Reducing the Incidence of Compassion Fatigue in Obstetrical Nurses

Practice Problem Compassion fatigue is a growing problem that can affect 21% to 39% of nurses who work in hospital settings (Berger et al., 2015). Compassion fatigue has been further exacerbated due to the COVID-19 pandemic. Compassion fatigue negatively impacts the nurses in profound physical and emotional ways. PICOT The PICOT question that guided this project was: For obstetrical nurses working in a nonprofit organization, what is the effect of a compassion fatigue program, compared with no program, on nurses in reducing compassion fatigue after two months? Evidence Current evidence shows that mindfulness decreases compassion fatigue and increases compassion satisfaction. Intervention This paper describes how a mindfulness program was implemented in obstetrical unit in a nonprofit hospital in central Virginia. Outcome The implementation of this mindfulness program has resulted in a 15.6% increase in compassion satisfaction, a 35.1% decrease in burnout, and a 39.5% decrease in secondary traumatic stress. Conclusion This EBP project demonstrated that the mindfulness program successfully decreased the incidence of compassion fatigue in obstetrical nurses at a statistically significant level. REDUCING INCIDENCE OF COMPASSION FATIGUE 3 Reducing the Incidence of Compassion Fatigue in Obstetrical Nurses The term “compassion fatigue” (CF) was first coined in the 1950s in nursing and with other first line responders (Milligan & Almomani, 2020). CF was introduced by Joinson (1992), where she described CF as a unique form of burnout (BO) influencing individuals in care giving careers including pastors, advisors, and particularly nurses. Critical care nurses provide care to highly critical patients and are at higher risk to develop CF (Sacco et al., 2015). This evidence-based practice (EBP) project examines the problem of CF in nurses who work in obstetrical units. The aim of this scholarly project is to reduce the incidence of CF through the implementation of a CF program which increases awareness and compassion satisfaction through practicing mindfulness. This paper discusses the significance of the practice problem; PICOT question; theoretical framework; evidence search strategy and results; themes with practice recommendations; setting, stakeholders, and system change; implementation plan with timeline and budget; evaluation plan; impact; dissemination plan; and conclusion. Significance of the Practice Problem Figley (1995) defined CF as “the natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other, for example, the stress resulting from helping or wanting to help a traumatized or suffering person” (p. 253). CF in nurses is well documented in literature (Hooper et al., 2010; Hunsaker et al., 2015; Mooney et al., 2017; Notle et al., 2017; Wu et al., 2016) and develops gradually from an undesired result of taking care of suffering individuals (Stamm, 1999). Moreover, CF is an emotional and physical fatigue that can be preventable when balanced by compassion satisfaction (Hunsaker et al.,

method to present the protocol that would best fit the flow of the hospital unit. The educational department and stakeholders are instrumental in sustaining the project in the future.
In this EBP project, Lewin's Change Theory was utilized to support the planned change and provided a framework for motivating acceptance of the intervention to reduce CF among nurses. Lewin's theory focuses on changing behaviors through a three-step approach which includes unfreeze, change, and refreeze (Mulholland, 2017). In the unfreezing phase, Lewin suggested that the old behavior must be changed in order for new behavior to be established (McGarr et al., 2012). The second step in Lewin's Change Theory is change, during which nurses and the organization adopt a new status of increased CS and resilience while reducing CF (Burnes, 2004). The third step in this theory is refreeze, which solidifies the new status of the behavior change. Refreeze requires patience and perseverance. During this step of the change model, the organization adopts the change to improve nurses' self-care and resilience and to sustain the reduction in CF (Burnes, 2004).

Evidence Search Strategy
An electronic search of digital databases utilizing the University of St. Augustine's library portal included: Cumulative Index to Nursing and Allied Health Literature Complete (CINAHL Complete), Public/Publisher MEDLINE (PubMed), Ovid Emcare, and PsycINFO.
The key words used in the advanced search included: compassion fatigue, nurses, nursing staff, nurse, interventions, strategies, and best practices. The search limited the report-type to peerreviewed academic journals, in the publication English language, and within the time frame January 1, 2015 to present date October, 2020. A title search using the above key words and the above general limiters resulted in 537 titles from the four databases.
The search in CINAHL resulted in a total of 141 articles. Boolean operators were used to capture the best search: compassion fatigue AND nurses OR nursing staff OR nurse AND interventions OR strategies OR best practices. The search in PubMed resulted in 20 articles. The terms compassion fatigue AND nurses OR nursing staff OR nurse AND interventions OR strategies OR best practices were utilized. The search in Ovid Emcare resulted in 307 articles.
The terms utilized were: compassion fatigue AND nurses. The search in PsycINFO resulted in 69 articles. The terms compassion fatigue AND nurses OR nursing staff OR nurse AND interventions OR strategies OR best practices were utilized.

Evidence Search Results
A total of 537 articles were carefully inspected to determine whether they met the inclusion criteria. This review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA). Articles were excluded if they were published before 2015, if they were written in a language different than English, and if their target population was non healthcare professionals such as teachers, firefighters, or caregivers.
Thirty duplicate articles were removed, and 300 articles were excluded as they focused solely on the prevalence of CF, CF risk factors, or non-healthcare professionals. The remaining 207 articles were evaluated, and 183 articles were excluded as they did not focus on CF, did not evaluate the effectiveness of a CF prevention or intervention program, or did not utilize a specific validated measure of CF. The application of these inclusion and exclusion criteria resulted in a total of 14 articles. See Figure 1 for the PRISMA diagram.
The 14 articles were evaluated for level and quality based on JHNEBP (Dang & Dearholt, 2017). One Level I, high quality Grade A article that was an experimental, randomized controlled trial (RCT) was found. No Level II articles were found. Seven articles were Level III, and two of those were high quality Grade A articles: a systematic review of a combination of RCTs and a non-experimental study with meta-analysis. The remaining five were good quality Grade B articles: exploratory pre-post interventional pilot study, explanatory quantitative study, mixed methods sequential design study, and two systematic reviews. The remaining four were Level V, with one being a high quality Grade A article: a training workshop for nurses. The remaining three were good quality Grade B articles: two pilot studies and one evidence-based program (Dang & Dearholt, 2017). A summary of primary research and systematic reviews can be found in Appendices A and B. A table describing the level of the articles is in Appendix C.

Themes from the Literature
While reviewing the literature, several themes emerged that address the components of the PICOT question. A thorough evaluation of the literature is provided in the evidence table that includes the level and quality of evidence-based support in Appendix A and systemic reviews in Appendix B. A synthesis of 14 articles of high and good quality, which utilized ProQOL as a validated tool to measure CF, concluded that increased awareness increases CS and reduces CF.
Eleven of the 14 good quality articles showed that increased awareness reduces CF and increases CS, while nine of the 14 showed that practicing mindfulness reduces CF and increases CS (see Appendix D).

Compassion Fatigue and Compassion Satisfaction
CF as a term represents the emotional, physical, and job-related impacts of spending one's energy over any period of time to provide compassionate, empathic care to others  Blackburn et al., 2020). CF is associated with a variety of adverse effects in the nursing profession, including psychological distress, decreased efficiency, increased absenteeism, and therefore the potential for increased risks to patient safety Yilmaz et al., 2018;. CF may lead to anxiety, depression, lack of ability to remain rational, mood lability, frustration, anger, and poor judgment. CF may lead to decreased retention of workers (i.e., increased turnover), decreased efficiency, increased work-related mistakes, and diminished employee satisfaction, all of which can contribute to substantial, but potentially preventable, costs for a company (Blackburn et

Increased Awareness
The most frequently cited intervention for reducing CF is increasing awareness of risk factors, causes, and symptoms of CF to empower nurses to identify and prevent its onset

Practice Recommendations
Based on the literature synthesis, the recommendation was to implement a nurse-centered CF reduction program. This includes presurvey using ProQOL-5, a CF program over 4 weeks, and a postsurvey using ProQOL-5. The program was made available to all nursing staff through their weekly newsletter. They were reminded by posters in the breakroom and flyers in the restrooms and locker rooms. There was an incentive of a drawing to select one participant to win a gift card. All participants, upon completion, received a self-care kit, including hand sanitizer, pen, and journal (Ortega-Campos et al., 2020; Wentzel & Brysiewics, 2017).

Project Setting
The project setting was the obstetrical unit located in a 391 bed, non-profit Catholic healthcare system, with 11 labor rooms, and an obstetrical emergency department that includes two triage rooms and two operative suites. The obstetrical unit is composed of a mother/infant unit, women's surgical unit, as well as ante-partum and post-partum units. The mother infant unit has 21 private rooms, while the women's surgical unit is a 12 bed gynecology unit. This unit accommodates antepartum patients, as well as postpartum patients if needed. The non-profit organization delivers an average of 2000 births per year.

Organizational Structure
This hospital is a part of four campuses in the area. The hospital where the project took place is one of the oldest campuses in the area, serving approximately 1,230,852 residents from across 61 zip codes.

Organizational Culture and Mission
The hospital was built in 1966 by the community for the community. The hospital is a Center of Excellence for Minimally Invasive GYN surgeries as certified by the Surgical Review Corporation and was named by Style Weekly as the "best place in Richmond to have a baby." The hospital is the first community hospital in the area to achieve Magnet Recognition by the American Nurses Credentialing Center for nursing excellence. The mission of the hospital is to provide good help to those in need and to bring people throughout the region to health and wholeness.

Organizational Need
Organizational need for the project stemmed from the recommendation of the clinical nurse specialist of the Neonatal ICU and obstetrical unit, as well as the obstetrical unit director, to utilize the ProQOL validated tool to assess and recognize the early signs and symptoms of CF.
The same tool measures compassion satisfaction, which are the pleasure and positive emotions derived from helping others, such as happiness, accomplishments, and satisfaction.

Organizational Support
The organizational support was initially provided by the Clinical Nurse Specialist of the NICU and Obstetrical Units who formed a multi-disciplinary team to address the need to recognize and reduce CF. The team included the unit director, chaplain, the clinical nurse specialist, and the social worker. The plan for sustainability for this project will be secured by the continued support and implementation of this project by the clinical nurse specialist of the unit.
To sustain the EBP, a policy was created that requires an annual CF program. The start of this project created a micro system change, and the project will be adapted and utilized by other units, creating a meso system change.

Stakeholders
Brainstorming is the strategy and tool that was utilized to identify the stakeholders for this quality improvement evidence-based practice project. The following are the stakeholders: the nursing professional development coordinator, clinical care leaders, and the nurse director for the Obstetrical Unit. Project support was launched by inviting the stakeholders via a Zoom meeting to discuss the policy and procedure to reduce CF.

Strength, Weakness, Opportunity, and Threat Analysis
An organizational Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis was conducted to assess the organization. The SWOT analysis provided an evaluation to determine the organization's readiness to implement the teamwork initiative (Agency for Healthcare Research and Quality, 2012). The SWOT analysis is provided in Appendix E.

Project Objectives
The EBP change reduces CF for obstetrical nurses by increasing CS. This aligns with the organization's mission to increase nurse awareness of CF and its early signs and symptoms and to create an intervention to mitigate its negative effect. The project's mission was to emphasize the nurses' wellbeing using mindfulness to increase resilience and therefore increase CS.
There are two main types of objectives: process objectives and outcome objectives.

Project Plan
The change model for this EBP project was Lewin's change model. Kurt Lewin was born in Poland in 1890. He was a pioneer in social, organizational, and applied psychology (Social Work Foot Prints, 2017). Lewin's change model is considered one of the cornerstone models for understanding organizational changes (Burnes, 2004). According to Bryant (2013), organizational culture is the product of beliefs, values, standards, and attitudes shared by individuals and groups that form the organization. Lewin's three stage model consists of the unfreezing, change, and refreezing states.

Unfreezing
The unfreezing consists of creating the perception that change is needed and moving toward the new desired level of behavior. The goal in the unfreezing state is to create an awareness of how the status quo is hindering the individual and organization to create a desire to change (Wojciechowski et al., 2016). Increased awareness of CF and the need to recognize the early signs and symptoms to avoid physical, emotional, or psychological consequences on the individual level, as well as avoiding institutional consequences on the organizational level, was the first step towards the change. The ProQOL tool results for each individual nurse offered the actual status of CF and CS. The training program increased nurses' awareness of CF and CS. To justify the significance of the EBP and the need to address CF, a presentation was included in the staff meeting and available electronically due to the COVID-19 pandemic to increase staff and management awareness. This presentation provided the nurses with the reasons for the change and offered a roadmap for the intervention. The ProQOL survey was offered to all participants to assess the baseline CF and CS. A demographic questionnaire was answered individually at the same time.

Change
Change is the process that has to be carefully planned and executed (Manchester et al., 2014). During this step, individuals learn new behaviors, processes, and ways of thinking. Therefore, training, communication, support, and time are critical for nurses as they are becoming familiar with the change to achieve the desired outcomes.
The more nurses that were prepared for this step, the easier it was to complete and achieve the change. During this state, offering interventions such as mindfulness and organizational resources assisted nurses in striving and applying the change in their daily activities to resist CF and increase CS. During this phase, the result of the ProQOL survey was shared individually and as a unit. The unit champions placed flyers and reminders in the break room, restrooms and by the computers in the nursing station to remind and encourage nurses to participate in the weekly mindfulness intervention. This took place weekly for a total of 4 weeks.
Reinforcement occurred in the daily huddles, staff meetings, and weekly newsletter. At the conclusion of the 4 weeks, another ProQOL survey was conducted to evaluate the effect of the intervention on CF and CS.

Refreezing
Refreezing is to symbolize the act of reinforcing, stabilizing, and solidifying the new change after the second phase (Burnes, 2004). According to Lewin's Change Model, this is the phase where the change takes place as the new normal to ensure that changes are permanent (Manchester et al., 2014). This phase will be sustained by the clinical nurse specialist and the nurse champions, who are passionate about improving nurses' wellbeing and CS, to ensure the continuity of the intervention after the implementation of the project. The CF program will be part of the new unit orientation and unit policy, and it will also be part of the annual competency.
A project timeline was important to stay on track and achieve the goals of the EBP project in a timely manner. The dates, tasks, and assigned team members are illustrated in the project timeline (see Appendix G). Although the cost of this project was minimal, it will save the organization more in the long run as replacing one nurse may cost 6 to 9 months' worth of the nurse's salary . See Table 1 for the project budget.

Results
The participants in this EBP project were the nurses who worked in the obstetrical unit who were 18 years of age and older. Since this DNP scholarly project poses a minimal risk to the participants, the IRB approved it as exempt (Johns Hopkins Medicine, n.d.). The project manager obtained permission to utilize the ProQOL tool (see Appendix H). Participants filled out the ProQOL survey pre and post intervention (see Appendix I). Participants were prescribed the intervention in the weekly newsletter and daily huddles. The nurse champions were instrumental to ensuring maximum contribution of the participants. The project manager obtained weekly mindfulness videos from a certified health coach to be offered to the staff (see Appendices J and K). All data were kept and transferred to the same SharePoint drive that is secured and includes limited access between only the DNP student and the DNP preceptor (see Appendix L).
Statistical analysis was conducted using the IntellectusStatistics software. Participant demographics including age group categories, day or night shift, education degree, and years of nursing experience and were described using frequency distribution and represented as a percentage. Frequencies and percentages are presented in Table 2. The ProQOL is a 30-item selfreport questionnaire with three subscales. The first subscale assesses CS, which is defined as the joy received from being able to execute one's job properly. Higher scores on this scale indicate more satisfaction with one's capacity to care for others effectively. BO, or emotions of hopelessness and difficulty dealing with work or doing one's job efficiently, is measured on the second subscale. The third subscale assesses secondary traumatic stress (STS), which is defined as work-related secondary exposure to people who have been exposed to severely or traumatically stressful events. BO and CF are associated with higher scores on these subscales.
On a 5-item Likert scale (from 1 = "never" to 5 = "very often"), participants were asked to rate how frequently each item was experienced in the past 30 days. Summing the item responses for each 10-item subscale is required for scoring.
The total compassion satisfaction score was found by adding up the sum of the following questions: 3, 6, 12, 16, 18, 20, 22, 24, 27, and 30. For the BO calculation, ProQOL guidelines reversed the score of the following questions: 1, 4, 15, 17, and 29 as the measure works better when these questions are asked in a positive way although they can tell us more when in their negative form. The total BO score was formed by adding the individual scores of the following questions: 1,4,8,10,15,17,19,21,26, and 29. The total STS score was formed by adding the individual scores of the following questions: 2, 5, 7, 9, 11, 13, 14, 23, 25, and 28. If each of these 3 categories scored 22 or less it was classified as low, while between 23 and 41 was classified as moderate, and 42 or more was classified as high. Based on these classifications, the results displayed a mean shift from a pretest classification of moderate to a posttest classification of high in CS and a mean shift from a pretest classification of moderate to a posttest classification low for both BO and STS.
The cross-tabulation variable for the demographic variables was the testing period that split the demographics for pre and posttest. The next step was to determine whether there was a statistically significant difference in the CS, BO, and STS scores between the pre and post testing periods. A two-tailed independent samples t-test was conducted to examine whether the mean of CS was significantly different between the pretest and posttest categories of the testing period.
This was done using three independent samples t-tests where each of the testing constructs was the dependent variable and the testing period was the independent variable. The results of each of these tests are shown in Tables 3, 4, and 5. The t-tests showed that there was a statistically significant difference in the CS, BO, STS scores between testing periods based on a p-value of less than or equal to 0.05; more specifically, the p-value for all three t-tests was less than 0.001.
The Pearson Correlation Coefficient Test was conducted to determine the correlation between CS, BO, and STS (see Table 6). Table 6 shows a strong negative relationship between CS and BO, a moderate negative relationship between CS and STS, and a fairly strong positive relationship between BO and STS.
Outcome measures included the percent of nurses who experienced CF and CS in the obstetrical unit before and after the implementation of this project. Additionally, secondary traumatic stress and burnout was assessed pre and post intervention based on the ProQOL survey. As a result of the mindfulness program, there was a 15.6% increase in the mean of the CS score from pretest to posttest, a 35.1% decrease in the mean of the BO score from pretest to posttest, and a 39.5% decrease in the mean of the STS score from pretest to posttest, as shown by the two-tailed independent samples t-tests.
Process measures included the percentage of nurses who completed the mindfulness program and the percentage of nurses who completed the ProQOL survey pre and post intervention. Balance measures for the 6-week EBP project did not cause any strain on the budget of the obstetrical unit because the intervention took place during the nurses' breaks and/or huddles. In the future, financial measures will include the total cost saved by the organization due to decreased nurse turnover rate as a result of an increased incidence of CS.

Impact
The project achieved both statistically and clinically significant results. Descriptive statistics indicated demographically that nurses between the ages of 26 and 54 were more likely to experience CF. The results indicate that most nurses, regardless of their age, nursing degree, and years of nursing experience benefit from mindfulness as an intervention to increase CS and reduce BO and STS. A statistically significant improvement was noted in CS and a reduction in BO and STS.
The project addressed an important problem in nurses experiencing CF including BO and STS especially during the COVID 19 pandemic. Mindfulness as an intervention increased CS by 15.6% and reduced CF by 39.5%. The COVID 19 pandemic caused limitations, including a limited number of participants, a low response rate for the pretest, and making this project virtual instead of face to face. Another limitation was that a paired t-test could not be performed on the ProQOL survey data to keep anonymity of participants. The nurse champions and stakeholders, under the guidance of the unit manager, will continue to offer awareness and intervention in practicing mindfulness. The mindfulness program will also be available for new hires and as a part of the nurses' annual competencies.
The project needed to be extended over a period of three months with multiple ProQOL surveys to further assess the impact of the program on reducing CF. Despite the above limitations, the results of this EBP project showed a statistically significant reduction in CF and an increase in CS, which warrants this program to be a part of initial nursing orientation, annual assessments, and widespread participation throughout the organization. The mindfulness program and protocol should be frequently evaluated to ensure sustainability of the EBP project.

Dissemination Plan
The first step to ensuring the dissemination was to share the outcome with the stakeholders, the team members, and the institution (Agency for Healthcare Research and Quality (AHRQ), 2014). Beyond raising awareness of CF, the goal is to engage hospital staff in the main intervention, as well as to promote the application of the CF policy (see Appendix M) to reduce CF and increase CS. The next step was to place flyers and develop newsletters to create the appropriate awareness about the project (AHRQ, 2014). Increased awareness will come through participants attending an introduction on the topic of CF and CS, which will be available virtually due to the COVID-19 pandemic (see Appendix N).
The DNP student shared the EBP project and outcomes with the nursing director, clinical nursing leaders, and unit staff. The distribution of the results of the DNP project will be included in the weekly newsletter email from the clinical nurse specialist and the DNP student. Another means for local and regional dissemination is to send emails and use websites and blogs to share the EBP project and increase awareness of the problem and the solution. The DNP student will share the EBP project goal and outcomes to the local and regional Virginia Council of Nurse Practitioner , the Virginia Nurses Association , and the Virginia Association of Doctors of Nursing Practice .
The DNP student is planning to publish the EBP project as an article in the Journal of Holistic Nursing. This journal is a peer-reviewed journal that promotes holism, wellness practice, and it is part of the Committee on Publication Ethics (2020) that is committed to transform and sustain the culture of publishing to ethical practice . On the journal's website, there is an author guide under the submission guidelines tab that offers great detail about specific guidelines in manuscript submission and time for review, decision, and production (Journal of Holistic Nursing, 2020).

Conclusion
The EBP project's aim was to implement a mindfulness program policy and protocol for the organization leaders to provide an intervention to the nursing staff to reduce CF and increase CS. The policy and protocol, data collection, data tracking, increased staff awareness, and pre and post ProQOL were developed and implemented. The intervention included an increased awareness of CF and mindfulness. CF is a global, national, and regional problem that affects nurses and healthcare providers. CF has an impact on decreased staff retention, increased workrelated mistakes, decreased employee satisfaction, and decreased patient safety (   Missing 0 (0%) 0 (0%)    Compassion satisfaction was found to be positively associated with compassion and inversely related to burnout. Self-Kindness was significant and inversely related to burnout. Self-judgment leads to compassion fatigue and burnout. Nurses who judges themselves harshly may feel consumed with critical self-talk, shame, and guilt, all these have negative impact on nurses' wellbeing.
High compassion satisfaction and self-compassion are associated with better quality of life, increased wellbeing, and greater resilience. Nurses who are self-critical tend to experience greater stress. Teaching self-compassion skills will increase sense of enjoyment from providing care to the patients and will decrease compassion fatigue and burnout. Limitations: -Small number of participants -Lack of comparison to pre and post training data as these questionnaires were given only at the beginning of their post graduate diploma.
-Further research needed to promote self-care in nurses. Klein The Wilcoxon signed-rank test was used to compare the change in ProQOLV scores from baseline, to the following: 2 months, 4 months, and 6 months. The Spearman rank correlation coefficient was used to assess the relationship between quality of life scores and resilience and coping style scores at baseline and at 6 months.
The organizational support and the intervention can reduce CF and increase CS. Adaptive coping styles should be fostered to facilitate CS and protect against CF. Staff may require additional support in combating CF during the holidays due to patient acuity, staffing schedules, and less experienced nurses working holiday hours. Additional work is recommended to explore the role of coping, resilience, and organizational support to reduce CF. Pediatric oncology nurses are susceptible to CF. Through the six month pilot program, nurses's CF levels were reduced, reflecting the benefit of CF program In ProQOLV scores: 81% of nurses had comparative outcomes from baseline to 2 months, 83% had comparative outcomes from baseline to 4 months, and 69% had comparative outcomes from baseline to 6 months. A statistically significant p=0.029 reduction in in secondary traumatic stress from baseline to 4 months.
subscales. Coping reaction is ranked through a fourpoint Likert scale from 1 to 4, with higher score indicates endorsing of coping trait. There are three main hypotheses in this study: -Nurses' compassion fatigue and burnout score will be lower than before the intervention -Nurses' compassion A nurse-led intervention program consisted of two face-to-face sessions (lecture, reading and video about CF and coping, exercise, baksi dance, mandala painting) and two counseling follow-up sessions by phone (motivational messages via smart phone). Instruments: -Information form for nurses: age, gender, marital status, number of children, education level, oncology training, years as a nurse, years working with cancer patients, occupation status and number of hours working per week, willingness to choose nursing, and willingness to work with oncology patients. -ProQOL-IV: This scale was developed to measure compassion satisfaction, compassion fatigue, and burnout symptoms. The scale is composed of 10-item scales.

None
To determine the effectiveness of a nurse-led intervention program on ProQOL and Post Traumatic Growth Inventory (PTGI). The sample size was predetermined by using a power calculation with the G-POWER 3.1 software analysis program. The power calculation was based on a medium effect size (0.5), an alpha of 0.05 and a power of 0.80. The sample size desired was 50 participants and only 43 nurses agreed to participate. The power of 0.99 was determined at 0.8 effect size (large), an alpha of 0.05 for the difference from the constant in a one sample case using t tests (n=43).
The nurse-led intervention program concluded that there was a decrease in post-intervention in nurses' scores for compassion fatigue and burnout, and an increase in compassion satisfaction. The ProQOL-IV reflected a p value <0.01 from pre to postintervention in the three subscales of compassion fatigue, burnout, and compassion satisfaction. The PTGI reflected a p value of <0.01 from pre to postintervention in the three listed dimensions. P value is significant as <0.05.
Limitations of the study: The research sample consisted mostly of female nurses.
It could be some biased as the participant nurses knew the purpose of the study and the nurse led the intervention was the researcher herself.
Conclusion: Nurse-led intervention was effective in decreasing CF and burnout of oncology nurses and increasing compassion satisfaction and for transforming traumatic experiences into PTGI. satisfaction score will be higher than before the intervention -Nurses will have a higher score on all subscales and total scores of the posttraumatic growth inventory than before the intervention. The quantitative part of the study reflected improvement near ideal with lower burnout, secondary traumatic stress, and CF. Staff members who participated in the debriefings were 25 and reported that it was helpful. About 30% of the staff who participated in the debriefings selected neutral option, therefore, future studies. ProQOL scores were average at baseline, which left a narrow margin for improvement; therefore, The following are the inclusion criteria: empirical studies, publication language: English or Spanish, oncology nurse sample, indicated a compassion fatigue measure in the study, and included prevalence rate of compassion fatigue, compassion satisfaction, and burnout.
The exclusion criteria were: review articles, systematic reviews, and/or metaanalysis studies using the same sample, articles with nursing students, and final studies (degree, master and thesis). -Meta-Analysis: 5 studies with total oncology nursing sample of n=900. The studies used ProQOL for the evaluation of compassion satisfaction, burnout, and compassion fatigue. These studies showed medium and high levels of burnout with a prevalence rate of 56% (38-74%), and compassion fatigue prevalence rate of 60% (37-81%). Creating a policy and procedure for nurses and staff to increase awareness and prevent CF. Long term -Reduction in medication errors -Increase in patient satisfaction -Decrease in nurse turnover The CF program will be available to other units in the hospital. It will also be available for new hires and as a part of the nurses' annual competencies.

Process
-At the end of 6 weeks of implementation, a 4 week program will be offered weekly for participants to reduce CF and increase CS. -In the first 2 weeks after IRB approval, there will be a recruitment of nurses who are going to participate in the ProQOL survey. Outcome -Short term: increase compassion satisfaction by 10% at the end of the intervention. -Intermediate: implement a CF program and policy to all hospital units by the end of 6 months -Long term: increase CS in the organization by 20% at the end of one year.
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