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Heart of Oncology Nursing

The Impact of a Knitting Intervention on Compassion Fatigue in Oncology Nurses

Lyndsay W. Anderson
Christina U. Gustavson
CJON 2016, 20(1), 102-104 DOI: 10.1188/16.CJON.102-104

Compassion fatigue is the emotional exhaustion and stress that nurses can feel when caring for terminally ill patients. This can contribute to high nursing turnover rates, result in poor job satisfaction, and lead to decreased ability to provide quality care. Oncology nurses are vulnerable to compassion fatigue because they develop relationships with patients battling life-threatening illnesses, provide end-of-life care, and encounter ethical dilemmas related to cancer treatment.

Compassion fatigue is the emotional exhaustion and stress that nurses can feel when caring for terminally ill patients. This can contribute to high nursing turnover rates, result in poor job satisfaction, and lead to decreased ability to provide quality care. Oncology nurses are vulnerable to compassion fatigue because they develop relationships with patients battling life-threatening illnesses, provide end-of-life care, and encounter ethical dilemmas related to cancer treatment.

Previous studies have explored compassion fatigue to understand its prevalence, causes, and deleterious effects on oncology nurses (Aycock & Boyle, 2009; Ferrell & Coyle, 2008; Potter et al., 2010; Sivesind et al., 2003). Aycock (2006) described the emotional burdens nurses carry when their patients are dying and denote that “attention to our own affective needs and grief establish a formidable platform of risk for oncology nurse caregivers” (p. 11). They highlighted the great care nurses provide to patients and their families and the contrasting lack of care that nurses provide to themselves. Aycock and Boyle (2009) suggested that overlooking self-health promotion opportunities increases nurses’ experience of compassion fatigue.

Arts and humanities programs, such as expressive writing exercises, have been shown to be beneficial for people with cancer (Morgan, Graves, Poggi, & Cheson, 2008). These programs have demonstrated improved physical quality of life after participation. Hilliard (2006) studied hospice workers and the effects of music therapy on their compassion fatigue and team building. In the study by Hilliard (2006), music interventions improved the participants’ team building but had no effect on their compassion fatigue ratings.

Carter, Dyer, and Mikan (2013) studied the impact of cognitive-behavioral therapy as an intervention for insomnia experienced by hospice nurses. They concluded that longitudinal studies were needed to investigate the effectiveness of their intervention. Houck (2014) created an educational program targeting cumulative grief and compassion fatigue in nurses. The program, Running on Empty? How to Rejuvenate, Recharge and Refill, consisted of one three-hour session designed to teach nurses self-care strategies, including Reiki, breathing techniques, guided imagery, stretching, and self-massage. The curriculum also included education about pastoral care and the availability of employee assistance programs. After the session, evaluations revealed that the participants felt less isolated in their grieving processes and were more likely to ask for help when needed. Based on the participants’ feedback at the completion of the program, the study hospital created additional resources for nurses.

Henry (2014) conducted a literature review regarding interventions to combat compassion fatigue. The review included studies on writing workshops, retreats, mindfulness training, mentoring programs, resilience training, and fellowship that demonstrated positive outcomes. Henry (2014) cautioned that many of the reported interventions lacked objective measurement tools and experimental designs.

Knitting to Lower Compassion Fatigue

Knitting has been shown to lower heart rate and blood pressure and reduce muscle tension (Dittrich, 2001). A review of the literature revealed no recent studies investigating knitting as a tool to manage the compassion fatigue experienced by oncology nurses. Combatting Compassion Fatigue Among Oncology Nurses: An Exploration of the Impact of a Knitting Intervention was designed by the authors to explore the impact of a knitting education program and the related incidence of compassion fatigue in oncology nurses. Participants were nurses recruited from MedStar Georgetown University Hospital Lombardi Comprehensive Cancer Center in Washington, DC. Eligible nurses worked part-time or full-time on one of two inpatient hematology and oncology units, had at least one year of oncology nursing experience, and had chemotherapy and biotherapy certification from the Oncology Nursing Certification Corporation. Exclusion criteria included travel nurses, per diem nurses, and oncology nurses with less than one year of experience because they did not have a lengthy exposure to the oncology patient population and, therefore, may not have been at the same risk level for compassion fatigue.

Study participants worked with knitting instructors from Project Knitwell (http://projectknitwell.org), a nonprofit organization whose mission is to bring the therapeutic benefits of knitting to people dealing with stressful situations. Project Knitwell volunteers taught oncology nurses to knit in hopes that they would gain the myriad benefits inherent in the simple act of knitting. In addition, the volunteers provided knitting instructions and materials in a knitting basket with varying kinds of yarn and needles to the respite lounge on each nursing unit. Nurses had the opportunity to knit while taking breaks, having lunch, or after dealing with stressful situations. When possible, study participants learned to knit in groups, which provided time to debrief over stressful situations while knitting. Each participant created a knitted square and these were conjoined, framed, and displayed on the nursing units at the end of the project.

Study Design and Result

The framework for this study is based on the mid-range Health Promotion Model (HPM) (Pender, 2006). The HPM examines the relationship between health-promoting behaviors and wellness. The model encompasses the individual’s background and experience and how it affects unique situations with regard to health-promoting decisions.

The effect of the knitting intervention on compassion fatigue was measured with a tool, the Professional Quality of Life: Compassion Satisfaction and Fatigue Scales, R-IV, developed by Hudnall Stamm (2008). This scale measures compassion satisfaction, compassion fatigue, burnout, and secondary stress using a numerical rating system. A participant’s score represents the intensity of what he or she is experiencing in each category, with a lower numeric score representing lesser intensity. Data were collected on compassion fatigue before and after a six-week period in which participants had exposure to the Project Knitwell intervention. Participants also answered open-ended survey questions after the intervention.

The final sample (N = 39) included nurses with varying levels of experience, ranging from 1–37 years in practice (mean = 8.16 years). Nurses ranged in age from 22–65 years (mean age = 32 years). Nurses participated in the knitting intervention between one and five times during the six-week period.

A significant change was observed from the preintervention burnout scores and postintervention burnout scores from a mean of 24.72 to 22.91, respectively. Hudnall Stamm (2008) noted the average score in this category to be 22. After the knitting intervention, the study participants were closer to the expected average. The nurses who reported the highest burnout scores preintervention had the most decrease in their burnout scores after the intervention. The same holds true for secondary traumatic stress scores, and a trend was noted toward significance on the compassion satisfaction scores. According to the results, the younger nurses (aged younger than 30 years) on the units experienced lower compassion satisfaction and higher burnout scores prior to the Project Knitwell intervention, and their scores improved after participating in the intervention, with higher reported compassion satisfaction and lower burnout scores.

The follow-up survey included open-ended questions to evaluate the study and its benefits. Comments were supportive of the intervention.

I really enjoyed learning to knit. It has provided me with a new skill.

[I] really enjoyed the soothing rhythm of knitting and creating something useful.

Oncology nursing is very demanding, and the staff members definitely need ways to de-stress, enjoy life, etc. So, learning a new creative skill is a good way to help accomplish this.

I feel like it was a very positive experience. In addition to freeing our minds and bringing back compassion, it was something for staff to bond over.

The census and acuity of the patient population was high during the six weeks of the knitting intervention, prompting several nurses to report that the unit was too busy to participate in the intervention as often as they would have liked. One nurse reported, “I’m willing to learn how to knit, but I was not able to participate in it because our floor is busy most of the time.” Another stated, “It is a great activity to have available on the floor. I don’t think a lot of the nurses felt they had enough time to participate in knitting more than once.” Other recommendations from the participants included expanding the number and variety of creative interventions to combat compassion fatigue. Of note, the nurses described painting and music interventions as tools to promote wellness.

One limitation of this study was the small convenience sample. In addition, providing the intervention to night shift nurses was challenging. The best time night shift nurses were available for a break was generally between 2 am and 5 am; however, finding a knitting instructor who was consistently available at that time was difficult.

Implications for Nursing

This study demonstrated that a knitting intervention may help oncology nurses manage stressors on their shift and combat compassion fatigue. The intervention provided nurses with an opportunity to process difficult work situations. Nursing practice should allow nurses to use their allotted break time for stress-reducing interventions, such as knitting, to decrease compassion fatigue and increase their compassion satisfaction. In addition, new nurses should be educated on the incidence of compassion fatigue and ways to prevent it. Knitting is one way to combat compassion fatigue and could be a valuable addition to several other interventions, such as Houck’s (2014) program, Running on Empty? How to Rejuvenate, Recharge and Refill.

Less compassion fatigue could increase retention and improve the quality of patient care. As a result of this study’s positive outcome, Project Knitwell was invited to offer bimonthly knitting sessions for nurses and other interested hospital staff. It also is included in the orientation program for new nursing hires to improve their self-care.


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About the Author(s)

Lyndsay W. Anderson, MSN, FNP-BC, OCN®, is a nurse practitioner at the MedStar Georgetown University Hospital and Capital Breast Care Center in Washington, DC, and Christina U. Gustavson, MSN, FNP-BC, OCN®, is a nurse practitioner in the Inova Melanoma and Skin Cancer Center at the Inova Medical Group in Fairfax, VA. The authors take full responsibility for the content of the article. The authors did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the authors or editorial staff. Anderson can be reached at lyndsaywanderson@gmail.com, with copy to editor at CJONEditor@ons.org.