Project – Compassion Fatigue and Quality of Nursing Practice among Critical-Care Nurses: A Study of Selected Tertiary Hospitals in Enugu State

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Nursing is a caring profession that requires practitioners to provide continuous physical, psychological, emotional and social support to individuals experiencing illness, injury and other forms of human suffering. Nurses are expected to demonstrate empathy, compassion, professional competence and emotional availability while simultaneously maintaining clinical judgement and patient safety. These expectations become particularly demanding in critical-care environments, where nurses care for patients whose conditions may change rapidly and whose survival may depend on timely and accurate interventions. Critical-care nurses are frequently exposed to severe illness, invasive procedures, emergency situations, death and the emotional distress of patients and their relatives. Such repeated exposure to suffering can create considerable psychological demands on nurses and increase their vulnerability to compassion fatigue. Cocker and Joss (2016) explained that compassion fatigue is associated with exposure to the traumatic experiences of people receiving care and is particularly relevant to healthcare professionals who repeatedly encounter suffering and trauma.

Compassion fatigue has become an important occupational concern within nursing because the emotional resources required for compassionate practice may become depleted when exposure to stressful and traumatic situations is prolonged. The concept is commonly discussed in relation to secondary traumatic stress and burnout, although these constructs are not identical. Secondary traumatic stress may arise when professionals experience trauma-related symptoms as a consequence of repeated exposure to another person’s traumatic experience, whereas burnout is more broadly associated with chronic occupational stress and emotional exhaustion. The Professional Quality of Life framework developed by Stamm conceptualises professional quality of life through compassion satisfaction, burnout and secondary traumatic stress, providing an important basis for understanding the emotional experiences of professionals who work with suffering individuals (Stamm, 2010). Research among nurses has shown that compassion fatigue is a significant professional concern, with intensive-care nurses particularly vulnerable because of the severity of patient conditions and the demanding nature of the clinical environment (Xie et al., 2021).

Critical-care nursing presents circumstances that may intensify compassion fatigue. Nurses working in intensive-care settings must frequently monitor unstable patients, administer complex treatments, respond to emergencies, communicate difficult information and support relatives during periods of uncertainty. The repeated experience of patient deterioration, unsuccessful resuscitation and death may generate emotional strain, especially where nurses have limited opportunities for psychological recovery. A recent systematic review of ICU nurses found that high workload, staffing constraints, moral distress, repeated exposure to suffering and inadequate psychological support were important contributors to burnout and compassion-fatigue-related outcomes. Similarly, a systematic review and meta-analysis involving intensive-care professionals found substantial levels of burnout and secondary traumatic stress and identified workload, organisational and psychological factors as important determinants (Badawy et al., 2026; Xie et al., 2021).

The problem of compassion fatigue is important because the emotional condition of nurses can influence their professional functioning and ultimately the quality of nursing practice. Quality nursing practice involves the provision of safe, timely, effective, patient-centred, evidence-based and professionally appropriate care. Donabedian (1988) conceptualised healthcare quality through the relationship between healthcare structures, processes and outcomes, suggesting that the quality of care cannot be separated from the conditions under which healthcare professionals perform their responsibilities. In nursing, quality practice therefore involves not only whether a nurse possesses appropriate knowledge and skills but also whether the nurse is able to apply those skills consistently and compassionately during patient care. When nurses experience severe emotional exhaustion, reduced empathy or psychological distress, their ability to maintain optimal professional performance may be affected.

Empirical evidence has increasingly demonstrated a relationship between nurses’ psychological well-being and the quality and safety of patient care. Poghosyan et al. (2010), in a cross-national investigation involving 53,846 nurses from six countries, reported that higher levels of nurse burnout were associated with lower ratings of quality of care. Similarly, a systematic review and meta-analysis involving 85 studies and 288,581 nurses found that nurse burnout was associated with poorer patient safety climate, more medication errors, falls, adverse events, missed care and lower nurse-assessed quality of care. Although burnout and compassion fatigue should not be treated as interchangeable concepts, the evidence provides an important basis for investigating whether emotional depletion associated with caring for critically ill patients may influence the quality of nursing practice (Poghosyan et al., 2010; Li et al., 2024).

The Nigerian healthcare environment makes the issue particularly relevant because nurses often work under demanding conditions involving heavy workloads, staffing challenges, long shifts and substantial patient-care responsibilities. Evidence from Enugu demonstrates that nurses experience occupational conditions that may contribute to emotional exhaustion and other dimensions of burnout. A qualitative study of nurses working in private hospitals in Enugu identified emotional exhaustion, depersonalisation and reduced personal accomplishment as important dimensions of nurses’ quality of work-life concerns. Participants associated emotional exhaustion with night shifts and excessive workload, while inadequate staffing was linked with difficulties in meeting patients’ nursing-care demands. These findings are relevant to compassion fatigue because repeated exposure to demanding care situations, combined with inadequate opportunities for recovery, may weaken nurses’ emotional resources and affect their capacity to sustain high-quality care (Okafor et al., 2023).

The issue is especially significant in tertiary healthcare institutions in Enugu State, where nurses provide care to patients with complex and severe health conditions and where hospitals also perform important teaching, specialist-care and research functions. The University of Nigeria Teaching Hospital, Enugu, for example, has a nursing services division responsible for nursing care, staffing, administration and specialised clinical units, including accident and emergency, oncology, neurosurgery, paediatrics, theatre and other areas requiring specialised nursing practice. The Federal Ministry of Health and Social Welfare also identifies the University of Nigeria Teaching Hospital, Enugu, among Nigeria’s teaching hospitals. In addition, the National Orthopaedic Hospital, Enugu, provides specialist orthopaedic and emergency services and maintains dedicated nursing services. The demanding nature of such clinical environments makes the emotional well-being of critical-care nurses an important consideration for maintaining professional standards and quality patient care (Federal Ministry of Health and Social Welfare, 2026; University of Nigeria Teaching Hospital, 2026).

Against this background, examining compassion fatigue and quality of nursing practice among critical-care nurses in selected tertiary hospitals in Enugu State is important. Existing evidence has established that nurses are vulnerable to compassion fatigue and that emotional exhaustion-related conditions can have implications for patient safety and quality of care. However, much of the available evidence on compassion fatigue has been generated outside Nigeria, while Nigerian studies have more commonly focused on burnout, general occupational stress or broader quality-of-work-life concerns. A Nigerian intervention study conducted among nurses at Lagos University Teaching Hospital demonstrated that structured nurse-led intervention could improve nurses’ knowledge and management of compassion fatigue, suggesting that the problem is relevant within the Nigerian healthcare environment. At the same time, there remains a need for context-specific evidence concerning critical-care nurses in Enugu State, particularly regarding whether the level of compassion fatigue is associated with the quality of nursing practice. This study therefore seeks to investigate compassion fatigue and quality of nursing practice among critical-care nurses in selected tertiary hospitals in Enugu State (Saliu, 2020).

1.2 Statement of the Problem

Critical-care nurses occupy one of the most demanding positions within the healthcare system because they provide continuous care to patients who are often critically ill, unstable or at high risk of death. Their responsibilities require constant observation, rapid clinical decision-making, technical competence, emotional support and effective communication with patients and relatives. The repeated exposure to pain, suffering, emergency situations, unsuccessful treatment outcomes and death may place nurses under considerable emotional pressure. Although compassion is central to nursing practice, prolonged exposure to patients’ suffering may produce emotional exhaustion and secondary traumatic stress, thereby increasing the risk of compassion fatigue among nurses. Evidence from systematic reviews indicates that nurses, particularly those working in intensive-care and emergency environments, are vulnerable to compassion-fatigue-related outcomes because of repeated exposure to severe illness and demanding working conditions (Cocker & Joss, 2016; Xie et al., 2021).

The problem becomes more concerning when compassion fatigue potentially affects the ability of nurses to maintain the expected standard of patient care. Nursing practice requires sustained attention, empathy, effective communication, accurate clinical judgement, adherence to professional standards and appropriate responses to patients’ changing conditions. When nurses become emotionally exhausted, they may experience reduced motivation, psychological withdrawal, irritability, diminished empathy or difficulty maintaining the same level of engagement with patients. Research has demonstrated that nurse burnout is associated with lower nurse-assessed quality of care and poorer patient-safety outcomes, including missed care and medication errors. Although these findings primarily concern burnout rather than compassion fatigue itself, they indicate why emotional well-being among nurses deserves attention when evaluating the quality of nursing practice (Poghosyan et al., 2010; Li et al., 2024).

Within Nigeria, there is an additional concern because nurses work in healthcare settings where staffing levels, workload, shift patterns and available institutional support may create substantial occupational demands. Evidence from Enugu has shown that nurses have reported emotional exhaustion associated with excessive workload and night shifts, while inadequate staffing may make it difficult for nurses to meet patients’ care needs. Such conditions may create an environment in which nurses continually expend emotional and physical resources without adequate opportunity for recovery. Furthermore, a Nigerian study at Lagos University Teaching Hospital demonstrated that nurses could benefit from structured interventions for managing compassion fatigue, suggesting that the phenomenon is not merely theoretical but represents a practical nursing workforce concern in Nigeria (Okafor et al., 2023; Saliu, 2020).

Despite the potential implications of compassion fatigue for nursing practice, there is limited context-specific evidence concerning the relationship between compassion fatigue and quality of nursing practice among critical-care nurses in tertiary hospitals in Enugu State. Existing Nigerian literature provides useful evidence on burnout, quality of work life and compassion-fatigue management, but comparatively less attention has been directed specifically toward critical-care nurses and the quality of care they provide in tertiary hospitals within Enugu State. This creates a research gap because findings from other countries or from non-critical-care nursing populations may not fully reflect the working realities of critical-care nurses in Enugu. It is therefore necessary to determine the level of compassion fatigue among critical-care nurses, assess the quality of their nursing practice and establish whether a significant relationship exists between the two variables. The findings may provide evidence for nursing administrators and hospital management to develop appropriate supportive measures that can protect nurses’ well-being while strengthening the quality and safety of patient care.

1.3 Purpose of the Study

The main purpose of this study is to examine the relationship between compassion fatigue and quality of nursing practice among critical-care nurses in selected tertiary hospitals in Enugu State.

Specifically, the study seeks to:

1. determine the level of compassion fatigue among critical-care nurses in selected tertiary hospitals in Enugu State;
2. assess the level of secondary traumatic stress experienced by critical-care nurses in the selected hospitals;
3. determine the level of burnout among critical-care nurses in the selected hospitals;
4. assess the quality of nursing practice among critical-care nurses in the selected hospitals.

1.4 Research Questions

The following research questions will guide the study:

1. What is the level of compassion fatigue among critical-care nurses in selected tertiary hospitals in Enugu State?
2. What is the level of secondary traumatic stress experienced by critical-care nurses in the selected hospitals?
3. What is the level of burnout among critical-care nurses in the selected hospitals?
4. What is the level of quality of nursing practice among critical-care nurses in the selected hospitals?

1.5 Research Hypothesis

The following null hypothesis will be tested at the 0.05 level of significance:

H₀: There is no significant relationship between compassion fatigue and quality of nursing practice among critical-care nurses in selected tertiary hospitals in Enugu State.

1.6 Significance of the Study

The study will be significant to critical-care nurses because it will increase awareness of the psychological and occupational demands associated with continuous exposure to critically ill patients. Understanding compassion fatigue may encourage nurses to recognise early warning signs and adopt appropriate professional and personal coping strategies.

The study will be beneficial to nursing administrators and hospital management because its findings may provide evidence for developing supportive work environments, staff-wellness programmes, counselling services, workload-management strategies and other interventions aimed at reducing compassion fatigue.

The study will be useful to patients and their relatives because improving nurses’ psychological well-being may contribute to more consistent, compassionate, attentive and patient-centred nursing practice. Quality nursing care is an important component of safe healthcare delivery.

The study will also benefit nursing educators and professional nursing bodies by providing evidence that may support the inclusion of psychological resilience, compassion-fatigue awareness, self-care and professional quality of life in continuing nursing education and critical-care nursing programmes.

The study will be relevant to healthcare policymakers because evidence generated from tertiary hospitals in Enugu State may assist in understanding workforce-related challenges that can affect the quality and sustainability of nursing services.

Finally, the study will serve as a reference for future researchers interested in compassion fatigue, burnout, secondary traumatic stress, professional quality of life, critical-care nursing and quality of nursing practice, particularly within the Nigerian healthcare context.

1.7 Scope of the Study

The study will focus on compassion fatigue and quality of nursing practice among critical-care nurses in selected tertiary hospitals in Enugu State, Nigeria.

The study will cover critical-care nurses working in selected critical-care units such as intensive-care units, accident and emergency units and other designated critical-care environments within the selected tertiary hospitals. The study will focus primarily on compassion fatigue as the independent variable and quality of nursing practice as the dependent variable.

The dimensions of compassion fatigue considered in the study will include secondary traumatic stress and burnout, while quality of nursing practice will be examined in relation to professional competence, patient-centred care, communication, responsiveness, safety practices, adherence to professional standards and effective delivery of nursing interventions.

The geographical scope will be limited to selected tertiary hospitals in Enugu State. The study will not cover nurses working exclusively in primary healthcare centres, community health centres or non-clinical administrative positions.

1.8 Operational Definition of Terms

Compassion Fatigue: A state of emotional and psychological strain associated with prolonged exposure to the suffering and traumatic experiences of patients, commonly reflected through secondary traumatic stress and burnout-related symptoms.

Critical-Care Nurse: A registered nurse who provides direct nursing care to critically ill or unstable patients in specialised clinical environments such as intensive-care, emergency or other critical-care units.

Quality of Nursing Practice: The extent to which nurses provide safe, effective, timely, compassionate, patient-centred and professionally appropriate care in accordance with established nursing standards.

Secondary Traumatic Stress: Trauma-related stress reactions experienced by a healthcare professional as a result of repeated exposure to the traumatic experiences or suffering of patients.

Burnout: A state of occupational exhaustion associated with prolonged exposure to work-related stress and commonly characterised by emotional exhaustion, depersonalisation and reduced personal accomplishment.

Compassion Satisfaction: The positive sense of fulfilment and professional satisfaction derived from helping and caring for patients.

Tertiary Hospital: A specialised healthcare institution that provides advanced diagnostic, therapeutic, specialist and critical-care services and may also perform teaching and research functions.

Nursing Practice: The application of professional nursing knowledge, skills, judgement, ethical principles and evidence-based interventions in the provision of patient care.

Critical-Care Unit: A specialised hospital unit in which patients with life-threatening or potentially unstable conditions receive continuous monitoring and advanced medical and nursing care.

1.9 Organisation of the Study

The study will be organised into five chapters. Chapter One will present the introduction, background to the study, statement of the problem, purpose of the study, research questions, research hypothesis, significance of the study, scope of the study, operational definitions and organisation of the study.

Chapter Two will review relevant literature related to compassion fatigue and quality of nursing practice. The chapter will cover conceptual review, theoretical review, empirical review and the identified gap in the literature.

Chapter Three will present the research methodology. It will discuss the research design, study area, population of the study, sample size and sampling procedure, instrument for data collection, validity and reliability of the instrument, method of data collection and method of data analysis.

Chapter Four will present the analysis and interpretation of data collected from the respondents. The research questions and hypothesis will be addressed using appropriate descriptive and inferential statistical techniques.

Chapter Five will present the summary of findings, conclusion, recommendations and suggestions for further studies.

Project – Compassion Fatigue and Quality of Nursing Practice among Critical-Care Nurses: A Study of Selected Tertiary Hospitals in Enugu State