Psychological Capital and Compassion Fatigue Among Nurses Working in Port Said Hospitals

Background: Nursing is an extremely stressful profession that can lead to compassion fatigue. Psychological capital is largely found to have an immense contribution toward advancing nurses' capacity to deal with stressful situations and protecting them from compassion fatigue. Aim: The study expected to explore the correlation between psychological capital and compassion fatigue among nurses working in Port Said hospitals. Subjects and Method: Design: A descriptive correlational research design was employed. Setting: The study was carried out in eight hospitals in Port Said Governorate namely ; El Salam Hospital, El Hayah Port Fouad Hospital, El-Nasr Hospital, El-Zohor Hospital, El-Mesah El-Bahary Hospital, Tropical (Fevers) & Liver Diseases Hospital, El-Ramad Hospital, and Port Said Psychiatric Health and Addiction Treatment Hospital. Subjects: Encompassed a convenience sample of 201 nurses employed in the aforementioned hospitals. Tools: Two instruments were used to collect the necessary data including; Psychological Capital Questionnaire, plus Secondary Traumatic Stress Scale, as well as a Personal and Job Data Sheet. Results: The study publicized that, more than three quarters (80.1%) of the studied nurses had moderate level of psychological capital, and less than two thirds (63.7%) of them had mild level of compassion fatigue. Conclusion: Obviously, a statistically significant negative correlation was found between total scores of psychological capital and compassion fatigue. Recommendations: Designing and applying periodically training programs to advance nurses' perception and skills regarding psychological capital, resilience, effective coping strategies, and stress-control approaches which may decline the prevalence of compassion fatigue.


INTRODUCTION
Nursing is considered to be an extremely challenging and demanding profession. There are numerous encounters that face nurses which can cause stress, comprising poor working conditions, long working hours, high turnover level, and lesser patient fulfillment. With the contemporary deficiency in nursing staff, nurses are generally working extended periods. Rising work burden, low salary, and insufficient financial rewards, absence of recognition and appreciation, ethical dilemmas, and inappropriate attitudes or lack of cooperation from patients and their families, all give the impression to cause frustration, dissatisfaction, a high level of stress, and undesirably affect nurses' passion and work fulfillment (Elsherif & Sabra, 2022;Itzhaki, Bluvstein, Broty, & Kostistky, 2018 ).
Nurses deliver empathetic care for patients suffering from critical emotional, somatic, mental, and spiritual requirements. Nevertheless, providing empathetic care can affect nurses negatively, making them sufferers of the ongoing stress of meeting workload of caring, amplified patient acuity, as well as great physical and psychological burdens (Lamadah & Sayed, 2014). Compassion is an indispensable element of nursing and a distinct trait of professional nurses. It comprises the capacity to assume a non-judgmental attitude, besides bear one's own suffering when confronted with others' pain and distress.
Compassion fatigue can be explained as "the state of significant depletion or exhaustion of the nurse's store of compassion, resulting from recurrent activation over time of emphatic and sympathetic responses to pain and distress in patients and their families" (Cocker & Joss, 2016). Compassion fatigue symptoms classified into; workrelated symptoms comprising avoidance of working with certain patients, diminished capacity to feel empathy toward patients and families, and absence of happiness.
Compassion fatigue leads nurses to distance themselves from the patient and family and emphasize on the technical features of the job, evade the crucial establishment of the nurse-patient relationship, and in general become more pessimistic regarding the capability for positive change (Duarte & Pinto-Gouveia, 2017).

Sample size:
The subsequent formula was used to determine the sample size (Mugenda & Mugenda, 2003) 20 The calculated sample size was 183 nurses, because of the anticipated drop out proportion (10%); the concluding sample size encompassed 201 nurses. They were recruited from any department of the above mentioned hospitals.

Instruments of data collection:
Instrument I: Psychological Capital Questionnaire: The Psychological Capital Questionnaire was developed by Luthans, Youssef, & Avolio (2007) in the English language and was translated by the researcher into the Arabic language. It is a self-reported Questionnaire consisted of 24 questions to assess different domains of psychological capital encompassing, self-efficacy, hope, resiliency, besides optimism. Every domain was considered by six questions.

Scoring system:
Every item of the questionnaire was rated by means of a six-point Likert scale extending from (1) "strongly disagree" to (6) "strongly agree." The scoring was reversed for items 13, 20, and 23. The score of the whole questions were summed; the highest score points toward a high level of psychological capital. For each domain, the scores of the questions were summed-up and the entire was distributed by the number of the questions, getting a mean score for each domain. Psychological capital levels was high if the percent score was higher than 90%, moderate if the percent score was between 60 to 90%, and low if the percent score was fewer than 60%.

Instrument II: Secondary Traumatic Stress Scale (STSS):
Secondary Traumatic Stress Scale was developed by Bride, Robinson, Yegidis, and Figley (2004) in the English language and was translated by the researcher into the Arabic language. It determined the frequency of compassion fatigue symptoms associated with indirect exposure to traumatic events through clinical work with traumatic populations within the last 7 days. The STSS is a 17-items self-report instrument consisted of three domains comprising intrusion (5 items), avoidance (7 items), and arousal (5 items).

Scoring system:
Each item in the STSS was ranked on a Likert scale extending from (1) "never" to (5) "very often." No reverse-scored items were found. The contributors' responses were summed up, and the total was scattered by the items' number giving a mean score of each respective domain. Compassion fatigue levels was suggested to be high if the percentage score was excess than 90%, moderate when the percent score was amongst 76 to 90%, mild if the percent score was between 50 to 75%, and little or no compassion fatigue if the percent score was fewer than 50%.
In addition to, A Personal and Job Data Sheet: This structured sheet was developed by the researcher in the Arabic language. It comprised personal data such as nurses' age, sex, marital status, income, and educational qualification. As well, it involved questions covering data interrelated to job characteristics as years of experience, and department.

Validity of the study instruments:
Data collection instruments were translated into Arabic language to realize the objectives of the existing study. The translation was completed in its two chief phases, forward and backward. The instruments' Arabic versions were translated back into English by two supplementary linguistic experts who were not familiar with the original versions after the forward translation was accomplished by two multilingual experts. The researchers then checked their translations for accurateness and eradicated any differences by comparing them to the original versions.
The construction, clarity, relevance, and extensiveness of the translated instruments were appraised by five judges in the psychiatric nursing field, four professors from Nursing Faculty, Port Said University, and one from Nursing Faculty, Mansoura University who were also invited to provide feedback on the final Arabic versions.
Hence, the necessary amendments were taken into account. Verifying the validity of the translated instruments extends for 6 weeks.

Reliability of the study instruments:
The translated instruments were verified to be reliable as Cronbach's alpha coefficient was judicious by means of α = 0.84 and 0.89 for Psychological Capital Questionnaire and Secondary Traumatic Stress Scale respectively. Ascertaining reliability continued for three weeks.

Pilot study:
Before incoming the actual study, a pilot study was carried out on 21 randomly selected nurses, who denote 10% of all the nurses being studied. The intention of the pilot study was to ascertain clarity, feasibility, and applicability of the study tools, evaluate the time required for filling in the study instruments, and to recognize obstacles that may be faced during data collection. Grounded on the outcomes of the pilot study, no modifications were done. The study tools were clear and vibrant. Nurses who shared in pilot study were excluded from the entire sample of the research work to reassure the constancy of the results. Pilot study was conducted on June 2020 for one month.

Field work:
Initially, an official letter was issued from the Dean of the Faculty of Nursing; Port cooperation and promise to carry out the study after appropriately description the inducement of the study. Accordingly, the directors referred the researcher to the nursing director of every hospital, the researcher attended every nursing director's office to illuminate the intention of the study and track an agreement. Successively, staff nurses who encountered the eligibility criteria as well as delivered their informed agreement were interviewed by the researcher afterward elucidating the intention and nature of the study to advance their collaboration.
The data collection instruments were filled by the studied nurses using a self-report technique that was done either individually or in small group in the attendance of the researcher to simplify any inquest to the studied nurses. Each participant needs approximately 20 to 30 minutes to complete the instruments. In order to evade patient care interference, the data collection process was done afterward around two hours of commencement of morning and afternoon shifts. After accomplishment, the researcher confirmed that wholly items incorporated in the instruments accomplished. Subsequently, the researcher showed gratefulness for the studied nurses for the effort and time they generously presented. The data were collected over three days weekly (Saturday, Monday, and Wednesday); covering three months from the first of July to the termination of September 2020.

Ethical considerations:
Firstly, an ethical permission was granted by the Scientific Research Ethics Committee of the Faculty of Nursing; Port Said University (NUR 2019071609), and the study protocol was approved by the General Authority for Universal Health Insurance and Ethical Committee of the General Secretariat of Mental Health and Addiction Treatment (GSMHAT), Ministry of Health, Egypt. Second, written consent was attained from the significant authorities of the above-mentioned settings. Thirdly, subsequent a vibrant elucidation of the study's intention, the nurses who were being studied provided their informed consent. Fourthly, the researched nurses' willing participation was guaranteed since they were allowed to end involvement in the study at any time without any repercussions. Fifthly, a complete discretion was sustained, and the researcher confirmed that the collected data will only be utilized for the study objectives. Lastly, the equivalence of the work of the aforementioned settings didn't disturb due to the data collection process.

Statistical analysis:
SPSS software, version 20.0 was utilized for data analysis. For qualitative data presentation, numbers and percentages were used, after performing the Kolmogorov-Smirnov test to confirm that the data were normally distributed, quantitative variables were described utilizing means besides standard deviations. To conclude the correlation between various study variables Spearman's rank correlation coefficient was calculated.
The acquired results were reflected significant if the P-value was equal or lower than 0.05.

RESULTS
Table (1): illustrates that nurses' age ranged between 20-51 years with a mean age ± SD of 29.1±6.9 years, the age of almost two thirds of them (65.7%) ranged between 20 to less than 30 years, 58.7% were females, and 46.2% of them were single. Regarding the educational qualification, it was found that, 44.8% of them graduated from the Technical Institute of Nursing, while only 1.0% of them had a master degree. In relation to income, above two thirds (69.1%) of the considered nurses had not enough monthly income. Table (2): reveals job characteristics of the studied nurses, as elicited, more than half of the studied nurses had less than 5 years of experience and worked in inpatient departments (55.7% and 54.7% respectively), 64.2% of them were working from 30 to less than 50 hours weekly. The table also showed that almost two thirds of the studied nurses (67.2%) were proud of nursing.                 Worldwide, nursing is considered as the furthermost demanding occupation. It is regarded as a stimulating profession for nurses psychologically besides physically.
Hence, paying attention of nurses' well-being must be a top concern. Compassion fatigue is a phenomenon requiring further investigation in the nursing profession to increase the understanding of its effect on nurses and the quality of care they deliver. Psychological capital has the capacity to empower nurses to be flexible and prosperous in stressful conditions. It had noteworthy effect on well-being, cognition, and behavior (Nolzen, 2018;Novitasari et al., 2022).
Psychological capital urges one to participate and perform in productive behaviors.
The four fundamental constructs of psychological capital including hope, optimism, resilience, plus efficacy are openly interrelated to workers' emotions and attitudes which in turn might influence their behavioral intentions (Pierdziwol, 2022). Thereupon, it was indispensable to assess psychological capital and compassion fatigue among nurses for sustaining their psychological health, and supporting them to cope assertively with their stresses, and accomplishing their valued role.
One of the existing work imperative outcomes was that, most of the study subjects had a moderate psychological capital level. The explanation of this result may be by reason of that psychological capital grows with the person from young age as a result of numerous factors such as love and support of the parents, and the person's past experience. Also, it may be enhanced by effective communication between nurses and their supervisors, an effective organizational environment, or nurses may perceive a low level of occupational stress. This result was supported by Zhou et al. (2017) who studied "Mediating effect of coping styles on the association between psychological capital and psychological distress among Chinese nurses" and argued that the majority of the nurses exhibited moderate level of psychological capital. However, an Egyptian study conducted by Metwaly and Ahmed (2018) to examine the impact of psychiatric nurses' psychological capital on their burnout and coping style, publicized that the studied nurses had a low level of psychological capital.
The contemporary findings broadcasted that mild level of compassion fatigue was exhibited by less than two thirds of the considered nurses. This might be interpreted by that, nurses may be afraid of telling that they were suffering from compassion fatigue because if they are expressing that, this may be an indication of seeking help, which may be discouraged or not considered because of the stigma attached to counseling, or expressing that they had compassion fatigue inferences reduced competency.
Alternatively, this may be due to the positive aspects of conveying support and caring for others may overshadow the distresses of the profession. Similar findings were verified from United States, as Hunsaker, Chen, Maughan, and Heaston (2015) studied "Factors that influence the development of compassion fatigue in emergency department nurses" and revealed that nurses had low level of compassion fatigue. Conversely, Zhang et al. (2018)  The contemporary study indicated that, young nurses had moderate psychological capital level. This could be due to that young nurses usually have physical and mental power to work hard to reach their goals and adapt to challenges and change. When facing failure, they bounce back quickly and change their approach to make sure they don't fail again. They have more aspiration, hope, and optimistic view for the future than older. In the same scene, Avey, Nimnicht and Pigeon (2010) in their study entitled "Two field studies examining the association between positive psychological capital and employee performance" confirmed that, psychological capital and age were negatively correlated significantly. Whereas, Sweet and Swayze (2017) in United States disclosed that, older nurses had high psychological capital level.
The contemporary work verified that, nurses who were proud of nursing, had high psychological capital level. This may be owing to that, people who take pride in their work may be more confident in themselves, having more hope for the future, and being more optimistic. Positive feelings towards job can help individual overcome difficulties, obstacles, and acquire accomplishments in the end. Accordingly, Badran and Youssef-Morgan (2015) who studied psychological capital and job satisfaction in Egypt stated that, there was a positive relation between job satisfaction and psychological capital.
Additionally, Tang (2020) clarified that, employees' job satisfaction and sustainable entrepreneurship have positive relationships with the resilience, hope, and optimism dimensions of the psychological capital.
Speaking about the relation between personal and job characteristics, and compassion fatigue levels, the results of the existing study illustrated that, moderate compassion fatigue level was statistically significant among nurses aged from 20 to less than 30 years. This might be attributed to that; younger nurses may be more susceptible to compassion fatigue as they bring great anticipations to a job. Also, they have not yet developed a peer support group or because they may fail to incorporate activities that renew or re-energize them to help better respond to the needs of others. These nurses may also be more prone to work extra shifts and fail to set realistic boundaries and timelines to complete necessary tasks, and this increasing their risk of compassion fatigue. While older nurses may have a higher amount of maturation, possess social and emotional competencies, and had time to develop professional resiliency skills to be maximally functional under the emotional demands of their work environment, thus improving their sense of self efficacy.
In line with the abovementioned, Sacco, Ciurzynski, Harvey, and Ingersoll (2015) in United States studied compassion satisfaction and compassion fatigue among critical care nurses and explored that, younger nurses generally experience high compassion fatigue than older nurses. In a discrepancy, Young, Derr, Cicchillo, and Bressler (2011) who studied compassion satisfaction, burnout, and secondary traumatic stress in heart and vascular nurses in Sweden verified that, younger nurses might not have been in the profession long enough for signs of compassion fatigue to develop. In such vein, Zhang et al. (2018) mentioned that the prevalence rate of compassion fatigue among nurses was not significantly correlated with age.
The contemporary study results publicized that, nurses with not enough income, had moderate compassion fatigue level. This may be probably due to the fact that, insufficient income would increase nurses' sense of emotional tension leading to compassion fatigue.
This result was on the same track with Circenis and Millere (2011) who reported that, inadequate salary was one of the contributing factors of compassion fatigue. Nonetheless, a study by Balinbin et al. (2020) who studied "Occupational determinants of compassion satisfaction and compassion fatigue among Filipino registered nurses" conveyed that, high monthly income was weighty a work-related factor of compassion fatigue.
The current study illustrated that, I.C.U and C.C.U nurses had higher level of compassion fatigue than nurses in other units. Possible explanation for this finding was that, I.C.U and C.C.U nurses was related to higher exposure to patients' deaths because of higher acuity, more severe symptoms, likelihood for complications, grieving families, repeatedly seeing pain and suffering, ongoing states of exhaustion, risk of exposure to danger, and more aggressive treatment regimes. In the same scene, Hinderer et al. (2014) in United States pointed out that, nurses worked in intensive care units had high compassion fatigue level. Besides, Elkonin and Van der Vyver (2011) in a study entitled "Positive and negative emotional responses to work-related trauma of intensive care nurses in private health care facilities" clarified that I.C.U nurses are at a great threat for compassion fatigue.
Results indicated that, female nurses had little compassion fatigue level than male nurses. This result was inconsistent with, Mooney et al. (2017) who studied "A preliminary analysis of compassion satisfaction and compassion fatigue with considerations for nursing unit specialization and demographic factors" and found that, compassion fatigue score was significantly lower in males than females. While, Hunsaker et al. (2015) revealed that there were no statistical significance relation was found between gender and compassion fatigue. Furthermore, Zhang et al. (2018) found that compassion fatigue among nurses was not significantly associated with gender and work duration.
The study findings explored that, nurses who were proud of nursing had little compassion fatigue level. This may be due to that, the more the person is proud of his profession, the more he can bear the troubles of this profession. In this concern, Chegini, Asghari Jafarabadi, and Kakemam (2019) studied "Occupational stress, quality of working life and turnover intention amongst nurses in Iran" and conveyed that, perceived job pride was associated with lower occupational stress, which may alleviate compassion fatigue. Also, Garg, Yadav, Chauhan, Verma, and Bansal (2020) who studied "Prevalence of psychological morbidities and their influential variables among nurses in a designated COVID-19 tertiary care hospital in India," mentioned that, the only protective factor from psychological stress that may diminish compassion fatigue was being proud of working in nursing profession.
As derived from the contemporary study, little compassion fatigue was statistically significant among single nurses. This may be elucidated by that, single nurses did not had the escalating burden of married life like increased life demands, difficulties, and worries of married people that add second pressure on married nurses that escalate their compassion fatigue level. This is in analogous with, Ruiz-Fernández et al. (2020) who publicized that, married nurses were more prone to compassion fatigue than single nurses. Dissimilar outcomes are reported in a different study, Yang and Kim (2012) found that, single nurses had higher compassion fatigue level.
Regarding the correlation between domains of psychological capital and compassion fatigue, findings disclosed that, statistically significant negative correlations were found between total scores of hope, intrusion, and avoidance. This could be attributed to that, hope may combat the consequences of compassion fatigue, and individuals with high hope function at a more optimal level than do their low-hope counterparts. Hope has a positive influence on health and well-being, and hopeful individuals are less reactive to stressful situations. Hopeful individuals are also able to identify productive paths toward reaching their identified goals and to manage and overcome stress easier, and they report overall low levels of daily stress. Accordingly, Rustøen, Cooper, and Miaskowski (2011) conveyed that level of hope was negatively correlated with intrusion and avoidance. Correspondingly, Hart et al. (2014) mentioned that, hope and adaptableness provide the possibility for incapacitating compassion fatigue; moreover, from a real-world view, hope among nurses is linked to better quality of life. Besides, Passmore, Hemming, McIntosh, and Hellman (2020) who studied "The relationship between hope, meaning in work, secondary traumatic stress, and burnout" described that, hope was negatively correlated with burnout and secondary traumatic stress.
Psychological capital has a vast contribution toward refining individuals along with organizational performance. It is a vibrant motivational issue that supplies nurses with compassion, passion, energies, and optimism in the face of complaints and despair.
Mostly, nurses work in an atmosphere characterized by a sustained series of stressful occasions; they pay no concern to the signs of distress and do not pay attention to their own requirements, leading to compassion fatigue. The current study eventual aim was to explore the correlation between psychological capital and compassion fatigue among nurses, The results publicized that, the total score of psychological capital was significantly negatively correlated with the total score of compassion fatigue, this may be illuminated by that, psychological capital could be invested through interventions to booster self-efficacy, optimism, resilience, and hope which are proposed as significant weapons against compassion fatigue.
Corresponding to the abovementioned, the conclusion of a study directed by Bao and Taliaferro (2015) conveyed that, a negative correlation was established between psychological capital and compassion fatigue. Zhao and Zhang (2010) also argued that there was a negative correlation between psychological capital and burnout which leading to compassion fatigue. In the same scene, Tang (2020) clearly stated that, psychological capital denotes typically the optimistic feature of an individual behavior. Therefore, it signifies hope, creativity, insight, accountability and other aspects of human nature which are necessary for becoming an entrepreneur and compassionate. These positive attributes of a human nature are mostly suggested to overshadow the negative sides such as stress, burnout, and compassion fatigue. It hence, focuses on getting a positive change within an individual by realizing future condition from its present situation.
The aforementioned discussion is directed to illuminate the influence of psychological capital in eliminating compassion fatigue. It can be undoubtedly inferred from the discussion that psychological capital promotes psychological wellbeing of individuals.
The positive psychological construct of an individual empowers to take risks and bear challenging stressful situations through emotional stability.
Without the least hesitation, this existing study is remarkable for equally theoretical and clinical implications, as it shed light on the significance and inevitability of bearing in mind psychological capital as a track leading to a scarcity of nurses' predisposition towards compassion fatigue. Therefore, it is hoped and predicted that this contemporary study results may guide and inspire health care organizations and managers in establishing interventions for nursing staff that may probably invest the four fundamental psychological capital constructs comprising optimism, hope, efficacy, and resilience. This, in turn, may diminish stress and compassion fatigue among nurses, and expand psychological safety in health care organizations.

CONCLUSION
The present study results inferred that, a statistically significant negative correlation was established between total scores of hope and intrusion. In addition, there were statistically remarkable negative correlations between total scores of avoidance, selfefficacy, hope, and optimism. As well, a statistically significant negative correlation was established between total scores of psychological capital and compassion fatigue among nurses.

The subsequent recommendations were proposed from the attainable study results:
 Designing and applying periodically training programs to advance nurses' perception and skills regarding psychological capital, resilience, effective coping strategies, and stresscontrol approaches which may decline the prevalence of compassion fatigue.
 Compassion fatigue screening programs should perfectly be developed for early effective detection and management.
 Organizations should provide preventative and proactive support services that prevent compassion fatigue and enhance psychological capital. Organizational policies and procedures should support staff in balancing work and personal needs, as well as provide for adequate time off, assignment rotations, flexible scheduling, education benefits, healthy lifestyle that supports their own well-being, and other self-care and development activities. Many compassion fatigue interventions are free, such as managers actively listening to their staff.
 Additional studies should be conducted to disclose obviously the factors contributing to compassion fatigue.
 It may be crucial for upcoming research to continue the scientific study on psychological capital to allow specialists to maximize the benefit that this concept can bring to the field of human resources.