PROFESSIONAL

Death anxiety and compassion fatigue

in critical care nurses
Fiona Milligan and Emad Almomani

Compassion can be seen in the sensitive understanding of

ABSTRACT another’s suffering by those delivering care, and who then
It may be argued that altruism, or the selfless concern for others, was seek solutions to relieve that suffering and promote wellbeing.
fundamental to the discipline of nursing; however, with the evolution Sinclair et al (2016) identified six themes of ‘perceptions of
of nursing, there has been debate within the profession and among compassionate care’. These consisted of the following:
service users about whether this element has been lost. Nurses deal ■ Nature of compassion
with increasingly complex and stressful situations, both patient and ■ Development of compassion
performance related. Additionally, demands on the service and capacity ■ Interpersonal factors related to compassion
constraints continue to place a significant burden on nurses and other health ■ Action and practical compassion
professionals. There are concerns that the cost of caring has had an impact ■ Barriers and enablers of compassion
at a personal and performance level within the nursing profession, highlighted ■ Outcomes of compassion.
particularly by the negative experiences described by NHS service users in These themes appear to give a broader, descriptive definition
the Francis report. Debate continues about the definition of ‘compassionate that could be applied in practice. They show the multifaceted
care’ and how we measure its delivery. Resolving these concerns is a high nature of compassionate care and the factors that impact on
priority for recruitment and retention strategies within both the NHS and care delivery.Within these themes there is a clearly identifiable
private sector healthcare organisations. emergent relationship between compassion fatigue, interpersonal
Key words: Compassion fatigue ■ Death anxiety ■ Critical care nurses factors and barriers and enablers.
■ Cultural and organisational influences
Compassion fatigue, or a gradual lessening of compassion
with associated symptoms of anxiety, stress and negative attitudes,
has the potential to impact significantly on productivity (Hooper

C
et al, 2010; Lilius et al; 2011). It is hypothesised that individuals
ompassion fatigue or secondary traumatic stress was who have a greater capacity for feeling or empathy are more
first recognised in the 1950s in nursing and other at risk of experiencing symptoms.The presence of compassion
frontline professionals, such as first responders and fatigue may be identified through assessing nurses’ personal
fire fighters, who dealt with traumatic incidents feelings relating to death and dying, or death anxiety (Coetzee
(Beck, 2011). Subsequently, ‘compassionate care’ and Klopper, 2010).
has featured in a number of key policy documents, in particular Mitchell et al (2006) found that nurses working in high-
those published following the Francis report (Francis, 2013; skill-level care environments often experienced higher levels of
NHS England, 2016). Debate continues about the definition stress than nurses working in areas where they are less exposed
of compassionate care and how its delivery is measured. In a to death and dying. Stress levels were found to be significantly
systematic review to define compassion, Perez-Bret et al (2016) higher in nurses working in clinical areas, where they were
came to the conclusion that: frequently exposed to sudden and traumatic deaths in patients.
Nurses working in critical care and emergency departments have
‘Compassion originates as an empathic response
a greater exposure to sudden and unplanned death than those
to suffering, as a rational process which pursues
who work in palliative care or community services (Mitchell et
patients’ wellbeing, through specific, ethical actions
al, 2006). However, it could be argued that, although death and
directed at finding a solution to their suffering’.
dying may be more expected within these areas, the relationships
that exist between nurses caring for patients over long periods
Fiona Milligan, Senior Educator, Nursing and Midwifery Education of time may also result in significant emotional distress when
and Research, Hamad Medical Corporation, Doha, Qatar, death occurs (Mitchell et al, 2006).
© 2020 MA Healthcare Ltd

fiona.milligan1@nhs.net Other factors that cause additional stress, specifically for

Emad Almomani, Critical Care Educator, Nursing and Midwifery nurses working in acute environments, include time constraints
Education and Research, Hamad Medical Corporation, Doha, Qatar and balancing decisions on care delivery for the end-of-life
Accepted for publication: March 2020 patient and that of the ‘rescuable patient’. Results from a number
of studies provide evidence of lower anxiety in nurses where

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these issues are less prevalent due to the clinical condition Table 1. Death Attitude Profile Revised (DAP–R)
of patients within these areas (Mitchell et al, 2006; Moola dimensions
et al, 2008) Culture, age and working experience may also
Measurable Explanation
influence coping mechanisms within this cohort (Peters et
dimension
al, 2013). Anecdotal evidence points to a ‘culture of silence’
in many organisations where stressful events within critical Fear of death Confronting death and the feelings evoked
care environments are not discussed, and where debriefing is Death avoidance Avoiding all thoughts or references to
random and rare. death to reduce death anxiety
It is suggested that because of frequent exposure to death
Approach/ Death is viewed as a gateway to a
and dying during their work ‘life’, many nurses experience acceptance happy afterlife
compassion fatigue in addition to developing a greater awareness
of their own mortality. The latter may result in experiencing Escape acceptance Death is viewed as an escape from a
painful existence
feelings related to ‘death anxiety’, which impacts on the delivery
of care at the end of life. As the focus is lost, and feelings of Neutral acceptance Death is viewed as a reality, which is
self-doubt, in association with entrenched feelings of negativity, neither feared nor welcomed
prevail, the ability to deliver compassionate care diminishes or
is lost (Black, 2007; Hooper et al, 2010).
In critical care units, the expectations of family are often The tool is cost-effective and both easily implemented and
unrealistic in relation to positive outcomes due to the validated in adult populations.The response dimension ranges
technology available and expertise that is synonymous with from fear avoidance to approach, escape and neutral acceptance
these environments. These factors contribute to high levels of (Wong et al, 2004).
anxiety and stress among teams. Ciccarello (2003) suggested
that nurses have the skills to deal with critically ill patients, Background
but are less skilled in caring for the dying patient. This would Historically there has been little education provided to nurses
support the concept of advanced care planning needs being working within critical care units on death or care of the dying
promoted in critical care units; including end-of-life discussions within critical environments (Curtis et al, 2010).This may have
to ‘humanise’ the environment (Angus et al, 2016). resulted from the view of critical care environments as being
Empirical evidence from studies looking at death anxiety in curative rather than palliative (Truog et al, 2008). There is an
nurses have predominantly taken place in Western societies, with anecdotal perception that, with advances in technology, death is
a small number in Asia.There is very little evidence from Middle an unlikely outcome in intensive care units (Truog et al, 2008).
Eastern or African countries. This may be due to cultural and Research has suggested that between 16 and 85% of healthcare
religious beliefs associated with specific population groups and workers across the clinical spectrum will develop compassion
a reluctance to explore the concept (Najjir et al, 2009). Other fatigue (Hooper et al, 2010). There has also been little in the
factors that may have impacted on available data are recruitment way of providing debriefing opportunities or recognition of the
of subjects and the ranking of importance of the subject matter need for a more formal structured approach within this highly
within healthcare organisations (Najjir et al, 2009). One study charged atmosphere to support staff post-traumatic incidents.
in a hospital in Israel examined the relationship between nurses There is much debate around the subject of whether
working in oncology and their attitudes towards death and compassion can be taught (Bray et al, 2014; Christiansen et
caring for dying patients.The Frommelt Attitude towards Caring al, 2015; Winch et al, 2015). Is it an inherent trait? How do
of the Dying and the Death Attitude Profile–Revised Scale was we measure compassionate care? Other themes related to
completed by 147 nurses and the conclusions were that personal delivery of compassionate care have included whether we can
attitudes towards death were associated with attitudes towards enable compassion care delivery through role modelling and
care of the dying patient. Some nurses used avoidance to cope what barriers to delivery exist. It is suggested that there are
with their own personal fears; secondary findings suggested several barriers to implementation including individual and
a link between culture and religion in the development of organisational factors, such as high workload, low staffing levels
death attitudes (Braun et al, 2010). The conclusions from the and lack of autonomy and feeling valued (Firth-Couzins et
literature review were that education programmes on death al, 2009).
and dying may reduce anxiety and improve end-of-life care.
Greater insight by nurses into their own beliefs or attitudes in Study aims and methodology
relation to death may also translate into patient care benefits. Thematic qualitative analysis was considered as a research
The Death Attitude Profile Revised (DAP-R) questionnaire methodology; however, anecdotal and observational evidence
is similar in concept to the Frommelt Attitude towards Caring suggested that this may not have been the most appropriate
© 2020 MA Healthcare Ltd

of the Dying and the Death Attitude Profile that can be used approach owing to the subject matter.This has been identified as
to assess attitudes and beliefs (Table 1). It is a multidimensional a factor in the lack of data in relation to this topic, with regional
questionnaire with a seven-point Likert scale that allows for a differences apart (Najjir et al, 2009). Following ethical approval, a
broader scope of response from ‘strongly disagree’ (SD) to ‘strongly mixed-methods study was undertaken.The quantitative arm used
agree’ (SA) and asks questions in five identified dimensions. non-random purposive sampling of qualified nurses working

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Table 2. Sociodemographic characteristics of the respondents in critical

Results
care units Data were analysed using the Pearson chi-squared test owing to
small numbers (relative risk=81) (Tables 3–5).
Variables SICU TICU MICU
Total=30 Total=27 Total=24 Demographic profile of sample
n(%) n(%) n(%) Participants were predominantly female, aged between 28 and 32
Gender years, educated to Bachelor of Science in nursing (BSN) level,
Male 11(36.7) 0 12(50) employed in the organisation from 2 to 11 years with 7-11 years’
Female 19(63.3) 27(100) 12(50) specialty experience.

Age group (years) Outcome data

20–27 years 3 (10.0) - - The nurses surveyed predominantly took a neutral or acceptance
28–35 years 2 (6.7) 5(18.5) 1(4.2) approach to death and dying. In neutral acceptance, death is
36–43 years 18(60.0) 14(51.9) 15(62.5) viewed as a reality, which is neither feared nor welcomed. Death
44–51 years 5 (16.7) 4(14.8) 6(25.0) is viewed as ‘a gateway to a happy afterlife. Fear of death positively
52–59 years 2(6.7) 3(11.1) — correlated, or was associated, with qualification, gender and years
60 years — 1(3.7) 2(8.3) in ICU and negatively correlated, or was associated, with age and
time employed in the organisation. Death avoidance positively
Profession
correlated with qualifications, gender, age group and years in ICU
Head nurse 1(3.3) 1(3.7) 2(8.3)
and negatively correlated to time employed in the organisation.
Charge nurse 1(3.3) - 22(91.7) Neutral acceptance positively correlated, or was associated,
Staff nurse 27(90) 26(86.7) — with qualification, age and years employed in the organisation,
Case manager 1 (3.3) — — and negatively correlated, or associated with, gender and years
Educational level worked in ICU.Approach acceptance positively correlated, or was
Associate degree in 6(20.0) — 1(4.2) associated, with qualifications, time employed in the organisation,
Nursing 3(10.0) 8(29.6) 3(12.5)
years worked in ICU and negatively correlated to age and gender.
Diploma in Nursing Escape acceptance positively correlated, or was associated,with
21(70.0) 19(70.3) 20(83.3)
Bachelor’s in nursing age and years employed in the organisation.Qualifications, age
and years employed in the organisation were positively associated
HMC experience (years) with a ‘neutral response’.
<2 3(10.0) 10(37.0) 4(16.7) All of the above variables and years spent in ICU were associated
2–6 14(46.7) 9(33.3) 7(29.2) with an ‘approach acceptance’. Female gender and longer working
7–11 10(33.3) 6(22.2) 6(25.0) lives spent in critical care were clearly identifiable risk factors for
12–16 3 (10.0) 2(7.4) 7(29.2) presence of compassion fatigue as evidenced through approach
ICU experience (years)
and neutral acceptance response.The most significant predictor
would appear to be length of time working in critical care.
<2 7(23.3) 11(40.7) 9(37.5)
Additionally, anecdotal evidence would suggest that less than 20%
2–6 12(40.0) 9(33.3) 5(20.8)
of the nursing workforce in Hamad Medical Corporation consists
7–11 10(33.3) 1(3.7) 7(29.2)
of the indigenous Qatari population group, with the nursing
12–16 1(3.3) 2(7.4) 2(8.3)
workforce consisting largely of expatriate migrant workers.
17–21 — 4(14.8) 1(4.2) Nursing personal are predominantly recruited from other Arab
countries in the region, India and the Philippines. Interpersonal
across three subspecialty critical care units in a hospital in Qatar factors in migrant populations that may impact on performance
(n=255 full time equivalent). The research questionnaire was include extended family financial support responsibilities, long
provided to the units along with secure boxes for completed absences from countries of origin and cultural and religious
data forms. DAP-R was used in conjunction with demographic beliefs. Contributory factors influencing participant responses
profile questions (Wong et al, 2004). may be the migration status of the nursing workforce. Ensuring
the health and wellbeing of all employees is an organisational
Primary outcomes responsibility; however, it may be that additional supportive
The primary outcomes of the study were to assess attitudes towards measures are required for this workforce group.
death and dying in a multicultural cohort of critical care nurses.
The hypothesis was that barriers and enablers to the delivery of Qualitative outcome data
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compassionate care are multifactoral and include interpersonal A small number of nurses (n=8) were asked to discuss the
causes. Independent variables of age, gender, professional following questions:
qualifications designation, length of time qualified and length of ■ Do you believe that we deliver compassionate care in our
time working in critical care units were measured against response intensive care units?
to the five dimensions of the DAP-R questionnaire (Table 2). ■ What are the barriers to delivery of care?

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The narrative highlighted two themes: the first being Table 3. Death Attitude Profile-Revised Scores of the studied subjects
predominantly that compassionate care was not delivered in working at surgical intensive care unit
critical cares units, the focus was on delivering competent
Dimension SD D MD U MA A SA
care. The second theme was that there was a desire to deliver
competent care; however, barriers were identified that included Fear of Sum 30 61 11 35 11 27 29
staff shortages and high turnover of patients. Professional death Mean 4.3 8.7 1.6 5.0 1.6 3.9 4.1
behaviour was associated with competency rather than
Death Sum 23 29 7 18 14 39 13
compassion as a result of having to prioritise clinical care. avoidance Mean 4.6 5.8 1.4 3.6 2.8 7.8 2.6

Discussion Neutral Sum 10 10 4 19 2 46 53

In the nurses working in critical care who were surveyed, there acceptance Mean 2 2 0.8 3.8 0.4 9.2 10.6
appeared to be an acceptance of death as either an escape from
Approach Sum 25 23 8 53 12 101 59
pain and suffering, or a reality. Qualifications, age and years acceptance Mean 2.5 2.3 0.8 5.3 1.2 10.1 5.9
employed in the organisation were positively associated with
a ‘neutral response’. These variables, including years spent in Escape Sum 32 40 2 15 8 21 25
ICU were associated with an ‘approach’ acceptance.This would acceptance Mean 6.4 8.0 0.4 3 1.6 4.2 5.0
suggest that there is an element of compassion fatigue within the SD=strongly disagree; D=disagree; MD=moderately disagreed; U=undecided;
nursing cohort working in critical care environments reflected MA=moderately agree; A=agree; SA=strongly agree
in their response to death and dying.What is also apparent from
the literature is the influence of culture and beliefs on attitudes
Table 4. Death Attitude Profile-Revised Scores of the studied subjects
to death and dying. Compassion fatigue in nursing populations working at trauma intensive care unit
has been underexplored specifically within Middle Eastern and
African populations.Additionally, migrant workforce populations Dimension SD D MD U MA A SA
have many significant issues that impact on coping abilities or Fear of Sum 17 30 6 42 20 56 13
compassion fatigue. These relate to personal life circumstances, death Mean 2.4 4.3 0.9 6.0 2.9 8.0 1.9
such as financial responsibilities for families and extended families
Death Sum 4 27 10 26 9 50 8
and the reasons for migration.Within the bigger picture of these
avoidance Mean 0.8 5.4 2.0 5.2 1.8 10 1.6
pressing concerns, the result may be a distinct separation between
professional and personal lives; with neither impacting on each Neutral Sum 5 5 8 24 6 52 35
other.Thus, the nursing role and actions may be functional and acceptance Mean 1.0 1.0 1.6 4.8 1.2 10.4 7
skilful but less empathetic. The job or task is completed to the
Approach Sum 8 16 13 67 10 106 44
best of their ability, but without the unnecessary emotional
acceptance Mean 0.8 1.6 1.3 6.7 1.0 10.6 4.4
expenditure. Multiple variables are suggested as factors that
impede or hinder the delivery of compassionate care. These Escape Sum 20 20 7 29 17 36 6
include traditional biomedical rather than patient-centred care acceptance Mean 4 4 1.4 5.8 3.4 7.2 1.2
models (Firth-Cozens and Cornwell, 2009); an overemphasis
SD=strongly disagree; D=disagree; MD=moderately disagreed; U=undecided;
on target-driven initiatives, cost measures including adjustment MA=moderately agree; A=agree; SA=strongly agree
of staff to patient number ratios, resulting in higher levels of
stress and staff burn-out (Bradshaw, 2009). Within this, nurse
attitudes towards death and dying may be a manifestation of the Table 5. Death Attitude Profile-Revised Scores of the studied subjects
working at medical intensive care unit
presence of compassion fatigue. It may become the easier option
to adopt a neutral acceptance or approach to death and dying Dimension SD D MD U MA A SA
to reduce the emotional labour of caring. Coping mechanisms Fear of Sum 22 30 12 19 12 55 13
develop to allow nurses to function within a clinical role without death Mean 3.1 4.3 1.7 2.7 1.7 7.9 1.9
the burden of caring, this is necessary for survival. Certainly
in societies or organisations where anxiety or stress impact on Death Sum 16 31 10 15 6 30 8
staff, emotional wellbeing and performance are not mandatory avoidance Mean 3.2 6.2 2.0 3.0 1.2 6.0 1.6
policies for evaluation or data collection. Neutral acceptance or Neutral Sum 4 4 4 10 6 38 50
approaches to death and dying may well be the preferred option acceptance Mean 0.8 0.8 0.8 2.0 1.2 7.6 10
for staff (World Health Organization, 2012).
Approach Sum 10 15 8 39 13 69 76
acceptance
Study limitations Mean 1.0 1.5 0.5 3.9 1.3 6.9 7.6
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The small sample size in the present study impacts on Escape Sum 22 27 7 14 8 27 11
generalisability to the wider population and statistical acceptance Mean 4.4 5.4 1.4 2.8 1.6 5.4 2.2
significance, with approximately 30% of total critical care
workforce participating in the survey.Annual leave and sickness SD=strongly disagree; D=disagree; MD=moderately disagreed; U=undecided;
MA=moderately agree; A=agree; SA=strongly agree
absence are not included in analysis of available respondents.

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coping or self-preservation strategies to ensure care continues

KEY POINTS to be delivered. However, no emotional attachment exists, and
■ It is suggested that, as the nursing profession has evolved, with its empathy is often absent. Death and dying may be a frequent
increasing capacity and performance-measure constraints, there has been traumatic occurrence with which nurses working in critical
a gradual erosion of compassion in care delivery care environments are faced. Without structured supportive
■ There remains debate on how compassion care is measured measures, such as staff wellbeing or counselling services, or
simple debrief and reflection exercises, the emotional and
■ It is suggested that barriers and enablers to the delivery of compassionate
physical impact that occurs due to repeated exposure can only
care are multifactorial and include interpersonal causes and the traditional
be dealt with on a personal level by detachment from the event
biomedical, rather than patient-centred, care models
that is causing the stress.Variables of extended family financial
■ There is recognition that compassion fatigue is real and present in health support responsibilities, long absences from countries of origin
professionals, and should be part of the corporate risk assessment profile and cultural and religious beliefs in a largely migrant nursing
of healthcare organisations workforce may be contributory factors influencing participant
■ The terms empathy and compassion are interlinked, and to separate or silo responses (Lancet, 2017). Klimecki et al (2012) propose, that
may be counterproductive. Greater measures to recognise distress and there exists a state of empathetic fatigue, rather than compassion
emotional fatigue in health professionals is crucial fatigue, where compassion remains but empathy as an emotion
is blurred or diminished. The state of empathetic fatigue is
Despite the small sample size, there is a positive correlation more difficult to measure, but clearly, predisposing factors are
seen between variables of age, gender duration of employment, similar to those of compassionate fatigue. The terms empathy
length of time working in ICU and responses. The nature of and compassion are interlinked and to separate or silo may
the subject being researched, the ethnicity and a largely migrant be counterproductive. What is clear is that greater measures
workforce may also have impacted on response rate. of recognition of distress and emotional fatigue in healthcare
In Qatar (Arab) nationals account for less than 15% of the professionals across the board is crucial.
total population, with other Arabs at 13%. Asia provides the Correlations with morbidity and mortality outcomes of
largest proportion of the expatriate workforce labour: 24% are patients in critical care units measured against evidence of
Indian, 16% Nepali, 11% Filipino and 5% each from Bangladesh compassion fatigue and patient/family satisfaction would be
and Sri Lanka. Anecdotal evidence that less than 20% of the useful indicators of a relationship existing between attitudes
nursing workforce in HMC is Qatari; therefore, the nursing to death and dying, and care delivery. The body of research
workforce consists largely of expatriate migrant workers. needs to be expanded with comparative analysis made across
Cultural, societal and religious beliefs may also influence views clinical and geographical spectrums. This is particularly true
on death and dying (Qatar World Population Review, 2018). when considering global employment migration as capacity
Pilot studies looking at implementing a process in which demands increase within healthcare organisations worldwide
recommendations for care and treatment in emergency (International Organization for Migration, 2018). Ageing
situations are provided may be useful for future work in this populations, increasing industrialisation and a shift in population
area. A substantial amount of work is being undertaken as part demographics in emerging nations have resulted in a capacity
of the ReSPECT campaign endorsed by the Resuscitation and demand gap that can only be filled through migration of
Council UK (RCUK) in promoting a process that guides people. However, culture, past and current life experiences
decision-making in emergency or life-threatening situations may impact on the interpretation of compassionate care.
(RCUK, 2019). Organisations and leaders are key stakeholders in promoting
the delivery of compassionate care through putting in place
Conclusions mechanisms for recognising compassion fatigue and promoting
There is a clear and pressing need for more research on supportive workplace environments.
compassion fatigue, attitudes towards death and dying and the The debate on whether compassion can be taught should
delivery of compassionate care.The ability to view death in the also be on the agenda of education and healthcare research
neutral or acceptance domains may indicate the development of groups. This phenomenon occurs across geographical areas
and sectors with multiple variables impacting on delivery of
compassionate care.The debate continues about how to address
CPD reflective questions this in a meaningful and effective way. Healthcare has become
a global commodity. Punitive individual blame cultures do
■ How do we measure whether we are delivering compassionate care?
little to address the wider concerns for patients, families and
■ What are the barriers and facilitators to the delivery of compassionate health professionals.
care and should time and resources be barriers to delivering it? Nurses working in high-skill-level care environments often
© 2020 MA Healthcare Ltd

■ What is the difference between empathetic and compassionate care and experience higher levels of stress than nurses working in areas
what are the subsequent implications on holistic care delivery? where they are less exposed to death and dying. Recognition
■ Have we moved towards readopting the traditional biomechanical model that compassion fatigue is a factor that impedes the delivery
of care in order to meet increasing service and target demands? of holistic and compassionate care is the first step. It is then
incumbent on organisations to put in place pathways that not

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only recognise the early stages of compassion fatigue, but provide https://tinyurl.com/yykaj2cg (accessed 21 July 2020)
Lancet. Caring for migrant health-care workers. Lancet.
support interventions to enable nurses to manage workplace 2017;390(10110):2325. https://doi.org/10.1016/S0140-6736(17)33044-1
stress and anxiety. BJN Lilius JM, Worline MC, Dutton JE et al. Understanding compassion
capability. Human Relations 2011;64:873–899. https://doi.
org/10.1177/0018726710396250
Conflict of interest: none Klimecki OM, Singer T. Empathic distress fatigue rather than compassion
fatigue? Integrating findings from empathy research in psychology and
Angus DC, Truog RD. Toward better ICU use at the end of life. JAMA. social neuroscience. In: Oakley B, Knafo A, Madhavan G (eds) Pathological
2016;315(3):255–256. https://doi.org/10.1001/jama.2015.18681 altruism. New York: Oxford University Press; 2012, pp 368–383
Beck CT. Secondary traumatic stress in nurses: a systematic review. Mitchell AM, Sakraida TJ, Dysart-Gale, Gadmer N. Nurses narratives of end of
Arch Psychiatr Nurs. 2011;25(1):1–10. https://doi.org/10.1016/j. life care. J Hosp Palliat Nurs. 2006;8(4): 210–221
apnu.2010.05.005 Moola S, Ehlers VJ, Hattingh SP. Critical care nurses’ perceptions of stress and
Black K. Health care professionals’ death attitudes, experiences, and advance stress-related situations in the workplace. Curationis. 2008;31(2):77–86.
directive communication behavior. Death Stud. 2007;31(6):563–572. https://doi.org/10.4102/curationis.v31i2.989
https://doi.org/10.1080/07481180701356993 Najjar N, Davis LW, Beck-Coon K, Carney Doebbeling C. Compassion
Bradshaw PL. Modernizing the British National Health Service (NHS)— fatigue: a review of the research to date and relevance to cancer-
some ideological and policy considerations. J Nurs Manag. 2003;11(2):85– care providers. J Health Psychol. 2009;14(2):267–277. https://doi.
90. https://doi.org/10.1046/j.1365-2834.2003.00354.x org/10.1177/1359105308100211
Braun M, Gordon D, Uziely B. Associations between oncology nurses’ NHS England. Compassion in practice. Evidencing the impact. 2016. https://
attitudes toward death and caring for dying patients. Oncol Nurs Forum. tinyurl.com/z4wfjon (accessed 21 July 2020)
2010;37(1):E43–E49. https://doi.org/10.1188/10.ONF.E43-E49 Perez-Bret E, Altisent R, Rocafort J. Definition of compassion in healthcare:
Bray L, O’Brien MR, Kirton J, Zubairu K, Christiansen A. The role of a systematic literature review. Int J Palliat Nurs. 2016;22(12):599-606.
professional education in developing compassionate practitioners: A mixed https://doi.org/10.12968/ijpn.2016.22.12.599
methods study exploring the perceptions of health professionals and pre- Peters L, Cant R, Payne S et al. How death anxiety impacts nurses’ caring for
registration students. Nurse Educ Today. 2014;34(3):480–486. https://doi. patients at the end of life: a review of literature. Open Nurs J. 2013;7:14-
org/10.1016/j.nedt.2013.06.017 21. https://doi.org/10.2174/1874434601307010014
Christiansen A, O’Brien MR, Kirton JA, Zubairu K, Bray L. Delivering Qatar Population Review. 2018. http://worldpopulationreview.com/
compassionate care: the enablers and barriers. Br J Nurs. 2015;24(16):833– countries/qatar-population (accessed 21 July 2020)
837. https://doi.org/10.12968/bjon.2015.24.16.833 Resuscitation Council UK. ReSPECT. 2018. https://www.resus.org.uk/
Ciccarello GP. Strategies to improve end-of-life care in the intensive respect/ (accessed 21 July 2020)
care unit. Dimens Crit Care Nurs. 2003;22(5):216–222. https://doi. Sinclair S, Beamer K, Hack TF et al. Sympathy, empathy, and compassion:
org/10.1097/00003465-200309000-00005 a grounded theory study of palliative care patients’ understandings,
Coetzee SK, Klopper HC. Compassion fatigue within nursing practice: experiences, and preferences. Palliat Med. 2017;31(5):437-447. https://doi.
a concept analysis. Nurs Health Sci. 2010;12(2):235-243. https://doi. org/10.1177/0269216316663499
org/10.1111/j.1442-2018.2010.00526.x) Truog RD, Campbell ML, Curtis JR et al. Recommendations for end-of-life
Curtis JR,Vincent JL. Ethics and end-of-life care for adults in the intensive care in the intensive care unit: a consensus statement by the American
care unit. Lancet. 2010;376(9749):1347–1353. https://doi.org/10.1016/ College [corrected] of Critical Care Medicine [published correction
S0140-6736(10)60143-2 appears in Crit Care Med. 2008 May;36(5):1699]. Crit Care Med.
Firth-Cozens J, Cornwell J. The point of care. Enabling compassionate care 2008;36(3):953–963. https://doi.org/10.1097/CCM.0B013E3181659096
in acute hospital settings. The Kings Fund, London; 2009. https://tinyurl. World Health Organization. Sixty-fifth world health assembly: daily notes on
com/yx927tna (accessed 22 July 2020) proceedings. 2012. https://tinyurl.com/y39l3yte (accessed 21 July 2020)
Francis R. T Report of the Mid Staffordshire NHS Foundation Trust public Winch S, Henderson A, Jones J. Recognizing the dialectic of compassionate
inquiry. 2013. https://tinyurl.com/omsm882 care in the workplace: feedback from nurse educators. J Contin Educ Nurs.
Hooper C, Craig J, Janvrin DR, Wetsel MA, Reimels E. Compassion 2015;46(5):228–232. https://doi.org/10.3928/00220124-20150420-03
satisfaction, burnout, and compassion fatigue among emergency nurses Wong TP, Reker GT, Gesser G. Death attitude profile–revised: a
compared with nurses in other selected inpatient specialties. J Emerg Nurs. multidimensional measure of attitudes towards death. In: Neimeyer RA
2010;36(5):420–427. https://doi.org/10.1016/j.jen.2009.11.027 (ed.) Death anxiety handbook: research instrumentation and application.
International Organization for Migration. World Migration Report 2018. New York: Taylor and Francis; 2004:121–148

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