See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/308956936

Change your life through journaling--The benefits of journaling for registered

nurses

Article in Journal of Nursing Education and Practice · October 2016

DOI: 10.5430/jnep.v7n2p90

CITATIONS READS
9 17,820

4 authors, including:

Lynda J. Dimitroff

14 PUBLICATIONS 53 CITATIONS

SEE PROFILE

All content following this page was uploaded by Lynda J. Dimitroff on 05 June 2017.

The user has requested enhancement of the downloaded file.

http://jnep.sciedupress.com Journal of Nursing Education and Practice 2017, Vol. 7, No. 2

ORIGINAL RESEARCH

Change your life through journaling–The benefits of

journaling for registered nurses
Lynda J. Dimitroff∗1 , Linda Sliwoski2 , Sue O’Brien3 , Lynn W. Nichols4
1
Nursing Department, Nazareth College, Rochester, United States
2
Greater Rochester Independent Practice Association, Rochester, United States
3
Physical Therapy Department, Nazareth College, Rochester, United States
4
Department of Nursing Research & Evidence-Based Practice, Rochester General Hospital, Rochester, United States

Received: May 16, 2016 Accepted: September 17, 2016 Online Published: October 8, 2016
DOI: 10.5430/jnep.v7n2p90 URL: http://dx.doi.org/10.5430/jnep.v7n2p90

A BSTRACT
Objective: The objective of this study was to determine the effect journaling had on the degree of compassion satisfaction (CS),
burnout (BO), and trauma/compassion fatigue (TCF) present in registered nurses (RNs). A secondary objective of this study was
to gain knowledge about participants’ experiences with journaling.
Methods: This study was a pre-test, post-test quasi-experimental design with a qualitative component. A total of 66 registered
nurses were recruited to participate in a journaling class. Each RN completed the Professional Quality of Life Scale Survey
Revision IV (ProQOL R-IV) three times. In addition to the surveys, participants were asked to answer two open-ended questions.
Results: CS, BO, and TCF all improved after taking the course. The overall change from Pre-survey to Post II-survey was
statistically significant for compassion satisfaction (p = .008); burnout (p = .0001); and, trauma compassion fatigue (p = .0001).
During constant-comparative analysis three themes were identified as: 1) journaling allowed me to unleash my inner most feelings,
2) journaling helped me to articulate and understand my feelings concretely, and 3) journaling helped me make more reasonable
decisions.
Conclusions: This study provides valuable information about journaling having a positive effect over time on the ability of
registered nurses to handle stress, increase CS, and decrease BO and TCF symptoms. While this information adds to the limited
literature, further research needs to be conducted with a larger sample.

Key Words: Journaling, Registered nurses, Compassion satisfaction, Burnout, Trauma/compassion fatigue

1. I NTRODUCTION Emotional exhaustion and burnout (BO) are costly to reg-

istered nurses (RNs) physically, emotionally, socially, and
spiritually, and, financially costly to health care organizations
Writing and wellness are natural allies. When approached in
in terms of nursing turnover. The overall health of our RNs
a purposeful and intentional way, journal writing can be an
has a direct impact on health care organizations. Emotional
agent for healing and change. Writing thoughts and feelings
exhaustion and BO of nurses are detrimental to patient care
in a journal develops insight, compassion for self, and body
outcomes. The nursing profession must explore opportu-
awareness. Writing organizes cognition, articulates intuition,
nities to strengthen the current workforce; and incorporate
and regulates emotion.[1]
∗ Correspondence: Lynda J. Dimitroff; Email: [email protected]; Address: Nursing Department, Nazareth College, Rochester, United

States.

90 ISSN 1925-4040 E-ISSN 1925-4059

http://jnep.sciedupress.com Journal of Nursing Education and Practice 2017, Vol. 7, No. 2

the development of self-care strategies and self-development Journaling is a method that encourages reflection and emo-
into the busy lives of nurses. tional discharge. The literature is saturated with the benefits
of journaling including self-awareness; release of pent-up
There is an abundance of literature supporting the benefits
emotions, record keeping–tracking your life experiences;
of journaling. Journaling encourages self-awareness, allows
relationship healing; exploring inner guidance-accessing sub-
for the opportunity to release emotions, and may assist in
conscious and unconscious minds; and, improved health.
making sense of complex situations.[2–14] The current study
Examples of improved health include: lowered blood pres-
explored the effects of journaling on reported symptoms of
sure, enhanced immune function, and decreased depressive
CS, BO, and, TCF in RNs. The very nature of working in
symptoms.[3, 8–11, 13, 18, 20]
the nursing profession lends itself to CS, BO, and TCF. Most
nurses have experienced some form of related symptoms in Journaling is a record of personal thoughts, daily events, and
their careers.[15] evolving insights. By giving the author a voice, journaling
allows the opportunity for the author to release emotions
As more technical and complex treatments emerge, the RN
and make sense out of complex life experiences. Journal-
is required to compassionately care for and give emotional
ing is a vehicle for self-understanding, self-guidance, ex-
support to treat the patient. Compassionate care and emo-
panded creativity, and spiritual development.[2] The journal
tional support of patients puts the RN in a very vulnerable
allows authors to freely express themselves without judg-
position. The empathy and compassion that are necessary for
ment, criticism or analysis. A scream, anger, whimper, sad-
supportive patient care are also the main characteristics that
ness, wail, and rage are all acceptable behaviors to the jour-
make nurses susceptible to TCF and BO. If RNs continually
nal.[2, 8–11, 13, 18, 20] Journal writing is a form of self-expression
neglect their own basic human needs for self-care, eventu-
that can add dimension to the author’s life.
ally, they will give way to symptoms of BO and TCF.[16] “. . .
Compassion fatigue can be emotionally devastating, result- Progoff has been credited with being the father of modern
ing in impaired performance which makes the goal of quality day journaling.[2] He has been recognized as the leader in un-
care almost impossible to accomplish”.[17] Exploring the derstanding the personal value of journal writing for growth
benefits of a structured journaling program for RNs may be and learning since 1966. Progoff[21] developed the Inten-
one strategy to reduce BO and TCF and encourage self-care. sive Journal Process Workshop, which is an instrument for
self-guidance to help people derive meaning of their unique
Pennebaker[14] investigated how writing about emotionally
life.
upsetting experiences can affect a person’s thoughts, feelings,
[18]
and physical health. Parr, Haberstroh, and Kottler state The review of the literature identified that journaling is an
that not disclosing personal thoughts and feelings can be un- effective tool to develop critical thinking in diverse fields of
healthy. Francis & Pennebaker[19] concluded that journaling education. Nurse educators have used journal entries, such
reduced blood pressure, moods, and absenteeism in subjects. as general observations, questions, speculative statements,
Pennebaker’s work[14] also indicated that journaling about expressions of self-awareness, statements of synthesis, revi-
meaningful topics improved the physical and emotional well- sions of previously held ideas, and the accumulation of new
being of individuals. Pennebaker[14] reported that there were information, to develop critical thinking in nurses. The use of
no differences in the benefits of writing related to personality, a journal for clinical experiences can have the same benefits
culture, or language. as those received from personal journal writing. The student
can find meaning in life and the journal allows the student
1.1 Literature review to release feelings about the clinical experience. Empathy
Despite the literature confirming the benefits of journaling, develops with reflective thinking.
it remains underused as a means of self-care in nursing. No
published research was found that examined the relationship 1.1.2 Compassion fatigue and compassion satisfaction
between journaling and extent of symptoms of CS, BO, or
“Compassion fatigue (CF) also called secondary trauma . . .
TCF expressed by RNs.
is about your work-related, secondary exposure to extremely
1.1.1 Journaling stressful events”.[22] In contrast, “compassion satisfaction
Journaling is one resource shown to improve health. Jour- is the sum of all the positive feelings a person derives from
naling is the act of writing down thoughts, perceptions and helping others”.[16] The empathy that nurses provide to their
feelings. Journaling about complex situations is a practical patients is life giving personally and professionally.[16, 23–25]
way for the author to have a relationship with her/his own “Compassion satisfaction has been identified as a construct
mind. The written word often provides clarity to a situation. that measures these affirmative experiences”.[25]
Published by Sciedu Press 91
http://jnep.sciedupress.com Journal of Nursing Education and Practice 2017, Vol. 7, No. 2

CF is a specific type of BO unique to the helping professions ing your job effectively. These negative feelings
and was first identified and described in the nursing literature usually have a gradual onset. They can reflect
by Joinson in the 1990s. RNs are especially at risk for de- the feeling that your efforts make no difference,
veloping CF due to the emotional and physical demands of or they can be associated with a very high work-
the profession. If the symptoms of CF are not identified and load or a non-supportive work environment.[22]
preventive actions are not taken, several consequences may
result from these prolonged feelings, including the inability Compassion fatigue results from the consequence of caring
to care for patients in a mutually satisfactory manner.[26] In for people who are suffering, rather than a direct response to
such situations, RNs may become more task-oriented and the work environment.[23–25, 35–39]
less relationship-oriented.[27]
Compassion fatigue develops as a result of the care provider’s
In some cases, the RN experiencing these symptoms over exposure to the patient’s experiences combined with empa-
time may choose to leave the nursing profession completely. thy for the patient. Burnout is a gradual wearing down of
While all health care providers are at risk for CF, nurse lead- the caregiver, by one’s feelings of being overwhelmed by
ers need to understand and recognize that RNs are particu- one’s work and feeling incapable of effecting positive change.
larly vulnerable. The stressors in nursing are related to close These feelings produce emotional withdrawal and diminished
patient and family relationships, the perceived lack of control empathy. When symptoms of CF are present, the caregiver
over disease outcome, and the deep involvement with death tries to continue to give patient care but feels as though s/he
and dying issues. RNs need help to recognize and cope with has failed at the profession.[29, 40, 41] Nurses experiencing CF
these stressors. Some of the helping strategies may include are left emotionally and psychologically unavailable to give
education, retreats, emotional expression, storytelling, and more to their patients and families.
journaling.[28]
Figley[29] suggested that empathy and emotional energy are
CF began under the umbrella of Post-Traumatic Stress Syn- the underlying drivers in the development of CF. Those care
drome (PTSS).[29] Early work in traumatology and the need providers who have an enormous capacity for feeling and
for early intervention for victims who were exposed to hor- expressing empathy tend to be more at risk.[31, 42] The profes-
rific experiences grew in the late 1980s when it became evi- sion of nursing puts the needs of patients first before tending
dent that those providing assistance to victims of trauma to its own needs. Caregivers in general, lack the attention
were experiencing adverse effects themselves outside of to their own personal, social and spiritual needs.[26, 32] This
work.[30, 31] The care provider experienced symptoms that order of priorities, coupled with the demand for caring for
mimicked those of the victims who were actually trauma- more patients in less time and with fewer resources, produces
tized. This phenomenon was called Secondary Traumatic decreased morale, decreased patient and nurse satisfaction,
Stress Syndrome (STS). STS occurs when one is exposed to increased health care costs, and behavioral changes in staff
extreme events which are directly experienced by another, nurses.[43]
and is overwhelmed by this secondary exposure to trauma.[29]
Statement of study aims, research question, and/or hypothe-
The historical development of the term CF came from the link ses:
between PTSS and STS.[29, 30, 32, 33] Compassion fatigue has
The objective of this study was to determine the effect jour-
been thought to be a combination of STS and BO precipitated
naling had on the degree of CS, BO, and TCF present in RNs.
by the delivery of care that brings health care professionals
A secondary objective of this study was to gain knowledge
into contact with suffering.[31, 34] The concept of CF cited
about participants’ experiences with journaling.
in the nursing literature by Joinson[32] described nurses who
were exhausted and worn down by daily interactions with
patients, hospital emergences, “increasingly sophisticated
2. M ETHODS
[32]
medical technology”, and hospital emergencies. The RN The study design was a pre/post-test quasi experimental de-
was exposed to a person or patient who had been trauma- sign with a qualitative component. Descriptive and infer-
tized rather than having direct exposure to the trauma. This ential statistics including Friedman’s two-way analysis of
differentiates CF from PTSS.[31] variance (ANOVA) by ranks, and pairwise comparisons were
chosen to analyze the responses to the Professional Quality
Symptoms of CF share multiple traits with those of BO; there of Life Scale Survey Revision IV (ProQOL R-IV) which
are however, differences. measured CS, BO, and TCF. Friedman’s two-way ANOVA
Burnout is associated with feelings of hopeless- by ranks is a non-parametric test similar to the one-way
ness and difficulties in dealing with work or do- ANOVA with repeated measures.[44] The Friedman test was
92 ISSN 1925-4040 E-ISSN 1925-4059
http://jnep.sciedupress.com Journal of Nursing Education and Practice 2017, Vol. 7, No. 2

used to test the differences between groups across multiple IV three times: the Pre-survey (prior to the intervention),
time periods (Pre-survey, Post I-survey, and Post II-survey) Post I-survey (immediately following the intervention), and
with the ordinal variables (CS, BO, and TCF). Post II-survey, and two open-ended questions (two months
after the intervention).
A descriptive qualitative method through constant-
comparative analysis was utilized to understand more about The ProQOL R-IV instrument measured the self-reported
the effects of journaling through responses participants gave frequency of various characteristics that RNs experienced
to the open-ended questions of the Post II-survey. The related to their work experiences over a 30-day period.
purpose of descriptive qualitative research is to describe
experiences as they are lived. In this instance, a qualitative, 2.1 Sample recruitment
descriptive approach allowed for a deeper understanding of At the beginning of the study, a brochure explaining the
the nurses’ experience with journaling. study, informational meeting dates, class dates and times,
and the Primary Investigator (PI) contact information was
Taylor[45] explained that
posted on nursing units and discussed in meetings at the hos-
. . . the search for the nature of a phenomenon pital where the study took place. In addition, eligible RNs
begins with the people, in their place and time, were contacted through the hospital and local professional
and it leads to an explication of the aspects of organizations via email and word of mouth. Interested RNs
a phenomenon. The nature of a phenomenon received a letter about the research project and were invited
is a reflection of the nature of people as human to attend a 1.5-hour informational meeting.
beings . . . who are living and making sense of
their experiences. 2.2 Pre-survey phase
During the Pre-survey Phase, (the informational meeting),
In qualitative research, data analysis is an on-going pro- the study was explained, there was an opportunity to ask
cess of interpretation, coding, and re-coding. Following the questions about the study, and the forms (informed consent,
verbatim transcription of the written responses to the two demographics, contact information, and the Pre-survey) were
open-ended questions, the transcripts were read, coded, and completed. In order to maintain confidentiality, each partici-
re-read. Two registered nurses (the Primary Investigator [PI] pant was assigned a code which was recorded on the contact
and the Research Mentor) analyzing the data allowed for au- information form and the surveys.
diting categories and themes, thus ensuring the dependability
and confirmability components of trustworthiness. 2.3 Intervention phase
The intervention was a six-week journaling program con-
Prior to data collection, Nursing Research Committee and
sisting of six 2.5 hour journaling classes. Each participant
Institutional Review Board approvals were obtained from the
was asked to attend all six classes and complete a 1-3 hour
institution where the study took place.
assignment after each class. Participants determined how
Though there were minimal risks to the participants, there much time they wanted to spend on assignments.
was the potential of bringing unresolved issues to the surface
At the first journaling class, each participant received, The
which could have led to temporary feelings of sadness or
write way to wellness, a workbook written by Kathleen
depression. If temporary feelings of sadness or depression
Adams.[46] This workbook was used throughout the six-week
persisted, the participant was encouraged to talk with a ther-
journaling program. At no time during the journaling pro-
apist. Participants who were in therapy were encouraged
gram were the participants asked to hand in their workbook
to review this research program with their therapist prior
or journaling assignments. There were optional opportuni-
to beginning the program. Participants were free to with-
ties at each session for the participant to verbally share their
draw from this study at any time. Any identifying personal
journaling experiences and feelings.
information was kept confidential.
In the event that a participant missed a journaling class, the
Participation in this study was voluntary. The study was
PI gave the RN the material covered in class and they were
categorized as minimal risk and involved approximately 15
asked to complete the work independently. If more than
hours over a six-week period. In addition, participants were
one class was missed, the participant was invited to attend
asked to complete homework assignments.
the subsequent journaling classes, however, they were not
The sample consisted of 66 RNs who were employed in the eligible to complete the Post I-survey, Post II-survey or open-
Rochester, NY area. Data were collected in three phases ended questions, receive CNE credits, or receive the Journal
which included the administration of the ProQOL Revision to the self [3] gift book at the completion of the journaling
Published by Sciedu Press 93
http://jnep.sciedupress.com Journal of Nursing Education and Practice 2017, Vol. 7, No. 2

program. qualitative questions. The Statistical Package for Social Sci-

ences for Windows, Version 23.0[47] was utilized for data
2.4 Post I-survey analysis. Statistical significance was detected using an alpha
Following the completion of the six-week journaling pro- level of 0.05.
gram, the participant completed the Post I-survey which took
Descriptive statistics were used to describe the sample and
approximately 15 minutes. Each participant received a sealed
included an analysis of age, gender, race, education, years
envelope with their name on the outside of the envelope. The
in nursing, position, and expertise in journal writing and are
survey inside contained their assigned code. After complet-
displayed in Table 1 characteristics of sample. Inconsistent
ing the Post I-survey, the participant placed the survey in a
normality was found therefore, non-parametric tests were
blank envelope, sealed the envelope, and gave the envelope
used to test for difference across three time periods. Post hoc
to the PI. This was to ensure confidentiality was protected.
testing was calculated to determine where significance was
between the three points in time.
2.5 Post II-survey
Two months after the completed journaling program, each CS, BO, and TCF all improved after taking the course. The
participant was sent the Post II-survey and the two open- overall change from Pre-survey to Post II-survey was sta-
ended questions (qualitative data) in the mail and asked to tistically significant for compassion satisfaction (p = .008);
complete each form. These forms included their assigned burnout (p = .0001); and, trauma compassion fatigue (p =
code number. .0001).

The participant was asked to return the completed surveys in Results were maintained (statistically significant) at the two
the stamped, addressed envelope within two weeks of receipt month period for BO (p = .0001) and TCF (p = .001) and
of the surveys. The participant received the CNE certificate were not maintained for CS (p = 1.0).
and the workbook, Journal to the self [3] after returning the These statistically significant results on all three scale means
completed final two forms. indicate a trend for a positive impact of the journaling inter-
vention classes.
2.6 Instrument
The Professional Quality of Life Scale R-IV Survey (Pro- 3.1 Quantitative
QOL R-IV) The ProQOL R-IV was used in this study to The quantitative results of this study were as follows:
measure CS, BO, and TCF. This instrument is the renamed (1) Journaling was statistically significant, increasing com-
third version of the Compassion Fatigue Self Test (CFST), passion satisfaction (p = .008).
a survey that has been widely used in assessing CF. The (2) Journaling was statistically significant in reducing
revisions addressed difficulties with separating BO and sec- burnout (p = .0001).
ondary/vicarious trauma and also reduced the participant (3) Journaling was statistically significant in reducing
burden by shortening the test from 66 to 30 items. Each trauma/compassion fatigue (p = .0001).
subscale contained ten items: seven items from the previous
version and three new items. 3.2 Qualitative
The Cronbach alpha reliabilities for the scales are as follows: Constant-comparative analysis was completed of the written
compassion satisfaction alpha = 0.87; burnout alpha = 0.72; responses to the two open-ended questions in the Post II-
and CF alpha = 0.80.[22] The construct validity has been survey. To ensure credibility, the analysis was completed by
well established in over 200 articles noted in the peer review both the PI and Research Mentor. Analysis was completed
literature. Early return on test-retest data suggested good individually and then individual results were compared to
reliability across time. Factor analysis techniques have been safeguard the accurate representation of the participants’ re-
applied in CFST revision to the ProQOL R-IV version. sponses and researchers’ construction of themes.
Saturation was reached by coding the written response to the
3. R ESULTS open-ended questions. Once the categories became repetitive,
Participants in this study were enrolled from a convenience themes were identified and the analysis process ceased. Dur-
sample of RNs who were employed at an acute-care fa- ing the analysis three themes were identified as: 1) journaling
cility in Rochester, NY. There were 66 matching surveys allowed me to unleash my inner most feelings, 2) journaling
for the three time points (pre-intervention/Time 1, Post I- helped me to articulate and understand my feelings con-
survey/Time 2, and two months after the intervention Post cretely, and 3) journaling helped me make more reasonable
II-survey/Time 3) and responses to the two opened-ended decisions.
94 ISSN 1925-4040 E-ISSN 1925-4059
http://jnep.sciedupress.com Journal of Nursing Education and Practice 2017, Vol. 7, No. 2

Table 1. Characteristics of sample (N = 66) emotions onto paper. This released “the pressure valve” of
Characteristic n %
emotions as one participant stated.
Age category One nurse said, “This by far was the best experience for me
19-29 5 7.6 as a person. It allowed me to unleash my inner thoughts. . . ”
30-39 10 15.2
Another said, “I use this journaling experience as a valve to
40-49 17 25.8
release pressure.”
50-59 31 47.0
60+ 3 4.5 One of the RNs expressed this by writing,
Gender
The journaling experience has been an invigo-
Female 65 98.5
rating cathartic extension of my journey. I have
Male 1 1.5
Race
never felt more connected or comfortable on
American Indian or Alaska Native 1 1.5 knowing that this was where I was supposed to
Asian 1 1.5 be. Though moments in my mind were painful
Black/African-American 1 1.5 I am so thankful that I was able to be a part of
Hispanic or Latino 2 3.0 this experience.
Native Hawaiian or Pacific Islander 1 1.5
White 60 90.9 Finally, one woman described the experience as,
Education
It helped to have a place to pour out thoughts or
RN-Diploma or Associate’s 24 36.4
‘rant’ by writing rather than getting the urge to
RN-BSN 37 56.1
RN-MSN or higher 5 7.6 do it out loud when it is not always appropriate,
Years in nursing and instead of feeding negative energy to others,
0-3 5 7.6 keep it to myself but still have an outlet to let it
4-9 9 13.6 out, instead of letting it build up inside.
10-15 9 13.6
16-20 7 10.6 Theme II: Journaling helped me to articulate and under-
21-25 9 13.6 stand my feelings concretely
26 or more 27 40.9 The journaling technique was therapeutic for nurses, in-
Position creasing awareness to focus on the real issues, and express
Adult only 3 4.5
thoughts and feelings through writing. Journaling helped the
Home care 2 3.0
nurses make their thoughts and feelings black and white.
Inpatient 14 21.2
Outpatient 7 10.6 The nurses agreed that the journaling class helped to increase
Medical 1 1.5 their awareness about feelings. One nurse wrote,
Pediatric/adult 5 7.6
It has been instrumental in helping me identify
Pediatric only 1 1.5
Surgical 2 3.0 and articulate my feelings about nursing and
Other 4 6.1 personal events in my life. . . Journaling forces
More than one specialty 27 40.9 me to put a name to that anxiety, quickly focus
Position on the root and would absolutely facilitate my
Administration or Management 6 9.2 ability to deal with it. Thank you, thank you,
Staff RN 46 70.7 thank you!
Other 9 13.8
More than one position 4 6.1 One participant discussed the journal in terms of an important
Rate expertise in journal writing tool, “The journaling intervention has given me knowledge
Novice 27 40.9
and power and tools to express my inner experiences on pa-
Beginner 28 42.4
per.” Finally, one participant stated, “(journaling) puts things
Competent 10 15.2
Advanced 1 1.5 on paper in black and white, right out in the open. . . ”
Theme III: Journaling helped me make more reasonable
Theme I: Journaling allowed me to unleash my inner most decisions
thoughts In the context of the class, the nurses discussed how much
The journaling intervention helped the participant’s stress journaling helped to make better decisions utilizing a new
at work because they had the ability to channel their inner skill - journaling. One RN wrote,
Published by Sciedu Press 95
http://jnep.sciedupress.com Journal of Nursing Education and Practice 2017, Vol. 7, No. 2

. . . I am able to refocus and reassess the situa- employed RNs in Rochester, New York. There may have
tion from a different angle. . . The power to step been a response bias with the RNs who chose to take part in
away from a stressful situation or experience by this study.
applying my emotions to paper has changed my
life. Situations at work do not upset me as easily 4.2 Recommendations for practice, policy, and future re-
today. search
The implications for practice include implementing a journal-
Another stated, “I think it made me even more in touch with ing program at the institution of study, for local professional
myself and created an awareness which helped me take care nursing organizations, and at local nursing schools; and, de-
of myself and therefore better care of others. I would say it veloping educational programs for healthcare providers on
helped, yes.” “. . . helps or forces you to do something about journaling. In addition, it would be beneficial to consider
it.” Finally, one nurse summarized all three themes, collecting post-intervention data at six and twelve month in-
When I feel stressed, I use free-flow writing to tervals. Examining these data points would provide valuable
get my ideas down. It really helps to get things information as to the long term benefits of journaling as a
on paper. After I finish writing and I reread it, it useful tool in sustaining CS and preventing BO and TCF.
really helps me to understand what I have been Overall, given the small sample size for this study the signifi-
feeling. . . and makes it easier to deal with. cant findings are important and notable. Recommendations
for future studies include replicating the study with a larger
4. D ISCUSSION AND CONCLUSION sample size.
Journaling is an important tool for registered nurses. Few
Compassion fatigue is a preventable and treatable phe-
of us question the physical and emotional toll RNs experi-
nomenon. Organizations with policies, interventions, and
ence as a result of the numerous demands placed upon them
evaluation methodologies that address CF risk may result
by their work. These demands affect individuals on both
in substantial employee benefit cost savings, uninterrupted
personal and professional levels, contribute to attrition in
professional nursing care, and increased patient family satis-
professions that are already experiencing shortages, and can
faction and may continue to be regarded in communities as
ultimately impact the quality of care received by patients.
an optimal choice in EOL [sic End of life] care.[49]
Obviously, it benefits RNs, the patients they serve, and our
healthcare system as a whole, to do what we can to pro-
vide RNs with the tools necessary to adequately address the B IOS STATEMENT
ongoing demands of providing care. Dr. Lynda J. Dimitroff, PhD, MSEd, BSN, RN, MCHES,
Assistant Professor, Nursing Department, Nazareth College,
“Compassion fatigue is prevalent across all spec-
Rochester, NY; Linda Sliwoski, MSN, RN, Certified Jour-
trums of the helping professions and is flourish-
naling Instructor, Nurse Care Manager, Greater Rochester
ing. Can we afford to ignore the consequences?
Independent Practice Association, Rochester, NY; Dr. Sue
If we do not care now, who will and when? At
O’Brien, PhD, PT, NCS, CEEAA, Assistant Professor, Phys-
what cost?”[48]
ical Therapy Department, Nazareth College, Rochester, NY;
Dr. Lynn W. Nichols, PhD, RN, Senior PhD Research Sci-
These results indicate that journaling does have a positive entist, Department of Nursing Research & Evidence-Based
effect over time on the ability of nurses to handle stress and Practice, Rochester General Hospital, Rochester, NY.
CF resulting from the work in their professions. A larger
study would be warranted so that additional information ACKNOWLEDGEMENTS
could confirm the results of this study. The authors of this article would like to thank Dr. Kathryn
Gardner, EdD, RN, Dr. Carmela Rehtz, EdD, RN, Mer-
4.1 Limitations rilee Ritter, Barb Buscaglia, MSN, RN, CNA-BC, Janice
As with all studies, limitations must be deliberated prior to Putrino, LMSW, and, Jennifer S. Burr, MLS, MA, Scholarly
applying the results of a study to a given setting. In this Communications Librarian and Associate Professor for their
study, there was an 81% return rate of matching surveys for assistance on this project.
the three intervention time points, however, the overall study
sample size (n = 66) was small and the participants were not C ONFLICTS OF I NTEREST D ISCLOSURE
randomly chosen. The study was conducted with currently The authors declare that there is no conflict of interest.

96 ISSN 1925-4040 E-ISSN 1925-4059

http://jnep.sciedupress.com Journal of Nursing Education and Practice 2017, Vol. 7, No. 2

R EFERENCES [21] Progoff I. At a journal workshop. The basic text and guide fir using
[1] Adams K. Expressive Writing: Foundations of Practice. Lanham, the Intensive journal process. New York: Dialogue House Library;
MD: Rowman & Littlefield Publishing; 2013. 176 p. 1975. 320 p.
[2] Adams K. Journal to the self: Twenty-two paths to personal growth. [22] Stamm BH. The ProQOL manual. Idaho State University: Sidran
New York: Warner Books; 1990. 239 p. Press; 2005. 29 p.
[3] Adams K. Journal to the self-work book. Lakewood, CO: The Center [23] Branch C, Klinkenberg D. Compassion fatigue among pediatric
for Journal Therapy; 2002. 72 p. healthcare providers. American Journal of Maternal and Child Nurs-
ing. 2015; 40(3): 160-166. PMid:25594692 http://dx.doi.org
[4] Baldwin C. Life’s companion. Journal writing as a spiritual quest.
/10.1097/NMC.0000000000000133
New York: Bantam Books; 1991a. 352 p.
[24] Hinderer KA, VonRueden T, Friedmann E, et al. Burnout, com-
[5] Baldwin C. One to one. Self-understanding through journal writing.
passion fatigue, and secondary traumatic stress in trauma nurses.
New York: M. Evans and Company, Inc.; 1991b. 170 p.
Journal of Trauma Nursing. 2014; 21(4): 160-169. PMid:25023839
[6] Bolton G, Field V, Thompson K. Writing works. A resource hand- http://dx.doi.org/10.1097/JTN.0000000000000055
book for therapeutic writing workshops and activities. Philadelphia,
[25] Smart D, English A, James J, et al. Compassion fatigue and satis-
PA: Athenaeum Press, Gateshead, Tyne, and Wear; 2006. 255 p.
faction: A cross-sectional survey among US healthcare workers.
[7] Bolton G, Field V, Thompson K. Writing routes. A resource handbook Nursing and Health Sciences. 2014; 16: 3-10. PMid:23663318
of therapeutic writing. Philadelphia, PA: Jessica Kingsley Publishers; http://dx.doi.org/10.1111/nhs.12068
2011. 238 p.
[26] Dec E. How renal professionals can deal with compassion fatigue.
[8] Brady EM, Sky HZ. Journal writing among older learners. Educa- Nephrology News and Issues. 2005; 19(11): 70-71. PMid:16270740
tional Gerontology. 2003; 29(2): 151-163. http://dx.doi.org/1
[27] Medland J, Howard-Ruben J, Whitaker E. Fostering psychosocial
0.1080/713844282
wellness in oncology nurses: Addressing burnout and social support
[9] Callister LC. The use of student journals in nursing education: Mak- in the workplace. Oncology Nursing Forum. 2004; 31(1): 47-54.
ing meaning out of clinical experience. Journal of Nursing Educa- PMid:14722587 http://dx.doi.org/10.1188/04.ONF.47-54
tion.1993; 32(4): 185-186. PMid:8388443
[28] Aycock N, Boyle D. Interventions to manage compassion fatigue
[10] Gillis A. Journal writing in health education. New Directions for in oncology nursing. Clinical Journal of Oncology Nursing. 2009;
Adult and Continuing Education. 2001; 90: 49-58. http://dx.doi 13(2): 183-191. PMid:19349265 http://dx.doi.org/10.1188
.org/10.1002/ace.20 /09.CJON.183-191
[11] Hiemstra R. Uses and benefits of journal writing. New Directions for [29] Figley CR. Compassion fatigue as secondary traumatic stress disor-
Adult and Continuing Education. 2001; 90: 19-26. http://dx.doi der: An overview. New York: Brunner/Mazel Publishers; 1995. 268
.org/10.1002/ace.17 p.
[12] Kuo C, Turton M, Cheng S, et al. Using clinical caring journaling: [30] Figley CR. Treating compassion fatigue. New York: Brunner Rout-
Nursing student and instructor experiences. Journal of Nursing Re- ledge; 2002. 227 p. PMid:12412153
search. 2011; 19(2): 141-149. PMid:21586991 http://dx.doi.o [31] Sabo B. Compassion fatigue and nursing work: Can we accu-
rg/10.1097/JNR.0b013e31821aa1a7 rately capture the consequences of caring work? International Jour-
[13] Mills SD. Electronic journaling: Using the web-based, group jour- nal of Nursing Practice. 2006; 12(3): 136-142. PMid:16674780
nal for service-learning reflection. Michigan Journal of Community http://dx.doi.org/10.1111/j.1440-172X.2006.00562.x
Service Learning. 2001; 8(1): 27-35. [32] Joinson C. Coping with compassion fatigue. Nursing. 1992; 22(4):
[14] Pennebacker JW. Opening up. The healing power of expressing emo- 116, 118-119, 121. PMid:1570090 http://dx.doi.org/10.1097
tions. New York: The Guildford Press; 1990. 249 p. /00152193-199204000-00035
[15] Burtson PL, Stichler JF. Nursing work environment and nurse [33] Racanelli C. Attachment and compassion fatigue among American
caring: Relationship among motivational factors. Journal of Ad- and Israeli mental health clinicians working with traumatized vic-
vanced Nursing. 2010; 66(8): 1819-1831. PMid:20557389 http: tims of terrorism. International Journal of Emergency Mental Health.
//dx.doi.org/10.1111/j.1365-2648.2010.05336.x 2005; 7(2): 115-24. PMid:16107043
[16] Saco TL, Ciurzynski SM, Harvey ME, et al. Compassion satisfaction [34] Marcus S, Dubi M. The relationship between resilience and com-
and compassion fatigue among critical care nurses. Critical Care passion fatigue in counselors. American Counseling Association –
Nurse. 2015; 35(4): 32-44. PMid:26232800 http://dx.doi.org VISTAS. 2006; 223-225.
/10.4037/ccn2015392 [35] Hunsaker S, Chen H, Maughan D, et al. Factors that influence the
[17] Keidel GC. Burnout and compassion fatigue among hospice care- development of compassion fatigue, burnout, and compassion satis-
givers. American Journal of Hospice and Palliative Care. 2002; 19(3): faction in emergency department nurses. Journal of Nursing Scholar-
200-205. http://dx.doi.org/10.1177/104990910201900312 ship. 2015; 47(2): 186-194. PMid:25644276 http://dx.doi.org
[18] Parr G, Haberstroh S, Kottler J. Interactive journal writing as adjunct /10.1111/jnu.12122
in group work. Journal for Specialists in Group Work. 2000; 25(3): [36] Mason VM, Leslie G, Lyons P, et al. Compassion fatigue, moral dis-
229-242. http://dx.doi.org/10.1080/01933920008411464 tress, and work intensive care unit trauma nurses. A pilot study.
[19] Francis ME, Pennebacker JW. Putting stress into words: The impact Dimens Crit Care Nurs. 2014; 33(4): 215-25. PMid:24895952
of writing on physiological, absentee, and self-reported emotional http://dx.doi.org/10.1097/DCC.0000000000000056
well-being measures. American Journal of Health Promotion. 1992; [37] Melvin CS. Professional compassion fatigue: What is the true cost
6(4): 280-287. PMid:10146806 http://dx.doi.org/10.4278/0 of caring for the dying? International Journal of Palliative Nursing.
890-1171-6.4.280 2012; 18(12): 606-611. PMid:23560318 http://dx.doi.org/10.
[20] Pennebacker JW, Colder M, Sharp LK. Accelerating the coping pro- 12968/ijpn.2012.18.12.606
cess. Journal of Personality and Social Psychology. 1990; 58(3): 528- [38] Slatton LA, Carson KD, Carson PP. Compassion fatigue and burnout.
537. http://dx.doi.org/10.1037/0022-3514.58.3.528 What managers should know. The Health Care Manager. 2011; 30(4):

Published by Sciedu Press 97

 http://jnep.sciedupress.com Journal of Nursing Education and Practice 2017, Vol. 7, No. 2

325-333. PMid:22042140 http://dx.doi.org/10.1097/HCM.0 [44] Pilchta SB, Kelvin, EA. Munro’s statistical methods for health care re-
b013e31823511f7 search. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams
[39] Potter P, Deshields T, Berger JA, et al. Evaluation of a compassion & Wilkins; 2012. 567 p.
fatigue resiliency program for oncology nurses. Oncology Nursing [45] Taylor B. Interpreting phenomenology for nursing research. Nurse
Forum. 2013; 40(2): 180-187. PMid:23448743 http://dx.doi.o Researcher. 1995; 3(2): 66-79. PMid:27285048 http://dx.doi.o
rg/10.1188/13.ONF.180-187 rg/10.7748/nr.3.2.66.s7
[46] Adams K. The write way to wellness - A workbook for healing and
[40] Rudolph JM, Stamm HB, Stamm HE. Compassion fatigue. A concern
change. Lakewood, CO: The Center for Journal Therapy; 2000. 158
for mental health policy, providers & administration. Proceedings of
p.
the 13th Annual Meeting of the International Society for Traumatic
Stress Studies Conference; 1997; Montreal, Canada. [47] IBM Corporation. Statistical Package for Social Sciences for Win-
dows. Version 23.0 [software]. Chicago, IL: IBM Corp. 2016.
[41] Stevens-Guille B. Compassion fatigue: Who cares for the caregivers?
[48] Showalter S. Compassion fatigue: What is it? Why does it mat-
Alberta RN. 2003; 59(7): 18. PMid:13677678
ter? Recognizing the symptoms, acknowledging the impact, devel-
[42] Salston MD, Figley CR. Secondary traumatic stress effects of work- oping the tools to prevent compassion fatigue, and strengthen the
ing with survivors of criminal victimization. Journal of Traumatic professional already suffering from the effects. American Journal of
Stress. 2003; 16(2): 167-174. PMid:12699204 http://dx.doi.o Hospice and Palliative Care. 2013; 27(4): 239-242. PMid:20075423
rg/10.1023/A:1022899207206 http://dx.doi.org/10.1177/1049909109354096
[43] Garrett DK, McDaniel AM. A new look at nurse burnout: The [49] Abendroth M, Flannery J. Predicting the risk of compassion fatigue.
effects of environmental uncertainty and social climate. Journal A study of hospice nurses. Journal of Hospice and Palliative Nurs-
of Nursing Administration. 2001; 31(2): 91-96. PMid:11271685 ing. 2006; 8(6): 346-356. http://dx.doi.org/10.1097/00129
http://dx.doi.org/10.1097/00005110-200102000-00009 191-200611000-00007

98 ISSN 1925-4040 E-ISSN 1925-4059

View publication stats