Running head:
COMPASSION FATIGUE IN EMERGENCY MEDICAL

COMPASSION FATIGUE IN EMERGENCY MEDICAL SERVICES (EMS):
THE INFLUENCE OF SELF-CARE ON COMPASSION FATIGUE AMONG
EMS PROFESSIONALS IN NORTHWESTERN PENNSYLVANIA
By
Kelly Martin, BSEd, BSN, MSN
MSN, Clarion and Edinboro Universities, 2015
BSN, Edinboro University, 2009
BSEd, Edinboro University, 2006
A DNP Research Project Submitted to Clarion and Edinboro Universities
In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice Degree
December, 2017

COMPASSION FATIGUE IN EMERGENCY MEDICAL
Compassion fatigue in emergency medical services (EMS): The influence of self-care on
compassion fatigue among EMS professionals in Northwestern Pennsylvania
Committee Signature Page
Student’s name
Committee Chairperson
Committee Member
Committee Member

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COMPASSION FATIGUE IN EMERGENCY MEDICAL
Dedication
I dedicate this study to the men and women working in Emergency Medical Services who devote
their lives to serving others in need during times of tragedy and crisis.

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COMPASSION FATIGUE IN EMERGENCY MEDICAL

Acknowledgements
I would like to acknowledge my committee, Dr. Terri Astorino, Dr. Viki Hedderick, and Julie
Schaefer, PA-C as well as my statistical consultant, Dr. Amy McClune, for the guidance and
expertise they provided throughout the successful completion of this study.

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COMPASSION FATIGUE IN EMERGENCY MEDICAL
COMPASSION FATIGUE IN EMERGENCY MEDICAL SERVICES (EMS): THE
INFLUENCE OF SELF-CARE ON COMPASSION FATIGUE AMONG EMS
PROFESSIONALS IN NORTHWESTERN PENNSYLVANIA
Kelly Martin, MSN, BSN, BSEd, CRNP, PHRN
Abstract
Compassion fatigue, also known as secondary traumatic stress disorder, results from repeated
exposure to the suffering of others, eventually exhausting his or her ability to show compassion.
Self-care has been suggested as a potential preventative or treatment strategy in compassion
fatigue however there has been limited documentation to validate this relationship. This study
utilized a non-experimental, descriptive correlational design in order to determine if EMS
professionals in Northwestern Pennsylvania, who practice self-care, experience less compassion
fatigue than those who do not. A survey which was comprised of The Professional Quality of
Life (ProQOL) scale, a validated tool for assessing compassion fatigue by evaluating secondary
traumatic stress, burnout, and compassion satisfaction, as well as the Health Promotion Lifestyle
Profile (HPLP) II, a tool to evaluate health promotion/self-care, was completed by 164 EMS
professionals in Northwestern Pennsylvania. Spearman’s rank correlation coefficient was
utilized to determine the relationship between self-care and compassion fatigue. The results
demonstrated a negative correlation between self-care and burnout (p<.000), a negative
correlation between self-care and secondary traumatic stress (p<.000), and a positive correlation
between self-care and compassion satisfaction (p<.000), suggesting lower levels of compassion
fatigue in those who practice self-care. These findings suggest that the implementation of selfcare may result in decreased compassion fatigue, improving the EMS professional’s quality of
life as well as patient outcomes.
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
Table of Contents
Introduction ..................................................................................................................................... 1
Background of the Problem ......................................................................................................... 2
Statement of the Problem ............................................................................................................ 6
Research Question ....................................................................................................................... 6
Definition of Terms ..................................................................................................................... 7
Need for the Study ....................................................................................................................... 8
Significance of the Problem ........................................................................................................ 8
Assumptions ................................................................................................................................ 9
Summary of the Problem ............................................................................................................. 9
Review of Related Literature ........................................................................................................ 10
Compassion Fatigue in EMS and fire department personnel .................................................... 10
Compassion Fatigue in Nurses and Physicians ......................................................................... 13
Strategies in the Prevention and Management of Compassion Fatigue .................................... 15
Gap in the Literature .................................................................................................................. 17
Theoretical Framework.............................................................................................................. 18
Summary of the Review of Related Literature .......................................................................... 20
Methodology ................................................................................................................................. 20
Research Design ........................................................................................................................ 21
Setting ........................................................................................................................................ 21
Sample ....................................................................................................................................... 21
Ethical Considerations ............................................................................................................... 21

COMPASSION FATIGUE IN EMERGENCY MEDICAL
Instrumentation .......................................................................................................................... 22
Data Collection .......................................................................................................................... 24
Data Analysis ............................................................................................................................. 25
Summary of Methodology ......................................................................................................... 25
Results and Discussion ................................................................................................................. 25
Description of the Sample ......................................................................................................... 26
Summary.................................................................................................................................... 31
Summary, Conclusions, and Recommendations ........................................................................... 32
Interpretation of the Findings .................................................................................................... 32
Theoretical Framework.............................................................................................................. 34
Limitations ................................................................................................................................. 35
Recommendations for Future Research ..................................................................................... 36
Implications for EMS Professionals .......................................................................................... 37
Conclusion ................................................................................................................................. 39
References ..................................................................................................................................... 41
Appendices .................................................................................................................................... 45
Appendix A: Permission Letter from EMMCO West ............................................................... 45
Appendix B: Permission to use the ProQOL, version 5 ............................................................ 46
Appendix C: Permission to Use the HPLP II ............................................................................ 47
Appendix D: Edinboro University IRB Approval Letter .......................................................... 49
Appendix E: Collaborative Institutional Training Initiative (CITI) Certificates ....................... 51
Appendix F: Consent to Participate in Research Study/Survey ................................................ 54
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
Appendix G: Permission to Utilize Survey Monkey for Research Study ................................. 56
Appendix H: Survey (ProQOL 5, HPLP2) ................................................................................ 57

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List of Tables
Table

Page

1: Component of Compassion Fatigue vs Self-care...........................................................28
2: Component of Compassion Fatigue vs Categories of Self-care ....................................30

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List of Figures
Figure

Page

1: Relationship between compassion satisfaction and compassion fatigue. ........................4

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COMPASSION FATIGUE IN EMERGENCY MEDICAL

COMPASSION FATIGUE IN EMERGENCY MEDICAL

Compassion fatigue in emergency medical services (EMS): The influence of self-care on
compassion fatigue among EMS professionals in Northwestern Pennsylvania

Chapter 1
Introduction
Compassion fatigue, also known as secondary traumatic stress disorder, continues to be a
growing concern across many health care disciplines. Compassion fatigue results from repeated
exposure to the suffering of others, causing the health care provider to vicariously experience a
trauma similar to that of the patient, eventually exhausting his or her ability to show compassion
for others (Bush, 2009.) Compassion fatigue manifests as various physical, emotional, spiritual
and social signs and symptoms which have deleterious effects on the health care provider both
personally and professionally (Henson, 2017.) As a result, the attitude of the health care
provider, ability to effectively fulfill his or her role, and patient outcomes are all negatively
impacted (Rosenstein, 2013.) If proper interventions are not carried out to combat compassion
fatigue, these symptoms become progressively worse (Bush, 2009.) According to Boyle, 2011,
without early identification and treatment, the health care provider may experience a permanent
inability to provide care and demonstrate compassion for others. Studies in both the nursing and
physician population indicate that the development of compassion fatigue is a contributing factor
to high turnover of health care professionals (Rosenstein, 2013.) According to Crim, 2017,
interventions, including implementation of self-care, may be a potential strategy in the
prevention and remediation of compassion fatigue. Self-care encompasses behaviors and
activities that counteract the effects of physical and emotional stress (Meinecke, 2010.)

COMPASSION FATIGUE IN EMERGENCY MEDICAL
Examples of self-care activities include achieving adequate sleep, good nutrition, regular
exercise, yoga, meditation, relaxation techniques, engaging in hobbies and participating in
counseling (Meinecke, 2010.) While the concept of compassion fatigue is becoming more
familiar in the health care arena, there remains a gap in the literature. Although there are
numerous studies evaluating the presence of compassion fatigue in the nursing and physician
population, there is a lack of studies regarding compassion fatigue in emergency medical
services (EMS) professionals. The purpose of this correlational study is to identify a relationship
between self-care practices and compassion fatigue among EMS professionals in Northwestern
Pennsylvania. EMS professionals were asked to complete the Professional Quality of Life
(ProQOL) survey as well as the Health Promotion Lifestyle Profile II (HPLP II) in order to
evaluate the relationship between compassion fatigue and self-care practices.
Background of the Problem
Compassion fatigue develops due to ongoing exposure to the pain and suffering of others
and observation of traumatic circumstances on a regular basis (Wentzel & Brysiewicz, 2014.) A
health care provider that experiences compassion fatigue may develop negative physical,
spiritual and psychological effects that affect his or her personal and professional life (Boyle,
2011.) Physical effects of compassion fatigue include immunosuppression, exhaustion,
myalgias, dizziness, gastrointestinal symptoms, insomnia, excessive sleep and cardiac rhythm
disturbances (Bruner & Rhodes, n.d.; Lombardo & Eyre, 2011.) Compassion fatigue can
manifest as psychological symptoms which include anxiety, fear, guilt, anger, irritability, sadness
and depression, substance abuse, memory impairment, inability to focus and poor decision
making (Bruner & Rhodes, n.d.; Lombardo & Eyre, 2011.) Spiritual effects, such as questioning
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
the meaning of life and prior spiritual beliefs, feeling as though one is unable to make a positive
difference in the world, as well as believing the world is malevolent are all associated with the
presence of compassion fatigue (Bruner & Rhodes, n.d.) According to Aycock & Boyle, 2009,
diabetes mellitus, hypertension, cardiovascular disease and obesity may also be consequences of
compassion fatigue.
A study conducted by El-bar et al., 2013, evaluated 3 concepts that may influence the
development of compassion fatigue: compassion satisfaction, secondary traumatic stress and
burnout. Compassion satisfaction is the result of the positive aspects of serving as a health care
provider (Stamm, 2010.) Compassion satisfaction encompasses three components of serving as a
caregiver: (1) the sense of fulfilment one experiences from carrying out his or her role; (2) the
caregivers perceived personal job performance as it relates to both ability and the level of control
he or she has over his or her exposure to secondary traumatic stress; (3) the amount of
camaraderie experienced by the caregiver and his or her colleagues (Sodeke-Gregson, Holttum,
& Billings, 2013.) Secondary traumatic stress, which is the trauma experienced second-hand by
a person caring for an individual undergoing a traumatic event, may cause the caregiver to
vicariously experience a similar trauma leading to an acute reaction that is comparable to those
suffering from post-traumatic stress disorder (Sodeke-Gregson et al., 2013.) Burnout is the final
element that relates to the development of compassion fatigue. The concept of burnout is
specific to the work environment and can be experienced in all professions. Factors which
contribute to the development of burnout include long work hours, understaffing, and serving
within a demanding role. Burnout differs from compassion satisfaction and secondary traumatic
stress in that the two latter concepts occur only among caregivers (Sodeke-Gregson et al., 2013.)
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
As demonstrated in figure 1, it is suggested that secondary traumatic stress, combined with
existing burnout, contributes to the development of compassion fatigue. In health care,
particularly in EMS, personnel are required to work long hours ranging from twelve to twentyfour-hour shifts, are often understaffed due to inability to recruit and retain qualified employees
and are routinely exposed to secondary traumatic stress, placing them at high risk for the
development of compassion fatigue.

Figure 1: Relationship between compassion satisfaction and compassion fatigue. Adapted from the
Professional Quality of Life Elements Theory and Measurement website. (2017). proqol.org

The relationship between compassion satisfaction and the development of compassion
fatigue is ambiguous. According to El-Bar et al., 2013, a caregiver suffering from compassion
fatigue may have an inability to experience compassion satisfaction. This may be due to an
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
inability to harbor positive feelings about a role that is negatively impacting the caregiver
personally and professionally. Another explanation for this phenomenon may be the rate at
which compassion fatigue develops versus compassion satisfaction. Compassion fatigue is
thought to develop acutely and therefore may not be counteracted by compassion satisfaction,
which develops via a slower process (Thompson, 2013.)
Marion Conti-O’Hare’s theory of the nurse as wounded healer serves as the theoretical
framework for this study. This model suggests that nurses as well as other health care
professionals, through experiencing and managing trauma within their own lives, may be able to
convert from walking wounded to wounded healers (Nurse as Wounded Healer website, 2017.)
The theory assumes that all humans experience trauma and for caregivers, this trauma may be of
both personal and professional origin. It is suggested that trauma will not resolve without
intervention and the way in which the caregiver copes with trauma dramatically affects patient
care. People have the ability to change their self-concepts, mindset and behavior which may lead
to an ability to demonstrate empathy, develop a rapport and provide unconditional support to
others, all of which promote the transformation from walking wounded to wounded healer
(Conti-O’Hare, 2002.) If the caregiver is able to heal from his or her personal or professional
trauma, he or she may use that experience in a therapeutic manner to help others (Nurse as
Wounded Healer website, 2017.)
This study relates to this framework by suggesting that with an intervention such as selfcare, EMS professionals may be able to recover from professional trauma, like secondary
traumatic stress disorder, also known as compassion fatigue. It also implies that the EMS

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COMPASSION FATIGUE IN EMERGENCY MEDICAL
professional may be able to use the experience of overcoming compassion fatigue to strengthen
his or her ability to show empathy and provide therapeutic benefit to others.
Statement of the Problem
EMS professionals are required to care for others in times of tragedy and crisis. Due to
the nature of the profession, they repeatedly witness traumatic events, pain, and suffering of
others. In addition, they are at high risk for burnout due to long work hours, increasingly high
demands, understaffing, low wages, inadequate rest and meal breaks, as well as insufficient
protection against violence (Jacobs, Heller, Waheed, & Appel, 2017.) These circumstances
place EMS professionals at great risk for the development of compassion fatigue. While there
are numerous studies regarding compassion fatigue in other professionals, there are few that
address compassion fatigue as it relates to EMS professionals.
Self-care has been suggested throughout the literature as a potential treatment or
preventative measure for compassion fatigue, however there is limited data documenting a
correlation between compassion fatigue and the practice of self-care strategies. Identifying
potential preventative or remedial strategies to combat compassion fatigue in a high-risk group
of health care professionals, such as those working in EMS, would allow for the development of
effective programs to improve the lives of EMS professionals, patient care, as well as contribute
to employee retention in a field that is currently struggling to maintain adequate staffing.
Research Question
The goal of this study was to answer the following question:
1.

Do EMS professionals in Northwestern Pennsylvania, who practice self-care,
experience less compassion fatigue than those who do not?
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Definition of Terms
The following list includes conceptual definitions of terms used within this study:
1. Emergency Medical Services (EMS) professionals is defined as unique health care
professionals in that they provide medical care and transportation in an out-ofhospital setting with medical oversight. EMS professionals are not independent
practitioners. While the practice is not independent, it is relatively unsupervised and
often has little backup. Therefore, EMS professionals must be able to exercise
considerable judgment, problem-solving, and decision-making skills.” (National
Highway Traffic Safety Administration [NHTSA], 2007, p. 18.)
2. Compassion fatigue is defined as “the emotional residue or strain of exposure to
working with those suffering from the consequences of traumatic events. It differs
from burn-out, but can co-exist. Compassion Fatigue can occur due to exposure on
one case or can be due to a ‘cumulative’ level of trauma.” (The American Institute of
Stress website, 2017, expression 1.) Compassion fatigue may manifest as physical,
spiritual and psychological effects such as sleep disturbance, exhaustion, anxiety,
irritability, depression, illness and a state of questioning one’s prior spiritual beliefs
(Bruner & Rhodes, n.d.; Lombdardo & Eyre, 2011.)
3. Health care provider is defined as a “person who provides any form of health care”
(“Health care,” 2002).
4. Compassion satisfaction is defined as the pleasure experienced from helping others in
need, having positive feelings about coworkers, and making a contribution to society
through one’s work in aiding others (Stamm, 2010).
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
5. Burnout is defined as a state of physical, mental, and emotional exhaustion brought
on by repeated exposure to stressful conditions. Burnout differs from compassion
fatigue in that it affects people working within any field that experience low work
satisfaction and are subject to exceedingly high work-related demands (El-bar, Levy,
Wald, & Biderman, 2013.)
6. Self-care is defined as behaviors and activities that counteract the effects of physical
and emotional stress. Examples include achieving adequate sleep, good nutrition,
regular exercise, yoga, meditation, relaxation techniques, engaging in hobbies and
participating in counseling (Meinecke, 2010.)
Need for the Study
Compassion fatigue, a growing concern among health care providers, has been associated
with the dissociation from oneself and substandard patient care (El-bar et al., 2013.) Although
studies conducted among other health care disciplines suggest that self-care strategies may
prevent or treat compassion fatigue, there have been no studies identified which evaluate the
correlation between self-care and the presence of compassion fatigue among EMS professionals.
Identifying a potentially effective strategy, such as the implementation of self-care activities,
within a high-risk group of health care providers, may facilitate the development of effective
prevention and intervention, resulting in improved patient care, provider satisfaction, and
retention of personnel.
Significance of the Problem
According to Coetzee and Klopper, 2010, “compassion fatigue is the final result of a
progressive and cumulative process that is caused by prolonged, continuous, and intense contact
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with patients, the use of self, and exposure to stress, which manifests with marked physical,
social, emotional, spiritual and intellectual changes that increase in intensity” (p.237.) Given the
deleterious effects of unidentified or mismanaged compassion fatigue, it is necessary to identify
potential strategies to promote awareness, prevention and treatment. Without appropriate and
timely intervention, the manifestations of compassion fatigue, including physical, professional,
and emotional signs and symptoms, may be irreversible (Boyle, 2011).
Assumptions
The study assumes the following:
1.

EMS professionals surveyed have experience providing patient care.

2. EMS professionals surveyed have answered questions truthfully
3. EMS professionals surveyed possess the ability to read and write in English.
Summary of the Problem
EMS professionals routinely provide care to patients experiencing significant trauma,
pain and suffering. In addition, EMS professionals are subject to an extremely stressful work
environment, which places them at high risk for the development of compassion fatigue. Several
studies among various health care disciplines have suggested that the implementation of self-care
strategies may be effective in the prevention and treatment of compassion fatigue. However, no
studies have been conducted evaluating the correlation between the practice of self-care and
presence of compassion fatigue among EMS professionals. Identification of potential strategies
for prevention and remediation of compassion fatigue within an at-risk group of health care
providers will allow for effective and timely intervention, preventing chronic, potentially
irreversible physical, professional and emotional consequences.
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
Chapter 2
Review of Related Literature
Providing care to patients experiencing pain and suffering has negative effects on the
wellbeing of the health care provider. According to Hoffman (as cited in Robinson, 2016) it may
result in the inability to feel and express genuine support and empathy. Compassion fatigue has
been described as the cost of caring, as it occurs in those who possess a desire to help others who
are experiencing crises (Phelps, Lloyd, Creamer, & Forbes, 2009.) Health care providers, such
as EMS professionals, have a unique role in that they are the first caregivers summoned in the
event of a medical crisis, and therefore have significant exposure to traumatic events which
require them to respond empathetically. Those who spend the majority of their careers
expressing empathy and caring for others are most at risk for compassion fatigue (Tellie, 2008.)
Chapter two provides a review of the current literature regarding compassion fatigue
among health care providers. It incorporates the following aspects of the literature:
1.

A discussion of compassion fatigue in EMS and fire department personnel

2. A review of the literature related to compassion fatigue in physicians, nurses, and
other health care professionals
3. An overview of health promotion and self-care strategies suggested as possible
compassion fatigue prevention and management techniques
4. A discussion of the gap in the literature
5. An overview of Conti-O’Hare’s Theory of the Nurse as Wounded Healer
Compassion Fatigue in EMS and fire department personnel
The concept of compassion fatigue was introduced by Joinson in 1992 as a way of
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
explaining her feelings of emotional devastation from working in the emergency department
setting (Lombardo & Eyre, 2011.) EMS and fire department professionals are tasked with the
responsibility of caring for patients and family members undergoing significant trauma in an
often stressful, chaotic environment. Stressors within the workplace as well as at home, coupled
with the lack of self-care, all contribute to the development of compassion fatigue (Wentzel &
Brysiewicz, 2014.)
A study by Argentero & Setti, 2011, aimed to explore the incidence of symptoms of
vicarious traumatization, a term used synonymously with compassion fatigue, and engagement
among rescue workers. Similar to compassion satisfaction, engagement refers to the positive
feelings experienced by the caregiver, associated with his or her work, which leads to increased
involvement and efficacy (Argentero & Setti, 2011.) The study also examined primary
predictors of vicarious traumatization and engagement in order to determine factors that may
benefit rescue workers.
The sample consisted of 782 Italian emergency workers, primarily consisting of
ambulance personnel, but also included firefighters, police and other rescue workers, all of which
were involved in critical operations, placing them in contact with traumatized subjects. Each
participant completed the Maslach Burnout Inventory-General Scale (MBI-GS) as well as the
Secondary Traumatic Stress Scale (STSS.) The results of the study indicated that organizational
factors, particularly the perceived level of job related support such as role clarity, predictability
and support from employer, were contributing factors in the development of engagement and
vicarious traumatization (Argentero & Setti, 2011.) This study confirms the compassion
satisfaction-compassion fatigue theory, suggested by the Professional Quality of Life Elements
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
Theory and Measurement website, 2017, which indicates that exposure to secondary traumatic
stress, coupled with organizational factors that may contribute to burnout, leads to the
development of compassion fatigue. High levels of job related support leads to increased
compassion satisfaction, which in turn may serve as a preventative measure in the development
of compassion fatigue.
Another study by Jahnke, Carlos Poston, Haddock, & Murphy, 2016, explored the effects
of repeated exposure to trauma (RET) on fire service personnel. This study was a component of
a larger qualitative study regarding the health of firefighters which was funded by the American
Heart Association. The sample consisted of both volunteer and career firefighters belonging to
34 different fire departments across the nation. Focus groups were led by the fire chief in each
department, which addressed perception of wellness, physical fitness, dietary trends among
firefighters, tobacco and alcohol use, sleep habits, safety/seatbelt usage, and policies regarding
the health of firefighters. Transcriptions of the focus groups were reviewed and evaluated for
trends.
The results demonstrated that the majority of firefighters suffered negative consequences
from repeated exposure to traumatic incidents versus fixation on one specific event. There was a
notable trend in firefighters expressing difficulty coping with the repeated exposure to a large
quantity of traumatic events due to the nature of their jobs (Jahnke et al., 2016.)
The study indicated that while firefighters are negatively impacted by RET, they often
adapt and may develop positive coping mechanisms, such as compartmentalization, repeatedly
thinking about the event until it becomes less powerful, and engaging in humor with colleagues
(Jahnke et al., 2016.) The authors suggest that future research should be conducted to determine
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
the protective factors which contribute to resiliency in this essential population of emergency
services personnel.
While there are numerous studies regarding compassion fatigue in health care
professionals, there are few studies which focus specifically on EMS professionals, further
supporting the need for additional studies regarding compassion fatigue among this population.
Compassion Fatigue in Nurses and Physicians
As with EMS and fire services professionals, nurses, physicians and other professionals
within the health care system often find themselves in the position of caring for traumatized and
dying patients, as well as their families. Several studies have been identified which explore
compassion fatigue within these groups of caregivers.
Yoder, 2010, carried out a study that aimed to explore the prevalence of compassion
fatigue, circumstances which contribute to its development, as well as coping strategies in this
population. The study took place in a 123-bed community hospital in Midwestern United States.
The sample consisted of 71 registered nurses working within various specialties of the facility.
The participants completed a 3-part questionnaire which consisted of demographics, the
Professional Quality of Life Scale (ProQOL) developed by Stamm (1997-2005) and a narrative
portion.
The study demonstrated that nurses aged 50 and above exhibited a greater incidence of
compassion fatigue as well as those employed within the home health and emergency department
settings. Nurses who worked 12 hour shifts versus 8 hour shifts and those who had higher levels
of education exhibited less compassion fatigue than their counterparts (Yoder, 2010.) Fifty-three
percent of nurses identified caring for patients of a particular condition/status, such as those
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
exhibiting challenging behaviors as well as patients with poor prognoses was the greatest
influencer in the development of compassion fatigue. System-based issues, such as workload
and decisions made by management, were identified by thirty-two percent of the participants as
being a major trigger contributing to the presence of compassion fatigue (Yoder, 2010.) The
authors also explored the coping mechanism developed by the participants in order to manage
compassion fatigue. Fifty-eight percent identified work-related coping mechanisms such as
informal debriefing, changing the nature of his or her work involvement, and engaging with
colleagues. Forty-two percent indicated that they utilize personal coping mechanisms such as
spirituality, placing a greater emphasis on nonwork related engagements, and attitude
modification. Awareness of potential triggers which may contribute to the development of
compassion fatigue a well as implementation of positive coping strategies may reduce the
deleterious effects of compassion fatigue among nurses (Yoder, 2010.)
Physicians working in clinical practice are also repeatedly subject to providing care to
distressed patients and are often working in undesirable conditions, placing them at risk for the
development of compassion fatigue.
El-bar et al., 2013, conducted a cross-sectional study to determine the prevalence and
significance of compassion fatigue among family practitioners working in the southern region of
Israel, Negev. The aim of the study was to explore the correlation between compassion fatigue,
burnout and compassion satisfaction and how it relates to socio-demographic variables and
work-related circumstances. The study took place at Clalit Health Services Clinics in Negev,
where questionnaires including the Professional Quality of Life Scale, were distributed to 194
family physicians. Of the 194 surveys distributed, 128 physicians responded. The results
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
demonstrated that physicians who were born abroad and were not affiliated with any academic
institution appeared to have a greater prevalence of compassion fatigue. Higher levels of
compassion satisfaction were associated with serving as a preceptor for residents as well as
serving in management roles (El-bar et al., 2013.)
Limitations of this study include that the study was conducted in an area where a
significant percentage of physicians immigrated to Israel from abroad and many had little to no
academic affiliation, which represent potential confounding factors. These results, however,
may be generalized to other regions due to a large number of foreign-born physicians and
international medical school graduates practicing within other nations (El-bar et al., 2013.)
Strategies in the Prevention and Management of Compassion Fatigue
The negative effects of compassion fatigue on health care providers have been
demonstrated in numerous studies. Compassion fatigue contributes to the development of
symptoms such as poor decision making, memory impairment, inability to concentrate, sleep
disorders, fatigue, myalgias, and loss of interest in activities, all of which negatively impact the
health care provider’s wellbeing and patient outcome (Phelps et al., 2009.) Few studies have
examined potential preventative measures and interventions in the management of compassion
fatigue.
In order to develop prevention and treatment strategies, it is necessary to identify factors
which may prevent or promote the development of compassion fatigue. According to Phelps et
al., 2009, there are various risk factors as well as protective factors associated with the
development of compassion fatigue. A study conducted by Boscarino, Figley, & Adams, 2004,
examined predicting factors of compassion fatigue and burnout of social workers who provided
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
assistance to people affected by the 9/11/2001 terrorist attack in New York City. A
questionnaire was mailed to 600 randomly selected practicing social workers, educated at the
master’s level or higher, who were current members of the National Association for Social
Workers. The sample consisted of two hundred and thirty-six social workers. Results of the
questionnaires indicated a positive correlation between the extent of involvement in the care of
these individuals and the experience of secondary traumatization. This suggests that the greater
the degree of caregiver involvement, the more likely he or she is to develop secondary
traumatization, also known as compassion fatigue. The study also identified a negative
correlation between secondary traumatization and working within a supportive environment. A
supportive working environment reduces the likelihood of burnout and promotes the
development of compassion satisfaction, resulting in a decreased chance of developing
compassion fatigue, further reinforcing the relationships demonstrated in Figure 1. Of note,
there was a negative correlation between burnout and working within a supportive environment
but there was no association between burnout and exposure to traumatized victims. This is
consistent with the findings of earlier studies suggesting that burnout is not related specifically to
providing care to suffering patients but rather associated with working conditions.
Along with risk factors, various protective elements have also been identified within the
literature. According to Phelps et al., 2009, serving in a role that requires a frequent empathetic
and supportive response due to repeated exposure to the distress and trauma of others, may lead
to vicarious traumatization. Therefore, developing and upholding emotional boundaries may
serve as a protective strategy against the development of compassion fatigue (Phelps et al.,
2009.) Occupational support such as peer support and camaraderie, spirituality, resilience and
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compassion satisfaction are all protective factors identified in the development of compassion
fatigue (Phelps et al., 2009.)
Phelps et al., 2009, suggests that incorporating primary prevention strategies, including
addressing isolation, inexperience, high work demands, lack of support as well as factors specific
to individual workplaces may protect the caregiver from developing compassion fatigue.
Secondary prevention tactics include encouraging those who are demonstrating early signs of
compassion fatigue to participate in self-screening questionnaires in order to identify their own
physical and emotional state, which may otherwise go unnoticed. Self-care strategies such as
ensuring a healthy work-life balance, eating a well balance diet, getting adequate sleep,
participating in enjoyable activities, taking vacations and breaks, and making time for things
which are of value to the caregiver, are also identified as potential strategies for secondary
prevention. Tertiary prevention techniques, which include a combination of primary and
secondary prevention strategies have been suggested in the literature. These strategies aim to
reduce symptoms, prevent worsening of the condition and restore the caregiver’s functioning to
the highest possible level, though these suggestions lack clinical validation and require further
research (Phelps et al., 2009.)
Gap in the Literature
While there are numerous studies regarding the effects of compassion fatigue and few
exploring preventative strategies in other health care professionals, there are no identified studies
evaluating such strategies among EMS professionals. While some existing studies may be
generalized to the EMS profession, it is necessary to conduct further research pertaining
specifically to this unique, high-risk population that is routinely on the front lines of devastating
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
circumstances, providing care to those in crisis. The existence or implementation of self-care has
been proposed as a potentially effective measure in the prevention and treatment of compassion
fatigue, though there is limited research that validates this relationship.
Theoretical Framework
Dr. Marion Conti-O’Hare’s Theory of the Nurse as Wounded Healer served as the
theoretical framework for this study. While this theory is aimed at the nursing profession, the
aspects of the model which are applicable to nurses are also shared by EMS professionals, in that
both roles provide medical care and emotional support to distressed patients.
The basis of the model is that nurses as well as other health professionals have all
experienced trauma in their lives and are able to transform from walking wounded to a wounded
healer by recognizing, transforming and overcoming the pain from trauma. Health care
providers are then able to use this growth to be of therapeutic benefit to others (Nurse as
Wounded Healer website, 2017.) According to the Nurse as a Wounded Healer website, 2017,
the theory assumes the following:



All human beings undergo trauma during their lifetime



For nurses and other health care professionals, this trauma may be of a personal and/or
professional nature



The way nurses and other health care professionals cope with this trauma has a
significant impact on patient care



Trauma will not resolve spontaneously but rather requires intervention



Trauma can be transformed, transcended, and used to benefit others
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COMPASSION FATIGUE IN EMERGENCY MEDICAL


Healing occurs with the transformation of oneself from walking wounded to wounded
healer



The ability to help others is directly proportional to the degree of transformation and
transcendence in a person’s life



The wounded healer is able to provide the greatest therapeutic benefit to others.



The nursing profession as a whole is wounded and must heal itself to survive.

The Nurse as a Wounded Healer website, 2017, defines walking wounded as “An individual
who remains physically, emotionally and spiritually bound to past trauma. This wounding can be
reflected in the nursing practice of the individual in many ways. The walking wounded have
limited consciousness related to how their pain is manifested in their lives.” The wounded healer
is defined as, “Through self-reflection and spiritual growth, the individual achieves expanded
consciousness, through which the trauma is processed, converted and healed” (Nurse as
Wounded Healer website, 2017.)
According to the Nurse as a Wounded Healer website, 2017, the theory employs the
Q.U.E.S.T. Model in order to facilitate healing of the health care professional:


“Question: How has trauma affected my life?”



“Uncover: What can I remember about the major instances or patterns of my personal or
professional trauma?”



“Experience: What are my feelings about these events or patterns?”



“Search for Meaning: What do these feelings and experiences mean to me?”



“Transform and Transcend: I change my world view by resolving trauma and becoming a
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
wounded healer.”
This model suggests that health care providers are able to recognize and change their current
behaviors, in order to recover from past personal and professional trauma. Health care providers
may then use this transformation to benefit themselves, their patients and the profession as a
whole. The degree to which an individual is capable of facilitating the healing of others relates
to his or her self-awareness and personal beliefs (Conti-O’Hare, 2002.)
Summary of the Review of Related Literature
Due to the nature of their work, EMS professionals are faced with significant daily
stressors and repeated exposure to vicarious trauma, placing them at an increased risk for the
development of compassion fatigue. Compassion fatigue negatively affects EMS professionals
both personally and professionally, resulting in substandard patient care, decreased patient
satisfaction and deterioration of the agency’s overall performance. Potential primary, secondary
and tertiary prevention of compassion fatigue have been identified in the literature though further
research is necessary to expand upon proposed interventions. EMS professionals and managers
should be educated on the risk factors and manifestations of compassion fatigue, so that
strategies may be implemented to protect this valuable population of healthcare providers. The
Theory of the Nurse as a Wounded Healer is applicable to both nurses and EMS professionals
and may serve to encourage those suffering from compassion fatigue to adopt health promoting
behaviors, such as self-care, to transform from the walking wounded to wounded healers, using
this experience to benefit others.
Chapter 3
Methodology
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
The purpose of this study was to examine the correlation between the presence of
compassion fatigue and implementation of self-care strategies among EMS professionals in
Northwestern Pennsylvania. The following chapter describes the research design, setting,
sample, instrumentation, data collection, and data analysis.
Research Design
This study utilized a non-experimental, descriptive, correlational design, intended to
determine the relationship between implementation of self-care strategies and presence of
compassion fatigue among EMS professionals in Northwestern Pennsylvania.
Setting
Participants were asked to complete a survey that was accessible via email. The survey
was distributed by EMMCO West, the governing body for all EMS professionals working within
Northwestern Pennsylvania. Included within the email, was a link that directed the participant to
the survey which was administered via survey monkey. The participants had the ability to access
and complete the survey from any physical location that allowed for email access.
Sample
The study utilized a non-probability, convenience sample of EMS professionals. It
included both male and female gender, personnel of all ages and years of experience, full and
part-time status, serving in paid and/or volunteer roles. The subjects consisted of personnel with
active certifications only.
Ethical Considerations
This research study was subject to the Edinboro University Institutional Review Board
(IRB) approval, per the policies of Edinboro University of Pennsylvania. IRB approval from
21

COMPASSION FATIGUE IN EMERGENCY MEDICAL
Edinboro University was granted. EMMCO West acknowledged Edinboro University IRB
approval upon granting permission to conduct this research via their agency. The researcher has
participated in the Collaborative Institutional Training Initiative Research Ethics modules as per
Edinboro University guidelines. The data collected via the survey contained no identifiers. The
survey was distributed via a link to Survey Monkey, 2017, which included the use of the site’s
security infrastructure.
An introduction was included within the email, which advised participants of their
anonymity and security of responses. Participants were informed of the voluntary nature of his
or her participation and of the option to opt out at any time during the completion of the survey.
Identifying information was not collected from the participants. Information regarding consent
was included in the email. Consent for participation in this study was implied if the participant
chose to begin the survey.
Instrumentation
According to Walker, Sechrist and Pender, 1987, (as cited in Neville & Cole, 2013) The
Health Promotion Lifestyle Profile II (HPLP II) is an instrument which was developed in order
to measure health promoting behaviors by categorizing lifestyle characteristics. The authors
determined that behaviors which promote health consist of physical activity, responsibility for
health, spiritual growth, adequate nutrition, stress management, and interpersonal support. All of
these behaviors are encompassed within the concept of self-care, which has been proposed to
potentially prevent and facilitate the recovery from compassion fatigue.
According to Walker & Hill-Polerecky, 1996, “the 52-item HPLP II consists of a total
scale and six subscales to measure behaviors in the theorized dimensions of health-promoting
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
lifestyle: spiritual growth, interpersonal relations, nutrition, physical activity, health
responsibility, and stress management. Data from 712 adults aged 18 to 92 were used to evaluate
validity and reliability. Content validity was established by literature review and content experts'
evaluation. Construct validity was supported by factor analysis that confirmed a six-dimensional
structure of health-promoting lifestyle, by convergence with the Personal Lifestyle Questionnaire
( r = .678), and by a non-significant correlation with social desirability. Criterion-related validity
was indicated by significant correlations with concurrent measures of perceived health status and
quality of life ( r's = .269 to .491). The alpha coefficient of internal consistency for the total scale
was .943; alpha coefficients for the subscales ranged from .793 to .872. The three-week testretest stability coefficient for the total scale was .892.” This instrument was used to determine
the presence of self-care activities which was then correlated with the presence of compassion
fatigue. Permission was granted, by the authors of the HPLP II, to utilize this instrument for the
purpose of this study.
The Professional Quality of Life Scale (ProQOL), version 5, is the most commonly used
tool to measure the positive and negative effects of working with people who have experienced
traumatic events (Stamm, 2010.) It is a 30-item inventory which utilizes a Likert scale format.
The ProQOL consists of 3 subscales, compassion satisfaction, burnout, and secondary traumatic
stress, which contribute to the development of compassion fatigue. Using only one of the scales
is not recommended, as compassion satisfaction is considered a moderator of compassion fatigue
(Stamm, 2010.) Burnout rarely exists at the same time as compassion satisfaction and when both
burnout and secondary traumatic stress are present, the most negative outcome is expected
(Stamm, 2010.)
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
Over 200 earlier, published studies utilizing the ProQOL have demonstrated good
construct validity (Stamm, 2010.) The three scales measure separate constructs. The
Compassion Fatigue scale is distinct. The inter‐scale correlations show 2% shared variance (r=
-.23; co-ơ =5%; n=1187) with secondary traumatic stress and 5% shared variance (r=-.14; co-ơ =
2%; n=1187) with burnout. While there is shared variance between burnout and secondary
traumatic stress the two scales measure different constructs and likely reflect the distress that is
shared in both concepts. The shared variance between these two scales is 34% (r=.58; co-ơ =
34%; n=1187.) While both scales measure negative aspects, they are distinct in that the
secondary traumatic stress scale evaluates fear while the burnout scale does not (Stamm, 2010.)
The ProQOL, version 5, was utilized in this study to evaluate the presence of compassion
fatigue, based upon the theoretical relationships of the three subscales: compassion satisfaction,
burnout and secondary traumatic stress. Permission was granted, by the authors of the ProQOL,
to utilize this instrument for the purpose of this study.
Data Collection
Responses were collected from EMS professionals that work within Northwestern
Pennsylvania. This population was chosen in order to include all certification levels recognized
within the state practicing in both volunteer and paid roles, in both rural and metro areas, so that
the results may be generalized to other areas practicing under this common model.

The aim

was to have 100 completed surveys returned for review out of 4,212 EMS professionals in the
region. The link to complete the survey via Survey Monkey (2017) was sent to the contact person
from EMMCO West for distribution to all EMS professionals with active certification, within
Northwestern Pennsylvania. The participants were asked to complete the survey by a specific
24

COMPASSION FATIGUE IN EMERGENCY MEDICAL
date. A follow up email was sent one week from the initial distribution which served as a
reminder to complete the survey. Permission was obtained from the director of EMMCO West
to utilize the Constant Contact system in order to distribute surveys for the purpose of this study.
Data Analysis
Following the deadline for survey completion, the results were analyzed. Several items
on the ProQOL were reversed scored and then a sum of each subscale was obtained. Lastly, the
z scores were converted to t-scores with raw score mean = 50 and the raw score standard
deviation = 10. Following the scoring of the ProQOL, the results were correlated with the health
promotion/self-care practice responses collected via the HPLP II, in order to answer the
following research question:
Research Question 1: Do EMS professionals in Northwestern Pennsylvania, who
practice self-care, experience less compassion fatigue than those who do not?
Summary of Methodology
This study utilized a non-experimental, descriptive, correlation design, which was
intended to determine the correlation between self-care practices and presence of compassion
fatigue among EMS professionals. The sample was a non-probability, convenience sample
which consisted of EMS professionals working within Northwestern Pennsylvania. It included
both male and female EMS professionals of all ages, holding active certification, serving in paid
and/or volunteer roles, with varied years of experience. Data was collected utilizing the ProQOL
5 and HPLP II in order to determine the correlation between compassion fatigue and self-care.
Chapter 4
Results and Discussion
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
The following chapter presents the results and provides a discussion regarding the
outcome of this study. This study was conducted utilizing the ProQOL, version 5, and the HPLP
II in order to determine the correlation between self-care and presence of compassion fatigue
among EMS professionals working within northwestern Pennsylvania. The ProQOL, version 5,
provided data regarding the three subscales that influence the development of compassion
fatigue, which consist of: compassion satisfaction, burnout and secondary traumatic stress. Data
was also collected via the HPLP II in order to determine the presence of health promoting
lifestyle practices, suggestive of self-care. These two instruments comprised the survey which
was completed by the nonprobability convenience sample of EMS professionals.
Description of the Sample
The survey was distributed via the EMMCO West Constant Contact system to 4,212
EMS professionals within northwestern Pennsylvania. Of the 4,212 EMS professionals
surveyed, 173 responded resulting in a four percent response rate. Of the 173 EMS professionals
who responded, nine completed only the ProQOL and failed to begin the HPLP II. As a result,
these nine participants were excluded from the data analysis. Of the remaining 164 participants,
10 failed to complete between one and four items of the survey. To account for these few
missing items, the average responses for those questions were calculated and substituted for each
corresponding, unanswered item. This data was then utilized in the analysis.
Research Question: Do EMS professionals in Northwestern Pennsylvania, who practice
self-care, experience less compassion fatigue than those who do not?
In order to screen for the presence of compassion fatigue, the ProQOL, version 5, was
administered. The ProQOL utilizes 3 subscales to evaluate the presence of compassion
26

COMPASSION FATIGUE IN EMERGENCY MEDICAL
satisfaction, burnout and secondary traumatic stress, all of which influence the development of
compassion fatigue. Based on the responses to the ProQOL (N=164), each participant’s answers
were scored and placed within one of three categories: low, average, high. In order to assign
each category, items 1, 4, 15, 17 and 29 were reversed scored, raw data was converted into zscores which were then converted into t-scores. Participants scoring less than or equal to 43.5
were included in the low category, those scoring between 43.6 and 56.5 were included in the
average category, while those scoring greater than or equal to 56.6 were assigned to the high
category. Each range was then converted into a numeric score ranging from one to three, with a
score of one representing the low category of compassion fatigue, two representing the average
category of compassion fatigue and three representing the high category of compassion fatigue.
In order to determine the presence of a health promoting lifestyle/participation in selfcare, the HPLP was scored and the mean was obtained resulting in a possible value between 52
and 208. This ordinal data was then converted into interval data and ranked either one, two,
three or four, representing those who never, sometimes, often or routinely practice self-care,
respectively.
Categories of each compassion fatigue component were then correlated with rank of selfcare practice utilizing Spearman’s rank correlation coefficient (rho.) A value of rho ranging
from .10 to .29 represents a small correlation, a rho of .30 to .49 indicates a moderate correlation
and a rho of .50 to 1.0 indicates a strong correlation. The direction of the correlation is based
upon the negative or positive nature of the correlation coefficient. A negative coefficient
indicates that there is a negative correlation between the two variables. A positive coefficient
represents a positive correlation between the two variables.
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
There was a moderately strong positive correlation between compassion satisfaction and
self-care practices, indicating that those who practice self-care tend to have higher levels of
compassion satisfaction. There was a strong negative correlation noted between burnout and
self-care practices, indicating that those who practice self-care tend to experience markedly
lower levels of burnout. Finally, there was a moderately strong, negative correlation between
secondary traumatic stress and self-care, suggesting that those who practice self-care tend to
have lower levels of secondary traumatic stress. Based upon the results of this study, those who
practiced self-care reported higher levels of compassion satisfaction, low levels of burnout and
low levels of secondary traumatic stress. In order to develop compassion fatigue, a person must
experience secondary traumatic stress in the setting of burnout, with a potential absence or low
level of compassion satisfaction (Professional Quality of Life Elements Theory and
Measurement website, 2017.) The data collected from this study supports this theory and
therefore it may be inferred that those who practice self-care are likely not suffering from
compassion fatigue.
Table 1: Component of Compassion Fatigue vs Self-care
Component of Compassion Fatigue
Compassion Satisfaction Correlation
Coefficient
Significance (p)
N
Burnout
Correlation
Coefficient
Significance (p)
N
Secondary Traumatic Stress
Correlation
Coefficient
Significance (p)
N

Average Health Promoting Lifestyle/Self-care
Practices
.493
.000
164
-.619

.000
164
-.321

.000
164
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
This information was further reduced into specific categories of self-care, by obtaining
the mean to a particular subset of questions and scoring via the same method utilized to obtain an
overall score for a health promoting lifestyle/participation in self-care. As recommended by the
authors of the HPLP II, the means rather than sums of scale items were utilized in order to retain
the 1 to 4 metric of item responses as well as to allow for meaningful comparisons of scores
across each subscale. This resulted in a score for the following subscales: physical activity,
nutrition, spiritual growth, interpersonal relations, stress management and health responsibility.
Health responsibility, according to the HPLP II, includes actions such as consulting with health
care professionals regarding unusual symptoms, obtaining second opinions from health care
providers when needed, working to improve health literacy and participating in health
maintenance activities.
Each component that comprises the concept of compassion fatigue was then correlated
with rank of each category of self-care, utilizing Spearman’s rank correlation coefficient (rho.)
A small but statistically significant positive correlation was noted between compassion
satisfaction and the categories of self-care: physical activity and nutrition. A moderate, positive
correlation was noted between compassion satisfaction and self-care categories: health
responsibility and stress management. There was a strong, positive correlation between
compassion satisfaction and self-care categories: interpersonal relations and spiritual growth.
There was a moderate, negative correlation between burnout and self-care categories: health
responsibility, physical activity, and nutrition. A strong, negative correlation was noted between
burnout and self-care categories: spiritual growth, interpersonal relations, and stress
management. Finally, a small but statistically significant, negative correlation was noted
29

COMPASSION FATIGUE IN EMERGENCY MEDICAL
between secondary traumatic stress and self-care categories: health responsibility, interpersonal
relations, and nutrition. There was a small, negative correlation between secondary traumatic
stress and physical activity, however this relationship was not statistically significant. There was
a moderate, negative correlation noted between secondary traumatic stress and self-care
categories: spiritual growth and stress management.
Table 2: Component of Compassion Fatigue vs Categories of Self-care
Component of
Compassion
Fatigue

Health
Responsibility

Physical
Activity

Nutrition

Spiritual
Growth

Interpersonal
Stress
Relations
Management

Compassion
Satisfaction
Correlation
Coefficient
Significance (p)
N
Burnout
Correlation
Coefficient
Significance (p)
N
Secondary
Traumatic
Stress
Correlation
Coefficient
Significance (p)
N

.373

.278

.213

.582

.534

.354

.000
163
-.385

.000
163
-.375

.006
163
-.367

.000
158
-.662

.000
162
-.556

.000
163
-.560

.000
163
-.197

.000
163
-.056

.000
163
-.183

.000
158
-.399

.000
162
-.293

.000
163
-.330

.012
163

.474
163

.019
163

.000
158

.000
162

.000
163

In order to suffer from compassion fatigue, the EMS professional must have exposure to
secondary trauma in the setting of burnout. Rarely, does compassion satisfaction occur
simultaneously with burnout and therefore those participants with high levels of compassion
satisfaction are unlikely to be experiencing compassion fatigue. Of the responses, those who
implement health promoting lifestyle or self-care activities experience high levels of compassion
30

COMPASSION FATIGUE IN EMERGENCY MEDICAL
satisfaction, low levels of burnout and low levels of secondary traumatic stress and are therefore
unlikely to be suffering from compassion fatigue. The opposite of this is also true, in that those
who are not practicing self-care have lower levels of compassion satisfaction, higher levels of
burnout and higher levels of secondary traumatic stress indicating the presence of compassion
fatigue. Based upon the results of this study and interpretation of data in accordance with the
CF-CS model (Professional Quality of Life Elements Theory and Measurement website, 2017), it
may be inferred that EMS professionals in Northwestern Pennsylvania, who practice self-care,
experience less compassion fatigue than those who do not.
Summary
The research question examined whether EMS professionals in Northwestern
Pennsylvania, who practice self-care, experience less compassion fatigue than those who do not.
Based upon the outcome of the data analysis, it was determined that there is a positive
correlation between self-care and compassion satisfaction, with a negative correlation between
self-care and both burnout and secondary traumatic stress. These findings, interpreted with
consideration of the theory demonstrated in the CS-CF model, indicate a negative correlation
between self-care and compassion fatigue, which was statistically significant at p < .05. The
results also indicate that all forms of self-care evaluated in the study are negatively correlated
with compassion fatigue, all of which were statistically significant with the exception of the
relationship between secondary traumatic stress and physical activity. Identifying this negative
correlation between self-care activities and compassion fatigue will allow for further efforts in
the development of compassion fatigue prevention and treatment strategies.

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COMPASSION FATIGUE IN EMERGENCY MEDICAL
Chapter 5
Summary, Conclusions, and Recommendations
Interpretation of the Findings
The purpose of this study was to determine if EMS professionals in Northwestern
Pennsylvania, who practice self-care, experience less compassion fatigue than those who do not.
The study was conducted via survey which included two published instruments, the ProQOL,
version 5, which served as a screening tool for compassion fatigue and the HPLP II, which
evaluated the presence of self-care. The survey link was distributed to 4,212 EMS professionals
in Northwestern Pennsylvania, by the EMMCO West Constant Contact system, with 164 EMS
professionals choosing to participate in the study by returning a completed survey. The survey
was completed anonymously via survey monkey over a two-week period.
While there were several limitations to this study which may encourage the development
of future research, this study determined that those EMS professionals surveyed, who practice
self-care, experience higher levels of compassion satisfaction, lower levels of burnout and lower
levels of secondary traumatic stress compared with those who do not. As indicated by the theory
regarding the development of compassion fatigue, as demonstrated in the CS-CF model, those
who experience high levels of compassion satisfaction, low levels of burnout and low levels of
secondary traumatic stress are unlikely to experience compassion fatigue. Therefore, based upon
the results of this study, it may be inferred that those who practice self-care are less likely to
experience compassion fatigue versus those who do not.
A second analysis was performed which evaluated the relationship between compassion
satisfaction, burnout and secondary traumatic stress and the specific categories of self-care
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
measured via the HPLP II: health responsibility, physical activity, nutrition, spiritual growth,
interpersonal relations, and stress management. The data from each individual category of selfcare revealed a positive correlation between participation in the activity and presence of
compassion satisfaction and a negative correlation between participation and presence of both
burnout and secondary traumatic stress. The negative correlation between physical activity and
secondary traumatic stress was not statistically significant, however, given the positive
correlation between compassion satisfaction and physical activity and negative correlation with
burnout, it remains unlikely that this group is experiencing compassion fatigue, as compassion
fatigue is thought to occur in the setting of burnout and secondary traumatic stress with an
absence of compassion satisfaction.
These findings further support previous findings in the literature, as discussed in Chapter
two. Those who demonstrated spiritual growth and interpersonal relations indicated high levels
of compassion satisfaction, as well as low levels of both burnout and secondary traumatic stress,
which suggest low levels of compassion fatigue. These findings are consistent with those
identified by Phelps et al., 2009, suggesting that peer support and camaraderie, spirituality, and
compassion satisfaction are all factors which protect an individual from the development of
compassion fatigue. In addition, Phelps et al., suggests healthy work-life balance, eating a well
balance diet, getting adequate sleep, participating in enjoyable activities, taking vacations and
breaks, and making time for things which are of value to the caregiver, serve as potential
strategies in the treatment of compassion fatigue. The data from this study supports this
hypothesis, in that participation in good nutrition and stress management activities, which
included achievement of adequate sleep, participation in relaxation techniques, making time for
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
recreational activities and having a healthy balance between work and play, resulted in a
negative correlation with the presence of compassion fatigue.
Theoretical Framework
Dr. Marion Conti-O’Hare’s, Theory of the Nurse as Wounded Healer, served as the
theoretical framework for this study. As discussed in Chapter two, this theory assumes that all
healthcare professionals undergo trauma, personal and/or professional, which affects both the
caregiver as well as the patient (Nurse as Wounded Healer website, 2017.) It is suggested that
through recognition of this trauma and implementation of an effective intervention, it is possible
to transcend from walking wounded to wounded healer. As a wounded healer, the caregiver is
able to use this transformation to benefit others by improving one’s ability to demonstrate
empathy, develop a rapport and provide unconditional support (Conti-O’Hare, 2002.) This
model emphasizes that without intervention, the trauma experienced by the caregiver will not
resolve (Nurse as Wounded Healer website, 2017.) This is significant because according to
Boyle, 2011, as discussed in Chapter one, compassion fatigue, without early identification and
treatment, may result in the caregiver’s permanent inability to provide care and demonstrate
compassion for others. Suffering from compassion fatigue not only negatively impacts the
caregiver’s ability to provide patient care but also the overall outcome of the patient (Rosenstein,
2013.)
Identification and treatment of compassion fatigue may allow for the EMS professional to
transcend from walking wounded to wounded healer, at which time he or she may use this
experience of overcoming one’s trauma to strengthen his or her ability to establish a rapport with
patients, show empathy and compassion as well as improve patient outcomes. It has been
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
suggested in the literature and supported by the results of this study, that self-care may serve a
role in the prevention and treatment of compassion fatigue. With the implementation of self-care
activities, those EMS professionals suffering from compassion fatigue, may be able to recover
from this trauma and use this experience of transcending from walking wounded to wounded
healer to provide therapeutic benefit to their patients.
Dr. Marion Conti-O’Hare has suggested that the nursing profession is wounded and must
heal itself so that it may survive (Conti-O’Hare, 2002.) This may also be true for the EMS
profession. EMS professionals are at great risk for compassion fatigue, as they are required to
care for others in times of tragedy and crisis. They repeatedly witness traumatic events, pain,
and suffering of others. They are part of a profession that does not readily promote self-care as
they are often required to work long hours, face increasingly high demands, carry out life-saving
work without adequate staffing levels, receive low financial compensation and are often not
provided with adequate rest and meal breaks (Jacobs, Heller, Waheed, & Appel, 2017.) In order
for the EMS profession to survive, EMS professionals and industry leaders must recognize the
importance of improving compassion satisfaction and reducing burnout as well as secondary
traumatic stress, thereby promoting prevention and treatment of compassion fatigue. Self-care
has been suggested in the literature and supported by the results of this study, as a potential
method that may increase compassion satisfaction, reduce burnout and secondary traumatic
stress, which may ultimately serve as an intervention to prevent and treat compassion fatigue.
Limitations
There were several limitations to this study. One limitation is that demographic
information, which may have provided further insight into potential confounding variables, was
35

COMPASSION FATIGUE IN EMERGENCY MEDICAL
not collected for this study. The respondents all work within Northwestern Pennsylvania which
may potentially skew data based upon factors unique to emergency medical services in that
particular geographical location. This study identifies a correlation between variables and does
not necessarily indicate causality, which may also represent a limitation. Lastly, it is theorized
that compassion fatigue develops as a result of the influence from three factors, compassion
satisfaction, burnout and secondary traumatic stress, rather than a single variable. These three
components are measured and scored via the ProQOL, the most commonly utilized instrument in
screening for compassion fatigue. The importance of screening for compassion fatigue based
upon all three of these components versus one particular variable is stressed by the authors of the
ProQOL. However, from a statistical standpoint, this may be considered a potential limitation as
this screening tool does not provide a direct measure of a single variable, compassion fatigue, but
rather allows for an inference to be made based upon the relationship of the three variables which
are theorized to either result in or provide protection from the development of compassion
fatigue.
Recommendations for Future Research
This study supports the need for further research regarding the influence of self-care on
compassion fatigue. While a correlation was identified that suggests self-care may influence the
development of compassion fatigue, interventional studies are needed to evaluate the direct
impact of self-care on compassion fatigue. Studies that include a larger sample size, representing
a larger geographical area, and encompass a variety of EMS operational models, may facilitate
the generalization of findings. In addition to conducting a similar study which evaluates
demographics of respondents, it may also be of benefit to determine the presence of pre-existing
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COMPASSION FATIGUE IN EMERGENCY MEDICAL
mental health issues, such as anxiety and depression, as well as personality traits that may
represent predisposing factors in the development of compassion fatigue. Furthermore,
expanding this research to evaluate characteristics which may offer protection from compassion
fatigue, such as resiliency, could provide further insight into identification of at risk populations
and lead to the development of individualized treatment strategies.
Implications for EMS Professionals
As previously stated, compassion fatigue has deleterious effects which negatively affect
both the caregiver and patient. Due to the nature of their work, EMS professionals are at great
risk for the development of compassion fatigue. Identification of preventative or remedial
strategies are imperative in order to improve the lives of those who are at risk for or currently
suffering from compassion fatigue, as well as the patients for whom they are providing care. The
results of this study indicate that EMS professionals who practice self-care exhibit lower levels
of compassion fatigue, suggesting this strategy as a potential preventative and/or treatment
method.
EMS professionals must first be aware of the concept of compassion fatigue, as well as
its negative consequences on the caregiver and the patients they serve. An organization’s
leadership has the ability to promote compassion fatigue awareness so that employees are
familiar with the concept and have knowledge of where they may seek assistance, if needed. In
the absence of awareness and identification of those suffering from compassion fatigue,
prevention and intervention strategies are not relevant. Screening for compassion fatigue may be
done via various free instruments, such as the ProQOL, which can be completed and scored by
the participant so that EMS professional may be aware of his or her own personal risk. It is
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important that EMS agencies recognize compassion fatigue as a potential consequence of
working within the EMS setting and foster an environment that promotes acceptance and
understanding of an individual who may be suffering from compassion fatigue, in the same
manner that a physical injury may be acknowledged. There is often great attention given to
prevention of physical injuries in EMS, such as education and training regarding proper lifting
techniques in order to prevent back injuries. A similar focus should be given to prevention of
compassion fatigue, as it also has significant, negative consequences for both the EMS
professional and agency.
The results of this study indicate that self-care may be a potential method of preventing
and/or treating compassion fatigue. Self-care activities such as practicing good nutrition, taking
part in physical exercise, achieving adequate sleep and practicing relaxation techniques in order
to manage stress are lifestyle changes that can be easily implemented without great expense or
adverse effects. These changes can occur at both the individual and organizational level and may
significantly improve the EMS professional’s quality of life, patient outcome and overall agency
performance. At the individual level, EMS professionals can independently initiate self-care
activities which meet their individual preferences and lifestyles, which may improve consistency
and sustainability. Organizations may opt to implement activities which encourage healthy
lifestyle changes such as the development of sports teams, on-site gym equipment, yoga classes,
gym memberships at a reduced, corporate cost, employee assistance programs which provide
counseling services, social outings, wellness plans, as well as mandatory down time and meal
break policies to allow for adequate rest and nutrition. For departments which have financial
constraints, there are circumstances where grant money may be used toward improvement of
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employee health within EMS and fire service.
This study provides further insight into potential preventative and treatment strategies for
compassion fatigue, specifically among EMS professionals. The results of this study suggest
that self-care may be a potentially effective method within this group of at-risk professionals.
However, additional research, including interventional studies, are required to further evaluate
the relationship between self-care and compassion fatigue among EMS professionals.
Conclusion
EMS professionals are frequently required to provide care to suffering patients
undergoing crises, which places them at great risk for the development of compassion fatigue.
Repeated exposure to these circumstances may lead the EMS professional to vicariously
experience a similar trauma to that of the patient, resulting in various physical, psychological,
and spiritual consequences, eventually exhausting his or her ability to show compassion for
others. The findings of this study are unique and significant because while there have been
numerous studies evaluating compassion fatigue among other health care disciplines, few studies
were identified that evaluate compassion fatigue in EMS professionals. In addition, there were
no studies noted that evaluate preventative strategies or treatment interventions, such as self-care,
within this at-risk population. As a result of this gap in the literature, this study was developed
and carried out in order to determine if EMS professionals in Northwestern Pennsylvania, who
practice self-care, experience less compassion fatigue than those who do not.
The results of this study indicate that the EMS professionals surveyed, who practice selfcare, experience higher levels of compassion satisfaction, lower levels of burnout and lower
levels of secondary traumatic stress, indicating low levels of compassion fatigue. These findings
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suggest that self-care may serve as a potential method for the prevention and treatment of
compassion fatigue among EMS professionals, ultimately improving the lives of EMS
professionals, patient outcomes and the EMS profession as a whole.

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References
Argentero, P., & Setti, I. (2011). Engagement and vicarious traumatization in rescue workers.
International Archives of Occupational and Environmental Health, 84, 67-75.
http://dx.doi.org/ 10.1007/s00420-010-0601-8
Aycock, N., & Boyle, D. (2009). Interventions to manage compassion fatigue. Clinical Journal
of Oncology Nursing, 13(2), 183-191. http://dx.doi.org/10.1188/09.CJON.183-191
Boscarino, J. A., Figley, C. R., & Adams, R. E. (2004). Compassion fatigue following the
September 11 terrorist attacks: A study of secondary trauma among New York City
social workers. International Journal of Emergency Mental Health, 6(1), 57-66.
Retrieved from https://www.academia.edu/4130142/boscarino_IJEMH
Boyle, D. A. (2011). Countering compassion fatigue: A requisite nursing agenda. Online Journal
of Issues in Nursing, 16(1). http://dx.doi.org/10.3912/OJIN.Vol16No01Man02
Bruner, V., & Rhodes, J. (n.d.). Understanding and overcoming compassion fatigue [PowerPoint
slides]. Retrieved from Navy Medicine website:
http://www.med.navy.mil/sites/nmcphc/Documents/health-promotion-wellness/woundedill-and-injured/understanding-overcoming-compassion-fatigue.pdf
Bush, N. (2009). Compassion fatigue: Are you at risk? Oncology Nursing Forum, 36(1), 24-28.
http://dx.doi.org/10.1188/09.ONF.24-28
Coetzee, S. K., & Klopper, H. C. (2010). Compassion fatigue within nursing practice: A concept
analysis. Nursing & Health Sciences, 12(2), 235-243. http://dx.doi.org/10.1111/j.14422018.2010.00526.x

41

COMPASSION FATIGUE IN EMERGENCY MEDICAL
Conti-O’Hare, M. (2002). The nurse as wounded healer: From trauma to transcendence.
Sudbury, Massachusetts: Jone and Bartlett.
Crim, E. R. (2017, June 1). Provider self-care through conscious, balanced relationships.
Counselor: The Magazine for Addiction Professionals, 18(3), 53-58. Retrieved from
http://www.counselormagazine.com
El-bar, N., Levy, A., Wald, H. S., & Biderman, A. (2013, August 15). Compassion fatigue,
burnout and compassion satisfaction among family physicians in the Negev area-A cross
sectional study. Israel Journal of Health Policy Research, 2(1), 31.
http://dx.doi.org/10.1186/2045-4015-2-31
Health care provider. (2002). In McGraw-Hill Concise Dictionary of Modern Medicine.
Retrieved from http:/medical-dictionary.thefreedictionary.com
Henson, J. S. (2017, March/April). When compassion is lost. MEDSURG Nursing, 26(2), 139142. Retrieved from https://www.amsn.org
Jacobs, K., Heller, N., Waheed, S., & Appel, S. (2017). Emergency medical services in
California: Wages, working conditions, and industry profile. Retrieved from
http://laborcenter.berkeley.edu
Jahnke, S. A., Carlos Poston, W. S., Haddock, C. K., & Murphy, B. (2016). Firefighting and
mental health: Experiences of repeated exposure to trauma. Work, 53(4), 737-744.
http://dx.doi.org/10.3233/WOR-162255
Lombardo, B., & Eyre, C. (2011). Compassion fatigue: A nurse’s primer. OJIN: The Online
Journal of Nursing, 16(1). Retrieved from www.nursingworld.org

42

COMPASSION FATIGUE IN EMERGENCY MEDICAL
Meinecke, C. (2010). Self-care in a toxic world. Retrieved from
https://www.psychologytoday.com/blog/everybody-marries-the-wrongperson/201006/self-care-in-toxic-world
National Highway Traffic Safety Administration. (2007). National EMS scope of practice model.
Retrieved from https://www.ems.gov/education/EMSScope.pdf
Neville, K., & Cole, D. A. (2013). The relationship among health promotion behaviors,
compassion fatigue, burnout and compassion satisfaction in nurses practicing in a
community medical center. The Journal of Nursing Administration, 43(6), 348-354.
http://dx.doi.org/10.1097/NNA.0b013e3182942c23
Nurse as Wounded Healer website. (2017). http://www.drmarioncontiohare.com/
Phelps, A., Lloyd, D., Creamer, M., & Forbes, D. (2009, February). Caring for carers in the
aftermath of trauma. Journal of Agression, Maltreatment & Trauma, 18, 313-330.
http://dx.doi.org/10.1080/10926770902835899
Professional Quality of Life Elements Theory and Measurement website. (2017). proqol.org
Robinson, T. M. (2016). Predictive factors of compassion fatigue among firefighters (Doctoral
dissertation, Walden University). Retrieved from
http://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=3435&context=dissertations
Rosenstein, A. H. (2013, August 15). Addressing physician stress, burnout, and compassion
fatigue: The time has come. Israel Journal of Health Policy Research, 2(32).
http://dx.doi.org/10.1186/2045-4015-2-32
Sodeke-Gregson, E. A., Holttum, S., & Billings, J. (2013, December 30). Compassion
satisfaction, burnout, and secondary traumatic stress in UK therapists who work with
43

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adult trauma clients. European Journal of Psychotraumatology, 4.
http://dx.doi.org/10.3402%2Fejpt.v4i0.21869
Stamm, B. (2010). The concise ProQOL Manual (2nd ed.). Retrieved from
http://www.proqol.org
Tellie, M. (2008). Compassion fatigue: The cost of caring. Nursing Update, 32(8), 34-37.
Retrieved from http://library.gcu.edu
The American Institute of Stress website. (2017). https://www.stress.org
Thompson, A. (2013, July). How Schwartz rounds can be used to combat compassion fatigue.
Nursing Management, 20(4), 16-20. Retrieved from http://journals.rcni.com/journal/nm
Walker, S. N., & Hill-Polerecky, D. M. (1996). Psychometric evaluation of the health promoting
lifestyle profile II. Unpublished manuscript, University of Nebraska Medical Center.
Retrieved from https://www.unmc.edu/nursing/faculty/HPLPII_Abstract_Dimensions.pdf
Wentzel, D., & Brysiewicz, P. (2014, January). The consequence of caring too much:
Compassion fatigue and the trauma nurse. Journal of Emergency Nursing, 40(1), 95-97.
Retrieved from www.jenonline.org
Yoder, E. (2010). Compassion fatigue in nurses. Applied Nursing Research, 23(4), 191-197.
http://dx.doi.org/10.1016/j.apnr.2008.09.003

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Appendices
Appendix A: Permission Letter from EMMCO West
To:

Edinboro University of PA
IRB Review Panel
Edinboro, PA

From:

William D. McClincy
Executive Director

Date:

October 12, 2017

Ref.:

Kelly Martin’s Research Project Survey Request

EMMCO West, Inc. is the regional emergency medical services (EMS) office for seven Northwest PA counties.
These include Clarion, Crawford, Erie, Forest, Mercer, Venango, and Warren counties. EMMCO West is a
contracted grant recipient for the PA Department of Health, Bureau of EMS. As part of our customer service
outreach, we use an online email server (ConstantContact). We use ConstantContact to communicate EMS system
information to EMS agencies and EMS practitioners. Our email server has access to over 4,000 email accounts.
Ms. Kelly Martin has requested permission and assistance from EMMCO West to send out a survey that is related to
her research initiative. The title of her research project is “Compassion fatigue in emergency medical services
(EMS): The influence of self-care on compassion fatigue among EMS professionals in Northwestern Pennsylvania”.
EMMCO West, Inc., as part of our work statement of activities with the PA Department of Health, is to assist with
EMS prehospital research initiatives. Ms. Martin’s request falls within our work statement parameters. EMMCO
West, Inc. will provide assistance through the use of the ConstantContact email system to distribute her online
survey for this research initiative.
Feel free to contact me if you have any questions or need additional information.

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Appendix B: Permission to use the ProQOL, version 5
Permission for Use of the ProQOL (Professional Quality of Life Scale: Compassion Satisfaction
and Compassion Fatigue) www.proqol.org
Accompanied by the email to you, this document grants you permission to use for your study or
project
The ProQOL (Professional Quality of Life Scale: Compassion Satisfaction and Compassion
Fatigue) www.ProQOL.org
Prior to beginning your project and at the time of any publications, please verify that you are
using the latest version by checking the website. All revisions are posted there. If you began project with
an earlier version, please reference both to avoid confusion for readers of your work.
This permission covers non-profit, non-commercial uses and includes permission to reformat the
questions into a version that is appropriate for your use. This may include computerizing the measure.
Please print the following reference or credit line in all documents that include results gathered
from the use of the ProQOL.
Stamm, B. H. (2010). The ProQOL (Professional Quality of Life Scale: Compassion Satisfaction
and Compassion Fatigue). Pocatello, ID: ProQOL.org. retrieved [date] www.proqol.org
Permission granted by Beth Hudnall Stamm, PhD Author, ProQOL ProQOL.org info@proqol.org
Help us help all of us. Please consider donating a copy of your raw data to the data bank. You can
find more about the data bank and how you can donate at www.proqol.org and
www.proqol.org/Donate_Data.html. Data donated to the ProQOL Data Bank allow us to advance the
theory of compassion satisfaction and compassion fatigue and to improve and norm the measure itself.

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Appendix C: Permission to Use the HPLP II
Dear Colleague:

Thank you for your interest in the Health-Promoting Lifestyle Profile II. The original
Health-Promoting Lifestyle Profile became available in 1987 and has been used extensively
since that time. Based on our own experience and feedback from multiple users, it was revised to
more accurately reflect current literature and practice and to achieve balance among the
subscales. The Health-Promoting Lifestyle Profile II continues to measure healthpromoting
behavior, conceptualized as a multidimensional pattern of self-initiated actions and perceptions
that serve to maintain or enhance the level of wellness, self-actualization and fulfillment of the
individual. The 52-item summated behavior rating scale employs a 4-point response format to
measure the frequency of self-reported health-promoting behaviors in the domains of health
responsibility, physical activity, nutrition, spiritual growth, interpersonal relations and stress
management. It is appropriate for use in research within the framework of the Health Promotion
Model (Pender, 1987), as well as for a variety of other purposes.

The development and psychometric evaluation of the English and Spanish language
versions of the original instrument have been reported in:

Walker, S. N., Sechrist, K. R., & Pender, N. J. (1987). The Health-Promoting Lifestyle
Profile: Development and psychometric characteristics. Nursing Research, 36(2), 76-81.
Walker, S. N., Volkan, K., Sechrist, K. R., & Pender, N. J. (1988). Health-promoting lifestyles of
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older adults: Comparisons with young and middle-aged adults, correlates and patterns.
Advances in Nursing Science, 11(1), 76-90. Walker, S. N., Kerr, M. J., Pender, N. J., & Sechrist,
K. R. (1990). A Spanish language version of the HealthPromoting Lifestyle Profile. Nursing
Research, 39(5), 268-273.

Copyright of all versions of the instrument is held by Susan Noble Walker, EdD, RN,
FAAN, Karen R. Sechrist, PhD, RN, FAAN and Nola J. Pender, PhD, RN, FAAN. The original
Health-Promoting Lifestyle Profile is no longer available. You have permission to download and
use the HPLPII for non-commercial data collection purposes such as research or evaluation
projects provided that content is not altered in any way and the copyright/ permission statement
at the end is retained. The instrument may be reproduced in the appendix of a thesis, dissertation
or research grant proposal. Reproduction for any other purpose, including the publication of
study results, is prohibited.

A copy of the instrument (English and Spanish versions), scoring instructions, an abstract
of the psychometric findings, and a list of publications reporting research using all versions of
the instrument are available for download.

Sincerely,
Susan Noble Walker, EdD, RN, FAAN Professor Emeritus
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Appendix D: Edinboro University IRB Approval Letter
This memo provides the notification concerning EU's Institutional Review Board (IRB)
determination of the human subjects protocol:

To: Dr. Terri Astorino, Principal Investigator; Kelly Martin, Co-Investigator

From: Elisabeth Joyce, Edinboro University Institutional Review Board Chair Protocol #
EU201748

Date Approved: 13-Oct-2017

Title: Compassion Fatigue in Emergency Medical Services (EMS): The Influence of
Self-Care on Compassion Fatigue among EMS Professionals in Northwestern Pennsylvania

The EU IRB Chair has designated this committee as reviewer of the application listed
above for exempt status. It has been determined that your protocol is categorized as Exempt
under federal regulations 45 CFR 46.101(b), since the research design involves one or more of
the following criteria: ___Research conducted in established or commonly accepted educational
settings, involving normal educational practices. _X_Research using educational tests, surveys
or interviews where respondents are not identified or are public officials. ___Research involving
observation of public behavior. ___Research involving collection, study, and use of existing data
where subjects are not identified. Exempt protocol means that as long as you continue your
research as described in your protocol application, the research does not require any further
review or oversight by the IRB. Should you change any procedure within your research, you are
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required to resubmit the protocol to the IRB for reconsideration and determination before you
implement any change. All data must be retained and accessible for three (3) years after the
completion of the project. Designation as exempt signifies only that the proposal adequately
qualifies under 45 CFR 46.101(b) for such status. It does not imply, directly or indirectly, any
institutional support or permission to conduct the study.

Should you have any questions or concerns, please feel free to contact me at 814-7322448.

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Appendix E: Collaborative Institutional Training Initiative (CITI) Certificates

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Appendix F: Consent to Participate in Research Study/Survey
EDINBORO UNIVERSITY OF PENNSYLVANIA
Edinboro, Pennsylvania
CONSENT TO PARTICIPATE IN A RESEARCH STUDY
Title of Study: Compassion fatigue in emergency medical services (EMS): The influence of selfcare on compassion fatigue among EMS professionals in Northwestern Pennsylvania
Principal & Co- investigators: Dr. Terri Astorino and Kelly Martin
Introduction
You are being asked by Kelly Martin to be in a research survey. This consent describes
your role as a participant in the survey. This research is part of the requirements for a
Doctorate in Nursing Practice degree at Clarion and Edinboro Universities.
Study Purpose
The purpose of this study is to determine the correlation between self-care and
compassion fatigue among EMS professionals in Northwestern Pennsylvania.
What Will Happen During the Study?
After reviewing the consent form, you will be given the opportunity to choose to
participate in the survey by clicking the “next” button. If you choose to not participate,
just exit out of your web browser. The time to complete the survey is estimated to be
approximately 20 minutes.
What Are the Possible Risks or Discomforts?
No demographic information will be collected, however, anonymity remains a potential
risk to the participant. In order to minimize the risk to the participant, no personal
identifiers will be collected by the researchers. This study will utilize Survey Monkey as
the instrument by which data will be collected. Survey Monkey employs security
measures to maintain anonymity as outlined in their security statement and privacy
policy.
What Are the Possible Benefits of Participating in This Study?
This research will benefit emergency medical services as a whole as well as the patients
served. By identifying the correlation between self-care and compassion fatigue,
awareness programs and other interventions may be implemented to prevent or remediate
the negative impact of compassion fatigue on EMS professionals.
How Will the Collected Data Be Kept Confidential?
Personal identifiers will not be collected. The researchers will disable the storage of
email or IP addresses. Survey Monkey provides a security infrastructure which includes
SSL/TLS encryption. Only the researchers will have access to the survey. Data will be
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retained for three years and will then be destroyed via a permanent deletion option
provided by Survey Monkey.
What Happens If I Have More Questions?
Your questions about a research-related injury or the research study will be answered by
Dr Terri Astorino at tastorino@edinboro.edu. If you have a question about your rights as
a research participant you can contact the chairperson of Edinboro University
Institutional Review Board, at irb-chair@edinboro.edu
What Will Happen If You Decide Not To Be in the Study?
Your participation is strictly voluntary; you may elect not to answer any or all of the
questions in the survey. If you change your mind about participating, there will be no
penalty, retribution, or repercussion for withdrawing from the study. To stop taking the
survey, exit out of your web browser.
By clicking the next button and beginning the survey, you acknowledge that you have read the
informed consent and agree to participate in the survey. You also acknowledge that you are at
least 18 years of age and that you understand that you have the right not to answer any or all of
the questions in the survey. Finally, you understand that you can quit the survey, without
penalty, at any time.

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Appendix G: Permission to Utilize Survey Monkey for Research Study

SurveyMonkey Inc. www.surveymonkey.com
For questions, visit our Help Center help.surveymonkey.com

Re: Permission to Conduct Research Using SurveyMonkey

To whom it may concern:

This letter is being produced in response to a request by a student at your institution who wishes to conduct
a survey using SurveyMonkey in order to support their research. The student has indicated that they require a letter
from SurveyMonkey granting them permission to do this. Please accept this letter as evidence of such permission.
Students are permitted to conduct research via the SurveyMonkey platform provided that they abide by our Terms of
Use, a copy of which is available on our website.

SurveyMonkey is a self-serve survey platform on which our users can, by themselves, create, deploy and
analyze surveys through an online interface. We have users in many different industries who use surveys for many
different purposes. One of our most common use cases is students and other types of researchers using our online
tools to conduct academic research.

If you have any questions about this letter, please contact us through our Help Center at
help.surveymonkey.com.

Sincerely,
SurveyMonkey Inc.
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Appendix H: Survey (ProQOL 5, HPLP2)

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