though moments in my mind were painful
I am so thankful that I was able to be a part of
this experience.
Finally, one woman described the experience as,
It helped to have a place to pour out thoughts or
‘rant’ by writing rather than getting the urge to
do it out loud when it is not always appropriate,
and instead of feeding negative energy to others,
keep it to myself but still have an outlet to let it
out, instead of letting it build up inside.
Theme II: Journaling helped me to articulate and under-
stand my feelings concretely
The journaling technique was therapeutic for nurses, in-
creasing awareness to focus on the real issues, and express
thoughts and feelings through writing. Journaling helped the
nurses make their thoughts and feelings black and white.
The nurses agreed that the journaling class helped to increase
their awareness about feelings. One nurse wrote,
It has been instrumental in helping me identify
and articulate my feelings about nursing and
personal events in my life.. .Journaling forces
me to put a name to that anxiety, quickly focus
on the root and would absolutely facilitate my
ability to deal with it. Thank you, thank you,
thank you!
One participant discussed the journal in terms of an important
tool, “The journaling intervention has given me knowledge
and power and tools to express my inner experiences on pa-
per.” Finally, one participant stated, “(journaling) puts things
on paper in black and white, right out in the open. . .
Theme III: Journaling helped me make more reasonable
In the context of the class, the nurses discussed how much
journaling helped to make better decisions utilizing a new
skill - journaling. One RN wrote,
Published by Sciedu Press 95 Journal of Nursing Education and Practice 2017, Vol. 7, No. 2
. . . I am able to refocus and reassess the situa-
tion from a different angle. . . The power to step
away from a stressful situation or experience by
applying my emotions to paper has changed my
life. Situations at work do not upset me as easily
Another stated, “I think it made me even more in touch with
myself and created an awareness which helped me take care
of myself and therefore better care of others. I would say it
helped, yes.” “. .. helps or forces you to do something about
it.Finally, one nurse summarized all three themes,
When I feel stressed, I use free-flow writing to
get my ideas down. It really helps to get things
on paper. After I finish writing and I reread it, it
really helps me to understand what I have been
feeling. . . and makes it easier to deal with.
Journaling is an important tool for registered nurses. Few
of us question the physical and emotional toll RNs experi-
ence as a result of the numerous demands placed upon them
by their work. These demands affect individuals on both
personal and professional levels, contribute to attrition in
professions that are already experiencing shortages, and can
ultimately impact the quality of care received by patients.
Obviously, it benefits RNs, the patients they serve, and our
healthcare system as a whole, to do what we can to pro-
vide RNs with the tools necessary to adequately address the
ongoing demands of providing care.
“Compassion fatigue is prevalent across all spec-
trums of the helping professions and is flourish-
ing. Can we afford to ignore the consequences?
If we do not care now, who will and when? At
what cost?”[48]
These results indicate that journaling does have a positive
effect over time on the ability of nurses to handle stress and
CF resulting from the work in their professions. A larger
study would be warranted so that additional information
could confirm the results of this study.
4.1 Limitations
As with all studies, limitations must be deliberated prior to
applying the results of a study to a given setting. In this
study, there was an 81% return rate of matching surveys for
the three intervention time points, however, the overall study
sample size (n = 66) was small and the participants were not
randomly chosen. The study was conducted with currently
employed RNs in Rochester, New York. There may have
been a response bias with the RNs who chose to take part in
this study.
4.2 Recommendations for practice, policy, and future re-
The implications for practice include implementing a journal-
ing program at the institution of study, for local professional
nursing organizations, and at local nursing schools; and, de-
veloping educational programs for healthcare providers on
journaling. In addition, it would be beneficial to consider
collecting post-intervention data at six and twelve month in-
tervals. Examining these data points would provide valuable
information as to the long term benefits of journaling as a
useful tool in sustaining CS and preventing BO and TCF.
Overall, given the small sample size for this study the signifi-
cant findings are important and notable. Recommendations
for future studies include replicating the study with a larger
sample size.
Compassion fatigue is a preventable and treatable phe-
nomenon. Organizations with policies, interventions, and
evaluation methodologies that address CF risk may result
in substantial employee benefit cost savings, uninterrupted
professional nursing care, and increased patient family satis-
faction and may continue to be regarded in communities as
an optimal choice in EOL [sic End of life] care.[49]
Dr. Lynda J. Dimitroff, PhD, MSEd, BSN, RN, MCHES,
Assistant Professor, Nursing Department, Nazareth College,
Rochester, NY; Linda Sliwoski, MSN, RN, Certified Jour-
naling Instructor, Nurse Care Manager, Greater Rochester
Independent Practice Association, Rochester, NY; Dr. Sue
O’Brien, PhD, PT, NCS, CEEAA, Assistant Professor, Phys-
ical Therapy Department, Nazareth College, Rochester, NY;
Dr. Lynn W. Nichols, PhD, RN, Senior PhD Research Sci-
entist, Department of Nursing Research & Evidence-Based
Practice, Rochester General Hospital, Rochester, NY.
The authors of this article would like to thank Dr. Kathryn
Gardner, EdD, RN, Dr. Carmela Rehtz, EdD, RN, Mer-
rilee Ritter, Barb Buscaglia, MSN, RN, CNA-BC, Janice
Putrino, LMSW, and, Jennifer S. Burr, MLS, MA, Scholarly
Communications Librarian and Associate Professor for their
assistance on this project.
The authors declare that there is no conflict of interest.
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Adams K. Expressive Writing: Foundations of Practice. Lanham,
MD: Rowman & Littlefield Publishing; 2013. 176 p.
Adams K. Journal to the self: Twenty-two paths to personal growth.
New York: Warner Books; 1990. 239 p.
Adams K. Journal to the self-work book. Lakewood, CO: The Center
for Journal Therapy; 2002. 72 p.
Baldwin C. Life’s companion. Journal writing as a spiritual quest.
New York: Bantam Books; 1991a. 352 p.
Baldwin C. One to one. Self-understanding through journal writing.
New York: M. Evans and Company, Inc.; 1991b. 170 p.
Bolton G, Field V, Thompson K. Writing works. A resource hand-
book for therapeutic writing workshops and activities. Philadelphia,
PA: Athenaeum Press, Gateshead, Tyne, and Wear; 2006. 255 p.
Bolton G, Field V, Thompson K. Writing routes. A resource handbook
of therapeutic writing. Philadelphia, PA: Jessica Kingsley Publishers;
2011. 238 p.
Brady EM, Sky HZ. Journal writing among older learners. Educa-
tional Gerontology. 2003; 29(2): 151-163.
Callister LC. The use of student journals in nursing education: Mak-
ing meaning out of clinical experience. Journal of Nursing Educa-
tion.1993; 32(4): 185-186. PMid:8388443
Gillis A. Journal writing in health education. New Directions for
Adult and Continuing Education. 2001; 90: 49-58.
Hiemstra R. Uses and benefits of journal writing. New Directions for
Adult and Continuing Education. 2001; 90: 19-26.
Kuo C, Turton M, Cheng S, et al. Using clinical caring journaling:
Nursing student and instructor experiences. Journal of Nursing Re-
search. 2011; 19(2): 141-149. PMid:21586991
Mills SD. Electronic journaling: Using the web-based, group jour-
nal for service-learning reflection. Michigan Journal of Community
Service Learning. 2001; 8(1): 27-35.
Pennebacker JW. Opening up. The healing power of expressing emo-
tions. New York: The Guildford Press; 1990. 249 p.
Burtson PL, Stichler JF. Nursing work environment and nurse
caring: Relationship among motivational factors. Journal of Ad-
vanced Nursing. 2010; 66(8): 1819-1831. PMid:20557389
Saco TL, Ciurzynski SM, Harvey ME, et al. Compassion satisfaction
and compassion fatigue among critical care nurses. Critical Care
Nurse. 2015; 35(4): 32-44. PMid:26232800
Keidel GC. Burnout and compassion fatigue among hospice care-
givers. American Journal of Hospice and Palliative Care. 2002; 19(3):
Parr G, Haberstroh S, Kottler J. Interactive journal writing as adjunct
in group work. Journal for Specialists in Group Work. 2000; 25(3):
Francis ME, Pennebacker JW. Putting stress into words: The impact
of writing on physiological, absentee, and self-reported emotional
well-being measures. American Journal of Health Promotion. 1992;
6(4): 280-287. PMid:10146806
890-1171- 6.4.280
Pennebacker JW, Colder M, Sharp LK. Accelerating the coping pro-
cess. Journal of Personality and Social Psychology. 1990; 58(3): 528-
Progoff I. At a journal workshop. The basic text and guide fir using
the Intensive journal process. New York: Dialogue House Library;
1975. 320 p.
Stamm BH. The ProQOL manual. Idaho State University: Sidran
Press; 2005. 29 p.
Branch C, Klinkenberg D. Compassion fatigue among pediatric
healthcare providers. American Journal of Maternal and Child Nurs-
ing. 2015; 40(3): 160-166. PMid:25594692
Hinderer KA, VonRueden T, Friedmann E, et al. Burnout, com-
passion fatigue, and secondary traumatic stress in trauma nurses.
Journal of Trauma Nursing. 2014; 21(4): 160-169. PMid:25023839
Smart D, English A, James J, et al. Compassion fatigue and satis-
faction: A cross-sectional survey among US healthcare workers.
Nursing and Health Sciences. 2014; 16: 3-10. PMid:23663318
Dec E. How renal professionals can deal with compassion fatigue.
Nephrology News and Issues. 2005; 19(11): 70-71. PMid:16270740
Medland J, Howard-Ruben J, Whitaker E. Fostering psychosocial
wellness in oncology nurses: Addressing burnout and social support
in the workplace. Oncology Nursing Forum. 2004; 31(1): 47-54.
Aycock N, Boyle D. Interventions to manage compassion fatigue
in oncology nursing. Clinical Journal of Oncology Nursing. 2009;
13(2): 183-191. PMid:19349265
Figley CR. Compassion fatigue as secondary traumatic stress disor-
der: An overview. New York: Brunner/Mazel Publishers; 1995. 268
Figley CR. Treating compassion fatigue. New York: Brunner Rout-
ledge; 2002. 227 p. PMid:12412153
Sabo B. Compassion fatigue and nursing work: Can we accu-
rately capture the consequences of caring work? International Jour-
nal of Nursing Practice. 2006; 12(3): 136-142. PMid:16674780
Joinson C. Coping with compassion fatigue. Nursing. 1992; 22(4):
116, 118-119, 121. PMid:1570090
/00152193-199204000- 00035
Racanelli C. Attachment and compassion fatigue among American
and Israeli mental health clinicians working with traumatized vic-
tims of terrorism. International Journal of Emergency Mental Health.
2005; 7(2): 115-24. PMid:16107043
Marcus S, Dubi M. The relationship between resilience and com-
passion fatigue in counselors. American Counseling Association –
VISTAS. 2006; 223-225.
Hunsaker S, Chen H, Maughan D, et al. Factors that influence the
development of compassion fatigue, burnout, and compassion satis-
faction in emergency department nurses. Journal of Nursing Scholar-
ship. 2015; 47(2): 186-194. PMid:25644276
Mason VM, Leslie G, Lyons P, et al. Compassion fatigue, moral dis-
tress, and work intensive care unit trauma nurses. A pilot study.
Dimens Crit Care Nurs. 2014; 33(4): 215-25. PMid:24895952
Melvin CS. Professional compassion fatigue: What is the true cost
of caring for the dying? International Journal of Palliative Nursing.
2012; 18(12): 606-611. PMid:23560318
Slatton LA, Carson KD, Carson PP. Compassion fatigue and burnout.
What managers should know. The Health Care Manager. 2011; 30(4):
Published by Sciedu Press 97 Journal of Nursing Education and Practice 2017, Vol. 7, No. 2
325-333. PMid:22042140
Potter P, Deshields T, Berger JA, et al. Evaluation of a compassion
fatigue resiliency program for oncology nurses. Oncology Nursing
Forum. 2013; 40(2): 180-187. PMid:23448743
Rudolph JM, Stamm HB, Stamm HE. Compassion fatigue. A concern
for mental health policy, providers & administration. Proceedings of
the 13th Annual Meeting of the International Society for Traumatic
Stress Studies Conference; 1997; Montreal, Canada.
Stevens-Guille B. Compassion fatigue: Who cares for the caregivers?
Alberta RN. 2003; 59(7): 18. PMid:13677678
[42] Salston MD, Figley CR. Secondary traumatic stress effects of work-
ing with survivors of criminal victimization. Journal of Traumatic
Stress. 2003; 16(2): 167-174. PMid:12699204
Garrett DK, McDaniel AM. A new look at nurse burnout: The
effects of environmental uncertainty and social climate. Journal
of Nursing Administration. 2001; 31(2): 91-96. PMid:11271685 00009
Pilchta SB, Kelvin, EA. Munro’s statistical methods for health care re-
search. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams
& Wilkins; 2012. 567 p.
Taylor B. Interpreting phenomenology for nursing research. Nurse
Researcher. 1995; 3(2): 66-79. PMid:27285048
Adams K. The write way to wellness - A workbook for healing and
change. Lakewood, CO: The Center for Journal Therapy; 2000. 158
IBM Corporation. Statistical Package for Social Sciences for Win-
dows. Version 23.0 [software]. Chicago, IL: IBM Corp. 2016.
Showalter S. Compassion fatigue: What is it? Why does it mat-
ter? Recognizing the symptoms, acknowledging the impact, devel-
oping the tools to prevent compassion fatigue, and strengthen the
professional already suffering from the effects. American Journal of
Hospice and Palliative Care. 2013; 27(4): 239-242. PMid:20075423
Abendroth M, Flannery J. Predicting the risk of compassion fatigue.
A study of hospice nurses. Journal of Hospice and Palliative Nurs-
ing. 2006; 8(6): 346-356.
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... In a study with 66 registered nurses who participated in a 6-week program comprising six 2.5-hour journaling classes, journaling was found to decrease burnout and compassion fatigue while increasing compassion satisfaction. 51 Participants indicated that journaling served as an outlet for expressing thoughts and feelings Write It Out! CPR for the Soul therapeutically, assisted them in decision-making on the job, and facilitated the ability to take care of themselves, which in turn helped them better care for others. 51 Fifteen Registered Nurse (RN) to Bachelor of Science students reported that reflective journaling prompted engagement in self-care and health promotion practices by reducing stress and bringing clarity to thoughts. ...
... 51 Participants indicated that journaling served as an outlet for expressing thoughts and feelings Write It Out! CPR for the Soul therapeutically, assisted them in decision-making on the job, and facilitated the ability to take care of themselves, which in turn helped them better care for others. 51 Fifteen Registered Nurse (RN) to Bachelor of Science students reported that reflective journaling prompted engagement in self-care and health promotion practices by reducing stress and bringing clarity to thoughts. 52 Implementing a 6-week positive writing intervention showed a statistically significant increased level of optimism and gratitude in mothers of troubled children. ...
Many nurses, although expert caregivers for their patients, often overlook extending this expertise to themselves by neglecting to implement self-care activities to nurture their own well-being. This neglect can precipitate a myriad of physical, mental, emotional, spiritual, and social consequences potentially leading to burnout or even an exit from the nursing profession. Initiating self-care using compassionate purposeful reflection (CPR) journaling, a kind of cardiopulmonary resuscitation for the soul, offers an antidote for self-care neglect and can foster self-compassion creating a protective shield against burnout. CPR journaling can aid in replenishing depleted stores of resilience and compassion enhancing nurses' well-being.
... 4). Journaling has been shown to increase compassion in nurses, reduce burnout, and decrease symptoms of trauma and compassion fatigue (Dimitroff et al., 2017). Finally, random acts of kindness facilitate compassionate actions and social connections, increasing nurses' resilience (Kinman et al., 2020;Miles et al., 2020, Wei et al., 2019. ...
Conference Paper
Full-text available
Abstract: The Restore U 21-Day Challenge is offered as an annual well-being tune-up for staff and faculty who experience stress, secondary trauma, and compassion fatigue while working at a regional health care facility. This study explored the experiences of program participants. Researchers wanted to know how the curriculum personally affected participants, how the workshop changed interactions between healthcare workers and patients, suggestions for the next Restore U 21-Day Challenge, and the nature of learning that occurred. Participants completed one or more of five activities shown to reduce stress, including naming three good things that happened that day, journaling, exercising for 10 minutes, meditating for 2 minutes, and doing a conscious act of kindness. Two hundred fifty-four employees completed both the pre-and post-program surveys. Participants reported being more positive, focused, and centered after completing the program. In addition, they were more empathetic, compassionate, and patient with clients. They also taught their patients some of the activities learned in the Restore U 21Day Challenge. Suggestions for future Restore U Challenge programs included more opportunities for interaction between participants, increased advertising, and additional activities such as guided meditations and TED talks. Respondents engaged in experiential learning, and their perspectives changed during the program. They reported being more grateful, positive, energized, focused, and patient. Our findings confirm the value of these activities to increased resilience. Program leaders may consider infusing technology in the next Restore U 21-Day Challenge and include more social events. Future studies may want to have more demographic information to understand better how these characteristics may affect participants' experiences in the program.
... Journaling/writing [168][169][170][171][172][173] Massage/relaxation/yoga [174][175][176][177][178][179] Mindfulness/meditation [180][181][182][183][184][185][186][187][188][189][190][191][192][193][194][195] Music therapy [196][197][198][199] Reiki 200,201 Self-reflection 202-205 a Books with exercises to enhance self-awareness of work-related emotional distress. 1,205 • Educate nurses, preceptors, and nurse leaders on how to identify behaviors caused by burnout and compassion fatigue and to become aware of their individual stress triggers, participate in self-care activities, and discuss resiliency • Improve clinician well-being by measuring, developing, and implementing interventions and then remeasuring • Offer nurses opportunities to reflect on and learn from their practice and from other practitioners • Work with internal teams to assess whether current electronic medical record systems may be customized to better support nursing workflow • Conduct regular staff meetings that include discussions about new organizational policies, processes, and outcomes from leadership meetings -making sure to engage nurses in these meetings. ...
Full-text available
Stress in nurses is multifocal, pervasive, and persistent. They practice in a contemporary heath care environment characterized by rapid change, the ongoing integration of novel technologies, and interpersonal challenges. Relationships with patients and families pose unique dilemmas related to witnessing anguish and trauma over time. Interventions are needed to counter the affective demands of nurse caregiving. To this end, national initiatives have been proposed to outline general work setting enhancements promoting well-being. Stressor-specific interventions have also been identified. The goal of this article is to provide an overview of the macro (organizational) recommendations for change and a micro (practice setting) blueprint of potential interventions to promote nurse well-being.
In South Africa, lay HIV counsellors are at the forefront of many HIV-related behavioural interventions. However, they have limited formal counselling training and little ongoing in-service support, leading to considerable variability in approaches to counselling. We describe the use of Intervention Mapping to develop a motivational interviewing counselling training and support program, titled “Thusa-Thuso - helping you help”, for lay HIV counsellors practising in primary health care clinics in South Africa. The program is contextually relevant, locally-produced, scalable, and is designed to impart sustained motivational interviewing counselling skills in lay HIV counsellors for improved antiretroviral therapy (ART) uptake in the universal-test-and-treat era.
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This brief book brings together researchers and practitioners from medicine, nursing, psychiatry, psychology, social work, marriage and the family and others to explain, measure, prevent, and treat compassion fatigue. This the introduction and other front matter for the book.
Although critical care nurses gain satisfaction from providing compassionate care to patients and patients' families, the nurses are also at risk for fatigue. The balance between satisfaction and fatigue is considered professional quality of life. To establish the prevalence of compassion satisfaction and compassion fatigue in adult, pediatric, and neonatal critical care nurses and to describe potential contributing demographic, unit, and organizational characteristics. In a cross-sectional design, nurses were surveyed by using a demographic questionnaire and the Professional Quality of Life Scale to measure levels of compassion fatigue and compassion satisfaction. Nurses (n = 221) reported significant differences in compassion satisfaction and compassion fatigue on the basis of sex, age, educational level, unit, acuity, change in nursing management, and major systems change. Understanding the elements of professional quality of life can have a positive effect on work environment. The relationship between professional quality of life and the standards for a healthy work environment requires further investigation. Once this relationship is fully understood, interventions to improve this balance can be developed and tested. ©2015 American Association of Critical-Care Nurses.
PurposeThe purpose of this study was twofold: (a) to determine the prevalence of compassion satisfaction, compassion fatigue, and burnout in emergency department nurses throughout the United States and (b) to examine which demographic and work-related components affect the development of compassion satisfaction, compassion fatigue, and burnout in this nursing specialty.Design and Methods This was a nonexperimental, descriptive, and predictive study using a self-administered survey. Survey packets including a demographic questionnaire and the Professional Quality of Life Scale version 5 (ProQOL 5) were mailed to 1,000 selected emergency nurses throughout the United States. The ProQOL 5 scale was used to measure the prevalence of compassion satisfaction, compassion fatigue, and burnout among emergency department nurses. Multiple regression using stepwise solution was employed to determine which variables of demographics and work-related characteristics predicted the prevalence of compassion satisfaction, compassion fatigue, and burnout. The α level was set at .05 for statistical significance.FindingsThe results revealed overall low to average levels of compassion fatigue and burnout and generally average to high levels of compassion satisfaction among this group of emergency department nurses. The low level of manager support was a significant predictor of higher levels of burnout and compassion fatigue among emergency department nurses, while a high level of manager support contributed to a higher level of compassion satisfaction.Conclusions The results may serve to help distinguish elements in emergency department nurses’ work and life that are related to compassion satisfaction and may identify factors associated with higher levels of compassion fatigue and burnout.Clinical RelevanceImproving recognition and awareness of compassion satisfaction, compassion fatigue, and burnout among emergency department nurses may prevent emotional exhaustion and help identify interventions that will help nurses remain empathetic and compassionate professionals.
Background: Compassion fatigue is a term used to describe the unique stressors affecting people in caregiving professions. Purpose: For nurses and other direct care providers, the impact of compassion fatigue may result in stress-related symptoms, job dissatisfaction, decreased productivity, decreased patient satisfaction scores, safety issues, and job turnover. Those who care for seriously ill children and their families are at increased risk for compassion fatigue. Constant exposure to children who are suffering, in combination with work place stressors and personal issues, may contribute to the development of compassion fatigue. Methods: The Professional Quality of Life Scale Version 5 was used to determine the risk for compassion fatigue among 296 direct care providers at St. Louis Children's Hospital. Results: Compassion satisfaction, burnout, and secondary traumatic stress scores did not differ by age, work category, level of education, or work experience. There were, however, significant differences in scores as a function of nursing unit. Nurses who work in the pediatric intensive care unit reported lower compassion satisfaction scores, and higher burnout and secondary traumatic stress scores. Clinical implications: Results demonstrated the risk for compassion fatigue and provided data necessary to support development of a compassion fatigue program for direct care providers.
The relationship of burnout (BO), compassion fatigue (CF), compassion satisfaction (CS), and secondary traumatic stress (STS) to personal/environmental characteristics, coping mechanisms, and exposure to traumatic events was explored in 128 trauma nurses. Of this sample, 35.9% had scores consistent with BO, 27.3% reported CF, 7% reported STS, and 78.9% had high CS scores. High BO and high CF scores predicted STS. Common characteristics correlating with BO, CF, and STS were negative coworker relationships, use of medicinals, and higher number of hours worked per shift. High CS correlated with greater strength of supports, higher participation in exercise, use of meditation, and positive coworker relationships. Caring for trauma patients may lead to BO, CF, and STS; identifying predictors of these can inform the development of interventions to mitigate or minimize BO, CF, and STS in trauma nurses.
Preparation for replacing the large proportion of staff nurses reaching retirement age in the next few decades in the United States is essential to continue delivering high-quality nursing care and improving patient outcomes. Retaining experienced critical care nurses is imperative to successfully implementing the orientation of new inexperienced critical care nurses. It is important to understand factors that affect work engagement to develop strategies that enhance nurse retention and improve the quality of patient care. Nurses' experience of moral distress has been measured in medical intensive care units but not in surgical trauma care units, where nurses are exposed to patients and families faced with sudden life-threatening, life-changing patient consequences.This pilot study is a nonexperimental, descriptive, correlational design to examine the effect of compassion satisfaction, compassion fatigue, moral distress, and level of nursing education on critical care nurses' work engagement. This is a partial replication of Lawrence's dissertation. The study also asked nurses to describe sources of moral distress and self-care strategies for coping with stress. This was used to identify qualitative themes about the nurse experiences. Jean Watson's theory of human caring serves as a framework to bring meaning and focus to the nursing-patient caring relationship.A convenience sample of 26 of 34 eligible experienced surgical intensive care unit trauma nurses responded to this survey, indicating a 77% response rate. Twenty-seven percent of the nurses scored high, and 73% scored average on compassion satisfaction. On compassion fatigue, 58% scored average on burnout and 42% scored low. On the secondary traumatic stress subscale, 38% scored average, and 62% scored low. The mean moral distress situations subscale score was 3.4, which is elevated. The mean 9-item Utrecht Work Engagement Scale total score, measuring work engagement, was 3.8, which is considered low.Content analysis was used to identify themes of Role Conflict With Management/Rules, Death and Suffering, Dealing With Violence in the Intensive Care Unit, Dealing With Family, Powerlessness, Physical Distress, and Medical Versus Nursing Values. Additional themes identified were caring, helping families, long-time interdependent relationships of colleagues, and satisfaction in trauma nursing.As work engagement increased, compassion satisfaction significantly increased, and burnout significantly decreased. Results of this study support moral distress as a clinically meaningful issue for surgical intensive care unit nurses. Moral distress scales were elevated, whereas work engagement scales were low. This finding was congruent with Lawrence's study and may reflect ongoing need for greater supports for experienced intensive care unit nurses, from both education and management. Future recommendations for research include examining the interaction of these variables in larger samples to examine additional explanatory factors as well as strategies for self-care, motivation, and behavior change.
The use of journals in university nursing education, as well as their role in continuing professional development for nurses and other health professionals working in clinical settings, are the focus of this chapter.