1. Introduction
“Nurses help people. And in doing so, we receive the unmatched satisfaction of knowing that we have made a difference to patients and their families” Dawn Marino (LeaderStat, 2020: p. 1) .
Nursing is a profession based on caring. One of the seven nursing values and moral responsibilities (in the code of ethics for registered nurses) is to provide safe, compassionate, competent, and ethical care (Canadian Nurses Association, 2017) . Nurses want to bestow the best care possible by using their clinical knowledge, judgment, and professional skills with compassion. We will explore how exceptional nurses provide and maintain exemplary and compassionate care throughout their careers.
The role of a nurse is complex and not easily understood or articulated. Throughout the years, scholars and nursing researchers have tried to define the core of nursing. For this paper, the holistic model, The Exemplary Practice Life of the Nurse, may help us understand and provide a framework to illuminate the fundamental quality of a nurse (Riley et al., 2021) . Riley et al. (2021: p. 1023) describe their holistic model as a framework, “counterbalancing the essential components while offering guidance to nurses in the whatever the situation that they confront in meeting the universally stated goal of health and wellness of all members of society”. The model by Riley et al. (2021) explains the nurse’s role and provides the foundation for exemplary nurse practice based on four pillars: 1) professionalism, 2) scholarly practice, 3) leadership, and 4) stewardship.
The first pillar of the model: professionalism, directs nurses to a practice based on characteristics, values, conduct, and actions that promote professional responsibility and accountability, advance passion for the profession, and help form therapeutic relationships based on respect, caring, and compassion (Riley et al., 2021) . Riley et al. (2021: p. 1019) note, “Nurses accept and value all individuals as equal, worthy of respect and with intrinsic worth, regardless of all other considerations”.
The second pillar: scholarly practice, is a fundamental component of nursing practice and necessary for professional growth and development (Riley et al., 2021) . Nurses must be prepared to competently use scientific knowledge, critical thinking, and creativity to deliver evidence-based care and to develop their practice expertise (Riley et al., 2021) . The scholarly practice also promotes therapeutic and collaborative relationships based on kindness, compassion, and respect between nurses, patients and their families, and other interdisciplinary team members, to best meet health and wellness goals (Riley et al., 2021) .
The third pillar: leadership, encourages nurses to adopt formal and informal leadership roles to help develop themselves and others as productive leaders while embracing kindness, respect, inclusivity, and cultural diversity (Riley et al., 2021) . Riley et al. (2021) assert that in collaborating with others to speak to health disparities, nurses, as mindful leaders, can help to advance health equity for society.
The final pillar: stewardship, is the ethical value that represents the responsible planning and management of resources. Riley et al. (2021) maintain that stewardship is the responsibility of all nurses to apply and communicate the advancement of the health and wellness of society throughout their work lifespan by ensuring transparency and accountability.
Working in complex environments, the roles of nurses change as the needs of the patient and society change. Providing and maintaining exemplary nursing care is based upon nurses’ commitment to continue to evolve professionally, collaborate with patients and multidisciplinary partners, and conduct their practice with respect, responsibility, and compassion (Riley et al., 2021) . We will use the above framework and try to understand how the participants in this study maintain their compassionate and exemplary care throughout their work lifespans.
2. Compassion
Compassion is empathy toward others and the need to help ease their suffering (Zhang et al., 2018) . Compassion is also a moral emotion or a virtue that motivates a nurse to try and alleviate patients’ suffering through acts of kindness, patience, and comfort (Gustafsson & Hemberg, 2022) . To be compassionate is to understand others’ feelings and to be able to convey that understanding to them (Lombardo & Eyre, 2011) .
Compassion is at the core of a therapeutic nurse/patient relationship, and one fundamental goal of a compassionate nurse is to ease a patient’s suffering. But is it possible for nurses to consistently maintain compassionate care when they regularly witness the pain and trauma of others? More so, Potter et al. (2010) wonder how oncology nurses sustain compassionate care when often exposed to anguished, suffering patients (and families), some of whom have no hope of recovery. Yet, some nurses cope and thrive in this demanding specialization despite challenging working conditions (i.e., inadequate staffing, unsafe working environments, insufficient personal protective equipment [PPE], long shifts, exposure to infection, etc.), even during the COVID-19 pandemic. Grossman (2021: p. 312) writes, “During the COVID-19 pandemic, nurses with well-developed resiliency and a strong professional commitment experienced moral dilemmas in life like never before yet found solutions that allowed them to maintain their drive to the bedside”.
We realize that some nurses cope and thrive because they are exceptional and resilient. Perry (2009: p. 19) describes these outstanding nurses and writes, “…their actions and interpersonal interactions are regarded by others as highly successful, that is they are the nurses their peers would choose to have care for them if they were diagnosed with cancer”. In this paper, we explore extraordinary nurses’ unique outlooks on life. Further, we describe strategies exemplary nurses employ to feel satisfied in their work and to remain compassionate in their care. The reflections of the nurses who participated in the study will help us understand how they prevent the effects of CF. We are optimistic that the nurses depicted in this paper can help others maintain exemplary and compassionate care and their commitment and passion for nursing. Our findings will be of interest to organizational leaders seeking approaches they can employ to decrease the occurrence of CF. Finally, we hope that nurse educators will see the benefit of teaching compassion and the strategies for its maintenance and that researchers will continue to study CF and how to circumvent it.
3. Background Literature
3.1. Compassionate Care
Compassion is essential in caring for patients and maintaining excellence in nursing practice. Watson (1997) states that compassionate caring is the essence of nursing, and the empathic relationship between the nurse and the patient is fundamental to her theory of human caring. Watson (1997: p. 5) describes the caring moment as “an existential turning point for the nurse, in that it involves pausing, choosing to ‘see’; it is informed action guided by an intentionality and consciousness of how to be in the moment—fully present, open to the other person, open to compassion and connection…”.
Watson (2021) describes caring as a science that develops philosophical and ethical fields of knowledge related to nursing practice. Watson (2021) writes that caring science encompasses the whole person (mind, body, and spirit) united with the environment as a single unit. The compassionate connection often transcends the physical into the spiritual. Simple words or gestures, smiles, touch, and silence can sometimes show great compassion and make a difference in the lives of the patient and the nurse (Perry, 2009) . An exceptional nurse focuses on caring for the individual (mindful of the person they were before becoming ill and remembering they are still the same person) rather than emphasizing disease or illness. As Riley et al. (2021: p. 1019) write, “Nurses possess the ability to provide expert humanistic and holistic care to self and others that reflect kindness, compassion, respect, and mindfulness in their practice”.
Elizabeth shared a memory of a patient that touched her when she was a novice nurse and helped shape her professional practice. Her story illustrates how simple gestures and words can communicate compassion and benefit both the patient and the nurse.
3.1.1. Elizabeth’s Story
A patient I remember vividly brought us all so much joy. Mrs. A was always happy and made everyone in the unit smile. I would comb her hair daily and help her apply beautiful pink lipstick because she no longer could. When she was healthier, Mrs. A told me she always wore pink lipstick. One day as we were standing in front of a mirror, Mrs. A looked intently at her reflection, touching her face, and saying, “Who is that? Me? So old and ill?” I embraced her and said, “That is you, and you are beautiful.” I continued to apply her lipstick because I knew it was important to her. After I finished, she looked in the mirror again and smiled.
Mrs. A touched my heart. I saw her as a “real” person (who liked pink lipstick) instead of a sick person. I realized what a privilege it was to be a nurse and to be able to share in the happy and sad moments of people’s lives. It was one of the most humbling yet satisfying moments in my career.
The following story shows that caring through touch and with silence can be the greatest and most compassionate care communicated to a patient.
3.1.2. Beth’s Story
“In report they announce that I am to give one-to-one care to a young woman with leukemia. She is distressed and agitated because of recent news that her disease is out of remission. Knowing that I will be her constant companion for the next eight hours, I try to think carefully about the approach I will take in our conversation. What should I say? How can I let her know that what she is feeling is normal? What can I do to offer her the support I know she needs?
As I enter her room, I am still unsure of my opening words, so I say nothing. Sitting close to her on her bed, I take her cold hand in mine. Softly stroking her forehead, I speak only with my eyes and touch. She seems relieved, and I can feel the tension ease. The silence, it appears, is a welcomed friend. It feels tranquil. Nothing is frantic; nothing needs to be said. It is as if the agony and strain have been replaced by music that we can both hear” (Perry, 2009: pp. 33-34) .
The next story shows that using humour during patient care (and all the emotions inherent in it) can be both funny and touching and create an irrevocable bond between a patient and nurse.
3.1.3. Chris’s Story
A patient who touched me deeply was a young man with cancer who was dear to everyone in our unit. He often used humour to cope with his diagnoses and once said, “I know I’m dying, but I don’t want to be there when it happens.” His words brought tears to my eyes, being both funny and poignant. He wanted us to laugh, and we did, but he saw our tears, and his eyes moistened too. One day he was transferred to another hospital for treatment. He called us frequently to talk. I knew I had made a difference in his life, and he made a life-altering difference in mine. I’ll never forget him.
The final story is about how an appreciation of exemplary nursing care from the public can significantly impact a nurse and help her feel pride and satisfaction in their profession.
3.1.4. Haida’s Story
One day in a mall, a lady inadvertently heard I was a nurse manager. She approached me and told me she received nursing care during the COVID-19 pandemic, and she wanted to thank me (and all healthcare workers) for the extraordinary care she received. Even though she was a stranger, her words touched me deeply. I felt moved, appreciated, and proud that nurses make such a positive difference in people’s lives.
3.2. Compassion and Compassion Satisfaction (CS)
As mentioned above, compassion is a core component in caring science and the motive for compassionate caring and maintaining excellence in nursing practice. To appreciate the concepts of CS and CF, we must first fully understand compassion. Gustafsson and Hemberg (2022) suggest that neither sympathy nor empathy is adequate when describing compassion. Instead, Gustafsson and Hemberg (2022) state, “Compassion is ethical conduct that mediates solidarity, commitment, and accessibility with the human at the center and treated with dignity” (Para. 9). Compassion is more than just feeling sympathetic; it transcends into personally understanding another person’s pain and taking action to relieve it. Understanding an individual’s pain and being moved by that pain is what empowers a nurse to act (Gustafsson & Hemberg, 2022) . Quantitative evidence and technical skills give strength and credibility to the professional side of nursing, but compassion is the human and moral aspect of nursing care (Dalvandi et al., 2019) . Therefore, compassion is both the foundation and a critical element that elevates nursing from simple technology to a caring profession.
When building on the description of compassion, compassion satisfaction (CS) is associated with a positive work experience (Baqeas et al., 2021) and the work satisfaction that results from experiencing positive emotions from compassionate caring and positive social relationships (Gustafsson & Hemberg, 2022; Lee et al., 2021) . Correspondingly, CS in a nurse (the sense of pleasure or fulfillment in doing a good job) can protect against stress and CF (Lee et al., 2021) and is necessary to continue providing exceptional care (Ryu & Shim, 2022) . CS is beneficial to both nurses and patients as it encourages nurses to continue delivering care with authentic feeling, knowing their efforts are alleviating the pain and suffering of others. In this way, nurses feel satisfied that they met their goals in realizing patients’ needs, and patients and their families are grateful for receiving exemplary and compassionate care (Ryu & Shim, 2022) . The pillar of professionalism in the Riley et al. (2021) model can provide a foundation to help nurses build and sustain therapeutic relationships based on mutual trust and respect. Mutual trust and respect build an effective professional and caring relationship between nurses and patients and increase nurses’ CS (Lee et al., 2021) .
3.2.1. Elizabeth’s Story
I sat on the patient’s bed after I medicated him for pain and touched his face gently trying to smooth the frown from his forehead. His wife was sitting on the other side of the bed holding his hand. I spoke quietly to both, trying to ease their anxiety and fear. After a while, the patient’s face relaxed, and he fell asleep. The patient’s wife looked at me, sighed deeply and smiled. I smiled back and tears filled both of our eyes. I thought, how can I not love this job when it connects me so closely to others and allows me to relieve suffering? Isn’t this the essence of life?
3.2.2. Beth’s Story
“The warm amber glow of a candle filters through the quiet air. In the bed covered with a patchwork quilt that she has made, a middle-aged woman breathes shallow, erratic last breaths. Her husband of a quarter century sits at her side brushing her cheeks with his stocky fingers and with occasional soft kisses. Although she is unable to talk, he tells her how much their life together has meant to him and how much he will miss her. As her breathing ceases, he gives her a final kiss and turns to me. Freely, I open my arms and my heart to him in his grief. I leave them alone for a moment to say goodbye. As I go, he says, ‘Thank you.’ I smile inside, feeling privileged to have shared in the final moments of their life together” (Perry, 2009: p. 32) .
Duarte and Pinto-Gouveia (2017) also propose that nurses who are the most empathetic toward patients’ feelings and suffering and try to understand experiences from others’ perspectives derive the most satisfaction from their work and are the most compassionate to others and themselves. Self-compassion or self-kindness is one of the principal characteristics that helps nurses understand themselves and subsequently to understand others (Duarte & Pinto-Gouveia, 2017) . In brief, nurses who understand their feelings and are compassionate to themselves can be empathetic to others and provide compassionate care.
3.3. Compassion Fatigue (CF) and Oncology Nurses
CF (vicarious trauma or secondary traumatic stress) is an insidious condition that can affect any individual who works in a caring profession. Professionals working in healthcare (i.e., nurses and other health practitioners), education (teachers), and emergency services (i.e., police officers, firefighters, paramedics, etc.) can all experience CF (Kamkar, 2019; Lombardo & Eyre, 2011) . For this paper, we concentrated on nursing (specifically oncology nursing).
CF is a complex phenomenon that has many precipitating causes. Some factors that can trigger CF in nurses are the repeated witnessing of physical and emotional suffering, deterioration of physical conditions, failed resuscitations, death of patients, unkindness from patients or their families, difficult working conditions, and more. CF is an emotional, physical, psychological, and spiritual exhaustion caused by prolonged exposure to the suffering of people and work-related stress (Gustafsson & Hemberg, 2022; Xie et al., 2021) . Zhang et al. (2018) define CF as “the progressive and cumulative outcome of prolonged, continuous, and intense contact with patients, self-utilization, and exposure to multidimensional stress leading to a compassion discomfort that exceeds nurses’ endurance levels” (para. 1).
Nurses are especially at risk of developing CF as they provide daily care and support to people in pain and at their most vulnerable (Zhang et al., 2018) . Nursing is a discipline that is both demanding and rewarding. Nurses provide care continuously, day and night, and try to meet therapeutic goals while respecting the autonomy and dignity of patients as human beings. Balancing these processes, which are both technical and professional yet personal and intimate, is complicated and often stressful (Duarte & Pinto-Gouveia, 2017; Perry, 2008) . When nurses feel their efforts are not meeting their care objectives and the requirements of their patients, CS becomes low, and they can experience CF (Ryu & Shim, 2022; Zhang et al., 2018) .
Oncology nurses may be at even greater risk for CF. The repeated offerings of empathic and compassionate care, often seemingly futile, can lead to stress and defeatist feelings in cancer care nurses (Kamkar, 2019; Xie et al., 2021) . Duarte and Pinto-Gouveia (2017) agree and write that oncology nursing is one of the fields most prone to occupational stress, burnout, and CF. One can understand how CF often manifests itself in oncology nurses. Cancer patients require multifaceted treatments to meet their physical, emotional, psychological, and spiritual needs (Perry, 2008) . Caring for patients with poor prognoses, being exposed to patients in severe pain or who are approaching death, and managing difficult patient and family situations can take its toll on oncology nurses and lead to CF (Baqeas et al., 2021; Potter et al., 2010) .
3.4. CF and Nurses’ Experiences during COVID-19
Nurses (especially oncology nurses) are at risk for developing CF from occupational stress, but of interest is that this risk increased dramatically for all healthcare workers (principally nurses) during the COVID-19 pandemic. Ondrejková and Halamová (2022) discovered that up to 60% of oncology nurses experienced CF. The survey on healthcare workers’ experiences during the pandemic (SHCWEP) by Statistics Canada (2022) reported that over 90% of nurses felt increased work stress during the pandemic (the highest percentage among all healthcare workers). Nurses, surveyed during the height of COVID-19, were the largest occupational group that indicated they intended to leave or change their jobs in the next three years (Statistics Canada, 2022) . The SHCWEP did not specifically mention CF, but the survey reported that 24.4% of nurses intended to leave their profession or change jobs due to job stress and burnout (70.9%), concerns about their mental health and well-being (53%), and lack of job satisfaction (48.8%) (Statistics Canada, 2022) . Therefore, we believe it is worthwhile to examine the attitudes of nurses who can sustain compassion in their care and the strategies that could help relieve occupational stress and forestall CF.
3.5. Detrimental Effects of Compassion Fatigue (CF)
The detrimental effects of CF are severe and numerous. These effects include adverse changes in nurses’ physiological, emotional, social/behavioural, and cognitive states (Kamkar, 2019; Zhang et al., 2018) . Kamkar (2019) notes that CF can cause detrimental physical symptoms in nurses, such as headaches, tension, dizziness, stomach upsets, nausea, sleep disturbances, and exhaustion. Negative emotional responses nurses may experience from CF include hopelessness, powerlessness, anger, irritability, sadness, detachment, anxiety, hypersensitivity, and reduced empathy (Kamkar, 2019) . Changes in social/behavioural practices due to CF may include loss of interest in activities previously enjoyed, decreased productivity and efficiency at work, increased relationship conflict, poor coping mechanisms (self-medicating and substance abuse), withdrawal, and self-isolation (Kamkar, 2019) . Finally, cognitive symptoms from CF may include difficulty making decisions, focusing, and concentrating, dwelling on the suffering of patients, self-blame about not doing enough, and decreased feelings of self-worth or efficacy (Kamkar, 2019) .
As noted above, the detrimental effects of CF are severe and hamper nurses in all aspects of their personal and professional lives. The consequences of CF also adversely affect patients and healthcare organizations and may lower the quality of care (Salmond et al., 2019) . Nurses suffering from CF cannot maintain the empathy and compassion essential for building strong and trusting nurse/patient relationships and providing quality care (Salmond et al., 2019) . Additionally, CF negatively impacts workplace environments by decreasing productivity and increasing staff turnover, thereby raising organizational costs (Lombardo & Eyre, 2011; Salmond et al., 2019) . Nurses with CF distance themselves from relationships and focus more on the technical aspects of their profession. Disconnecting from relationships may cause productivity and quality care to suffer and absenteeism and job turnover to increase (Salmond et al., 2019) . Arimon-Pagès et al. (2019) concur that CF profoundly affects nurses’ health and increases organizational costs because nurses suffering from CF often feel compelled to change units or leave their profession entirely. Therefore, it is critical to investigate how some nurses can forestall CF and give and sustain outstanding and compassionate care while remaining satisfied and fulfilled in their careers and lives.
4. Methodology of Study
This study used a qualitative exploratory design. Data consisted of reflections from nine oncology nurses (including the principal researcher) and one doctor regarding their personal experiences with patients and families and their strategies to maintain compassion in their care over many years of employment. The participants’ ages were between 34 and 68. Their work experience varied from five to 35 years. All were oncology specialists working on an oncology unit in a larger urban hospital in Canada. A literature review on CF and how nurses circumvent it provided background on the topic and strengthened the validity and potential transferability of the study results.
The study respondents were contacted via social media (i.e., WhatsApp and Messenger) and invited to participate. Each participant agreed to be a co-author in the study and a co-creator of the data by providing narratives regarding their work experiences and personal reflections on CF. The principal investigator conducted semi-structured interviews and subsequent discussions akin to focus groups via social media or face-to-face settings. The interviews and group discussions were audio recorded. The Research Ethics Board approved the study before data collection.
Data sources included interview transcripts, transcripts of the group discussion audio files, and written narratives (stories) provided by the participants, Elizabeth Gorny-Wegrzyn (RN, BScN, MN), Chris Morin (RN, BScN), Nasser Fakun (RN), Haida Paraskevopoulos (RN, BScN), Jackie Cummings (RN), Shanin Bronstein (RN), Mijeong Kim (RN), Helen Politakis (RN), Howard Stuart (MD), and Beth Perry (RN, Ph.D.). The participants consented to have their real names used in publications related to the research, and we have listed them as co-authors for sharing their reflections.
5. Data Analysis
The lead researcher transcribed the interviews and group discussion audio files. All personal information from the narratives and reflections was replaced with codes to secure confidentiality and anonymity. Each co-creator/participant revealed initial themes by sharing their narratives and thoughts on compassion and CF. Data from the personal stories were then analyzed using thematic analysis (TA), focussing on recurrent themes identified by each participant (Clarke & Braun, 2017) . Subsequent discussions with the participants established the meanings of the narratives.
Data were read multiple times before being coded, analyzed, condensed into categories and sub-categories, re-read, re-grouped, and re-analyzed until themes expressed by each co-creator in their interviews and reflections were identified (Clarke & Braun, 2017; Kiger & Varpio, 2020) . TA was chosen for data analysis in this study because of its flexibility regarding the type of research question, sample size and population, process of data collection, and methods of meaning creation (Clarke & Braun, 2017) . We wanted to use an easily accessible and flexible approach to generating codes and themes (meanings) across data related to a shared concept. Clarke and Braun (2017: p. 297) write that “TA can be used to identify patterns within and across data in relation to participants’ lived experience, views and perspectives, and behaviour and practices; ‘experiential’ research which seeks to understand what participants’ think, feel, and do”. The themes that emerged from the data are discussed in a subsequent section of this paper.
6. Strategies to Maintain Compassionate Care and Circumvent CF
Mann et al. (2022) recommend that to maintain exemplary and compassionate care and help circumvent CF, nurses, educators, and organizational leaders must first be capable of identifying the symptoms of CF and then implementing effective strategies to prevent or diminish them. These preventative strategies should be employed at both personal (self-care) and organizational (education and support) levels to help nurture compassion and resilience in nurses and to help mitigate the occurrence of CF (Mann et al., 2022) .
6.1. Personal Strategies
There are numerous strategies nurses can employ to maintain their compassion in care and lessen their risk for CF. These strategies include self-care approaches such as ensuring adequate sleep, nutrition, and exercise and balancing their work and personal lives by engaging in pleasurable hobbies, social interactions, and spirituality outside work (Gustafsson & Hemberg, 2022; Salmond et al., 2019) . Mann et al. (2022) add self-care strategies such as stress management through mindfulness and meditation and increased awareness of the importance of mental health, all of which can reduce the risk of CF.
Other personal strategies to curtail CF might entail increasing self-compassion and self-forgiveness, acknowledging limits, setting professional boundaries, and requesting help from colleagues and superiors (Baqeas et al., 2021; Gustafsson & Hemberg, 2022) . Nurses who are more self-critical and less self-forgiving are more disposed to CF (Baqeas et al., 2021) . Nurses who maintain a positive attitude about life and are self-compassionate are more likely to circumvent CF and feel more compassion for others (Baqeas et al., 2021; Gustafsson & Hemberg, 2022) . Baqeas et al. (2021) suggest that focusing on the positive changes nurses make to the lives of patients and families, acknowledging limitations, and forgiving themselves for unfortunate occurrences beyond their control forestall CF and help nurses maintain their enthusiasm and passion for nursing. Continuing nursing education by strengthening professional and communication skills, increasing self-awareness through self-reflection, and connecting with peers (in formal debriefing and discussion groups and informal recreational and social gatherings) can increase feelings of interrelatedness with others and can empower nurses to be more effective and compassionate (Salmond et al., 2019; Baqeas et al., 2021) . Salmond et al. (2019) assert that “coping is often multifaceted: there is no ‘one size fits all’ approach. Individual nurses develop their personal resilience plan and are on the alert for a misaligned work-life balance.” (Para. Personal approaches). In brief, there are many effective personal strategies to help sustain compassion and decrease the risk of CF that nurses can individualize to their unique needs.
6.2. Professional Strategies
Salmond et al. (2019) note that aside from personal strategies to forestall CF, a supportive and nurturing work environment is imperative to deal with and prevent CF. The first and most crucial step in managing CF is acknowledging that it exists and can profoundly affect the health of staff and undermine the quality of care they give patients. The second step is to provide support that can help reduce stress during work. Strategies such as having supportive and compassionate organizational leaders, establishing formal and informal peer support groups, arranging debriefing sessions after stressful work events, supporting the need for schedule and assignment changes, ensuring mandatory break times, and making psychological and emotional support available through counselling can significantly reduce the risk of CF (Gustafsson & Hemberg, 2022; Salmond et al., 2019) .
Other organizational strategies include assisting in team development (among staff and between staff and management), providing mentorship, encouraging staff self-awareness, promoting self-reflective practices, and providing in-service education to increase awareness of the risk of CF and how to circumvent it (Salmond et al., 2019) . An organizational culture that acknowledges the potential risk of CF and supplies appropriate support does much to help nurses mitigate this risk. Nurses with productive tools to combat CF are more likely to sustain exemplary and compassionate care and continue to thrive.
6.3. Educational Strategies
Nursing education provides nurses with tools to thrive as compassionate nurses and people. Compassion is taught, to a certain extent, through mentorship and example. Nurse educators who embrace pedagogies based on kindness can foster learning environments that support open communion and motivate students to feel compassion toward others (Gorny-Wegrzyn & Perry, 2021) . Encouraging nursing students from different backgrounds with unique life experiences to have open discussions encourages human connections, advances an understanding of the opinions, beliefs, and values of others, and cultivates feelings of empathy and compassion as students identify with each other (Gorny-Wegrzyn & Perry, 2021) . Su et al. (2020) agree, stating that the student nurses in their study recognized that compassionate care and inclusion are critical for their professional development and the development of the nursing profession. Su et al. (2020) concluded nursing students needed educators and managers to provide supportive school and work environments to help them in their professional development and that nurse mentors/preceptors need to model compassionate care to help teach students how to provide compassionate care to others.
In the same sense, continuing education throughout a nurse’s career is vital to maintaining compassion in care and circumventing CF. Advancing nursing theories, evidence-based practices, and professional skills and incorporating them into daily care can make nurses more effective and less stressed (Salmond et al., 2019) . Promoting education and training in specialized nursing fields (cancer care and palliative care, in this instance) can make nurses feel more confident in their care and relieve work-related stress (Baqeas et al., 2021) . Finally, providing informal and formal in-services to strengthen communication skills, increase awareness of the symptoms of CF, and promote skill development in coping and self-care can help forestall CF and encourage a work-life balance (Salmond et al., 2019) . In brief, utilizing the above strategies (personal, professional, and educational) can help nurses thrive in their chosen professional fields despite demanding conditions and situations and ensure they maintain their compassion in care. As indicated in the framework by Riley et al. (2021) , when building a nursing practice based on the four pillars of professionalism, scholarly practice, leadership, and stewardship, nurses can maintain exemplary and compassionate care throughout their nursing careers.
7. Findings and Discussion
The following section discusses the themes that emerged from the participants’ reflections. It became evident that oncology nurses who can forestall CF and maintain an enthusiasm for nursing have 1) a positive outlook on life, 2) use specific strategies for self-care, and 3) employ unique approaches when caring for patients and families. These themes became apparent through data analysis, and each is explored in more detail below.
Theme 1: Positive Attitude toward Life
The first theme that came to light was that the study participants all have a positive attitude toward life. The participating nurses enjoyed their personal lives with family and friends and felt their professional lives were valuable and worthwhile. Many described themselves as optimists even during difficult times and trying circumstances, as the following conversation excerpts illustrate.
Elizabeth’s Perspective
I think of myself as an eternal optimist. No matter what’s happening, I don’t give up because I feel that by trying, things will work out in the end. The outcome may not be perfect, but it will be better and worth trying. The comfort of the patient is always our primary goal.
Chris’s Perspective
It’s all about balance in life, giving and receiving. We do our best and hope that we help others in the process. Any effort is worthwhile. Making someone feel better motivates us to continue to provide care with compassion.
Nasser’s Perspective
I’m an easygoing person who takes things in his stride. The key to being happy in nursing and life is to try your best in each situation and not agonize over the things you have no control over.
Jackie’s Perspective
Putting in the effort and making a difference is what’s important. Reassuring patients and calming their fears or concerns makes what we do rewarding and valuable.
Mijeong’s Perspective
I’m originally an RN from South Korea and now work as a charge nurse in Canada. There are differences in healthcare and lifestyle in the two countries, but accepting these differences and challenges and remaining motivated is the key to preventing compassion fatigue in nursing and being happy.
Helen’s Perspective
I always see the positive side of every situation and try my best to achieve a positive outcome. Easing a patient’s discomfort is meaningful to our work and our lives.
The positive perspective on life enabled the participants in this study to enjoy their personal lives and enrich their professional lives by allowing them to grow as nurses and people (Kim & Chang, 2022) . Salmond et al. (2019) note that when a nurse cares for a patient during a crucial moment in the person’s life, an intimate connection forms between them. This intimacy allows the nurse to share in the patient’s suffering (i.e., altered life, pain, loss, and death), forming a connection that leads to satisfaction, inspiration, and fulfilment in the nurse when the patient’s pain and suffering are relieved or eased (Salmond et al., 2019) . Each nurse in this study stated that their work experiences made them feel grateful for life in general and that they felt a sense of satisfaction, joy, and pride when they changed people’s lives for the better. Riley et al. (2021: p. 1021) describe professionalism as a “multidimensional lived experience” that includes “identity formation, comportment, acceptance and accountability for professional responsibilities and expectations”. The following experts from the data demonstrate this shared experience and nurses’ prioritization in caring for patients and families with compassion, respect, and accountability (Riley et al., 2021) .
Elizabeth’s Story
Being responsible for life (a human life) is a heavy burden, but saving a person’s life, easing someone’s pain, or just making them smile is the best feeling in the world. I feel a sense of satisfaction when patients get better and return home. But there can be equal satisfaction in helping individuals die peacefully, pain-free and with dignity. End-of-life care is often demanding but also rewarding. How can I not feel fulfilled at the end of the day?
Chris’s Story
Not all days are perfect, but we feel satisfied when we’ve done our best and see the patients relieved of discomfort. Our goal is to provide the best care possible to the patients, and when we achieve this goal, we go home with a sense of fulfillment that spreads into our everyday lives. The pride in our work keeps us coming back and being grateful.
Haida’s Story
Being a nurse manager, I work behind the scenes, but my priority is always the care of the patients and the support of the nurses. Thank yous are appreciated and fulfilling, but my work satisfaction comes when the staff is happy. A happy and supported work staff gives the best patient care.
Helen’s Story
I started my career filled with eager anticipation to help people. People told me my enthusiasm would wane over the years, but that isn’t true. I’m more passionate about my work today than ever before. The satisfaction and fulfillment of doing my best for a patient make me grateful to be a nurse.
Theme 2: Strategies Used for Self-Care
The second theme that emerged from the study was that the participating nurses used many individual strategies for self-care. All reiterated that they were grateful for life and enjoyed activities outside of work (i.e., time spent with family and friends, meditation and relaxation, catching up on sleep, and exercise such as swimming, dancing, biking, yoga, etc.) that allowed them to return to work happy, rested, and refreshed.
Elizabeth’s Self-Care Strategy
Yoga is the go-to exercise I practice daily. I also love other activities, like dancing, reading, listening to music, and going out with family and friends. Yoga gives me a great workout and a chance to breathe, relax, reflect on my day, and rejuvenate.
Chris’s Self-Care Strategy
Taking my children to school and sports activities helps me destress after work. These activities can be hectic, but they take me away from work into a family-oriented environment that relaxes and refreshes my thoughts and feelings.
Nasser’s Self-Care Strategy
The foremost thing aside from work is my family. My children help me relax and to think about their futures and how I can help them. The sense of accomplishment at work helps me accomplish things at home. I like to renovate at home to help myself destress.
Mijeong’s Self-Care Strategy
It seems that my strategies to destress have changed with age. In my twenties, for example, I went out to movies or just hung out with friends after my shift. Now, in my mid-thirties, I exercise to help control my stress, and I learned that getting enough sleep was vital to rejuvenate myself. I also use strategies like listening to music, reading books, keeping a diary, and cooking healthy food.
The co-investigators voiced that continuing their education and developing themselves as professionals was crucial to their sense of taking care of their own needs (Kim & Chang, 2022) . They felt that additional courses and in-services on oncology and palliative care, as well as general nursing techniques, theory, and practice, would make them more confident and better able to cope and adapt to various work situations. This perspective also empowered the participants to evolve as professionals within a scholarly practice by acknowledging that they needed to continue learning to give the best and most compassionate care and to successfully address health inequities (Riley et al., 2021) .
Elizabeth’s Perspective
Going to a continuing-education course is always a plus. You learn about the newest and most effective nursing techniques used worldwide, gain new perspectives and outlooks from others, and have an outing related to your work in a different and less stressful setting. We all want to be better nurses and give the patients the best care possible.
Mijeong’s Perspective
I think self-motivated learning promotes happiness by strengthening growth potential for daily life and nursing. Continuing education advances confidence in nurses and can potentially improve the whole healthcare system.
The participating nurses also used positive interpersonal relationships with patients and their families, colleagues at work, and their own families and friends as coping strategies in times of stress (Kim & Chang, 2022) . The participants stated that they relied on activities and supportive communication with family members and friends to help them enjoy life and destress after work. The participating nurses also relied heavily on mentors and co-workers to help support and comfort them after distressing situations at work through formal and informal de-briefing sessions. In keeping with the framework suggested by Riley et al. (2021: p. 1020) , all nurses share the responsibility of leadership and stewardship in different ways across the lifetime of their careers, and “stakeholders, who are invested in the practice life of the nurse, are also recognized as important influencers because they support the development and promotion of conditions that are conducive to sustaining professionalism”. The following quote from the doctor included in this study indicates this influence.
Howard’s Perspective
More so than monetary incentives, the support of administration and work colleagues can influence the retention of healthcare professionals and increase their work satisfaction. Nurses value a supportive work environment that embraces them as equal collaborators in decision-making. In my observations, nurses who feel they are equal members of an interdisciplinary team maintain their passion for the profession and continue to give compassionate and exemplary care to the patients.
Going out together for a pleasurable activity (i.e., a sports event, holiday party, supper at a restaurant, etc.) could be used as an effective coping mechanism to counteract the stress at work. Many participants considered their colleagues as work-family. In sharing information, even within informal gatherings, nurses and other health professionals can mentor, teach, and support each other and address ethical and financial decisions and health policy (Riley et al., 2021) . The co-investigators stated that discussing work situations (both joyful and tragic) with people who they knew would understand did much to refocus their minds on the positive aspects of their work, as the following data excerpts indicate.
Elizabeth’s Perspective
Sometimes all we need after an eventful day is to go out together as a work family! We can laugh, cry, or talk about our day. We use dark humour that we know our peers will understand. A sympathetic touch on the arm or an empathetic look from a colleague tells us they’ve been there too, and we’re not alone. It helps reaffirm our compassion for patients and encourages us to maintain our enthusiasm for nursing.
Nasser’s Perspective
The support of management is crucial in maintaining morale but going out with colleagues from work (many of whom are like family) can be the most important thing to keep the team happy and working well.
Chris’s Perspective
There is a bond and understanding between team members. Only a work colleague can understand our dark humour. Going out together in a social milieu can strengthen that bond and help the team be happier and more cohesive despite any emotional upheavals at work.
Jackie’s Perspective
There is a camaraderie between colleagues at work that makes our lives easier. We go out together because we want to spend time with each other outside of the working environment. We think of the nurses, doctors, and other healthcare practitioners as our family, and their support helps us feel happy and fulfilled at work.
Shanin’s Perspective
Going out to social events with colleagues from work is essential to the harmony of the unit and maintains our passion for nursing. We love and support each other at these outings, and that makes us want to continue our work and give care to the best of our ability.
Theme 3: Unique Approaches to Caring for Patients and Families
The final theme that emerged is that the participants in this study used unique approaches when caring for patients and their families. Perry (2009) writes that many nurses keep professional boundaries and never allow themselves to become emotionally attached to patients. Perry (2009) states that sometimes she is questioned whether it is appropriate for a nurse to blur these boundaries, and she replies that exemplary nurses seem to allow a sharing bond to form with some of their patients and that these relationships are often the most positive and rewarding for the nurse. Perry (2009: p. 39) writes, “…if you talk to exemplary nurses, they say that it is these experiences where they feel especially close to specific patients or family members that have taught them the most and that have fueled their ability to continue to care”.
In the same sense, the co-investigators in this study stated that they allowed themselves to become emotionally connected with the patients to some extent. By doing so, they felt more empathetic, often imagining themselves or their family members in the patient’s situation, and thereby honestly caring for them with compassion. The study participants also used creativity in their approach to patients, combining the art and science of nursing, and considered the individual and cultural beliefs of the people they cared for. Riley et al. (2021: p. 1019) define exemplary nurse practice as “the best of the best of the art and science of nursing, and it represents the highest level of knowledge, expertise, and competence”. The following data excerpts demonstrate these approaches.
Elizabeth’s Approach
All patients deserve the best care we can give. I think of how I want someone to treat me or anyone in my family. I try to care for and comfort others in the same way. Patients and their families should be listened to carefully because their thoughts and feelings are important and should be respected. The goal is to optimize comfort and maintain the autonomy and dignity of the patients.
Mijeong’s Approach
I approach patients and their families with two principles. The first is never to ignore what patients tell me. For instance, pain is subjective and can be physical, emotional, or psychological. I put aside potential biases and act on what the patient tells me. The second is based on a Korean saying, “the thorns under my fingernails hurt the most.” The second principle helps me set priorities and better satisfy patients and their families by delegating tasks or personally assessing problems.
Chris’s Approach
We use creativity with the patients in our unit. The creative strategies include making people feel at home by buying them small gifts (like chocolates) for special occasions. Music is also a prominent therapy used. Whether we sing, play the radio, or use the professional services of a music therapist, the patients are happier and feel better. That’s always our goal.
Shanin’s Approach
I let the patient and family guide my approach to them. People come from different backgrounds, and what may be acceptable to some may not be to others. My strategy is to respect the person and their individual beliefs.
Salmond et al. (2019) write that a meaningful relationship between a nurse and a patient is both a responsibility and a gift that enhances compassionate care and leads to job satisfaction. Perry (2008) concurs, stating the participants in her study perceived their nurse/patient relationships as a gift that encompassed the responsibility of their role as a nurse.
The co-investigators in this study stated they felt privileged that patients allowed them to share their lives, vulnerable moments, and valuable achievements. They felt great satisfaction that patients let them into their lives and trusted them with their care. The trust placed in them was a responsibility the participating nurses took seriously, and they worked to maintain that trust throughout the therapeutic nurse/patient relationship. The participating nurses stated the more they cared, the more satisfied they were with their work. Riley et al. (2021) affirm that nurses must maintain personal and professional accountability to provide and maintain compassionate and exemplary care while treating patients with respect and dignity. Below are some stories for the data that illuminates this experience.
Elizabeth’s Story
I feel privileged when a patient trusts me to care for them. A patient once told me, “I dreamed about an angel last night. I asked her to come help me, and you came.” Her words touched me. We use knowledge, critical thinking, and technical skills to do our jobs, but connecting with another person with genuine feelings is part of our work that I’m most proud of. I felt honoured that she trusted me, and I knew it was my responsibility to help her.
Mijeong’s Story
I’ll never forget the first patient who died when I was a new grad. I lacked experience and felt guilty that inside, I thought the patient was demanding. After the patient’s death, her sister thanked me for my care and told me she felt guilty because she was tired of caring for the patient for so long. I felt privileged that the sister confided in me and grateful that she appreciated my nursing care. That experience taught me to understand the feelings people may experience during end-of-life (sadness, guilt, fatigue, and relief). I give better and more compassionate care to patients as a result.
Finally, our co-investigators used approaches that made their patients feel respected, valued, and validated by being attentive to seemingly minor yet essential elements in a caring and trusting relationship. Perry (2009: p. 38) wrote, “…it became even more obvious to me that it is the little things between being a great nurse and being an exemplary nurse”.
Similarly, the participating nurses in this study often used simple techniques and gestures (i.e., humour, silence, smiling, touching, etc.) to build a therapeutic yet human and caring connection with patients and their families. These compassionate approaches made the patients feel safe, respected, and cared for. When the patients felt safe, the nurses felt satisfied with a job well done. The final data excerpts below demonstrate these experiences.
Elizabeth’s Story
The patient was nervous about the insertion of an intravenous. I held his hand, smiled at him, and explained each step of the procedure. I saw him relax and smile back. I knew my touch and smile helped him trust me to do the best I could for him.
Helen’s Story
I touched the shoulder of an anxious patient and felt how tense it was. We were going to talk about her treatment, but instead, I sat quietly beside her. After a while, her shoulder untensed, and she sighed. I knew she was ready to talk then.
Chris’s Story
The patient wanted to talk and for me to listen. He needed to express the feelings pent up inside him, so I sat and listened carefully. Later he told me that my listening meant so much.
8. Conclusion
Empirical evidence reveals that CF adversely affects nurses’ physical, psychological, emotional, and spiritual health. In doing so, CF also affects patients and healthcare institutions by lowering the quality of care and raising organizational costs. Our study has shown that there are effective strategies nurses can use to circumvent CF, mitigate its overall effects, and continue to provide exemplary and compassionate care to patients. These strategies enable nurses to retain their passion for the profession and maintain work satisfaction and pride over the lifetime of their careers.
The model, The Exemplary Practice Life of the Nurse, by Riley et al. (2021) , helped to frame our study. The three themes that emerged in the discussion: positive attitude towards life, strategies used for self-care, and unique approaches to caring for patients and families illustrated how the participants’ perspectives and stories related to the pillars of professionalism, scholarly practice, leadership, and stewardship and how they were able to build on this foundation. Future studies on CF (its adverse effects and methods to mitigate it) are imperative for the health and wellness of nurses, other health professionals, and society.
Funding
This project was funded by the Athabasca University Academic Research Fund.