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Wounded healers during the COVID‐19 syndemic: Compassion fatigue and compassion satisfaction among nursing care providers in Greece

Abstract Purpose The aim of this study was to investigate compassion fatigue (CF) and compassion satisfaction (CS) in nursing care providers in COVID‐19 units. Methods A mixed‐method study with 105 nurses. Results 23% of participants reported high CF risk while 77% expressed high to moderate potential for CS. Adequate preparation/education, clear and accountable leadership, and team sharing of feelings, experiences, and responsibilities during the transition in the COVID‐19 unit helped participants to deal with overwhelming anxiety which if unattended could bring about frustration and long‐lasting feelings of powerlessness. Practical Implications In the face of the present and future pandemics, there is a clear need to prepare healthcare organizations and nursing care providers to cope with the emotional content of public health emergencies while protecting themselves and avoid absorbing unmanageable emotions.


| INTRODUCTION
The word "pandemic" etymologically joins the ancient greek words "pan," meaning "all," and "demos," meaning "the people," and was chosen by WHO to describe the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-Cov-2) outbreak to denote a Public Health Emergency of international concern. On the other hand, the term "syndemic" constitutes a portmanteau of the Greek words "synergy" and "epidemic" and is credited to the anthropologist Merrill Singer, who focused his attention on the social and ecological conditions that created such phenomena and contribute to acknowledging that the pursuit of a purely biomedical solution tο COVID-19 is deemed to fail (Horton, 2020). Indeed, the COVID-19 pandemic has shattered the daily routine, business, schools, and lifestyle of the globe (Coroiu et al., 2020;Kristeva, 2020), caused an unprecedented economic crisis that is advancing before us and can not yet be assessed (Horton, 2020) while claiming the lives of millions of people and inflicting suffering and disenfranchised grief to the latters' affected family members (Stroebe & Schut 2021). Amongst this dramatic landscape, frontline nurses come to provide compassion.
Compassion lies at the core of health and social care. It transcends empathy, that is the affective and cognitive capacity to understand the other person's inner state by adding the motivation and/or courage to do something to relieve or prevent suffering (Sinclair et al., 2017). Lanara (1991) in her book "Heroism as a nursing value -A philosophical perspective" explains why compassion for the suffering patient as a person in a cure-orientated healthcare system requires heroism, passion for social justice, and zeal for righteousness. She analyzed Jesus' parable of the good Samaritan as a description of caring for the suffering patient with trauma, that is a "first-aid" incidence at a roadside (in Luke 10:30-35). The Samaritan (foreigner) bound up the wounds of a battered, blood-spattered helpless victim of cruel robbers pouring in oil and wine (i.e., a common remedy of ancient times). He carried the suffering individual to an inn despite the loss of time, fear of robbers, becoming dirty and other types of sacrifice required to help, in sharp contrast to Levitt (i.e., priest) who passed by indifferently although his mission was to serve compassionately those in need. Lanara (1991) concludes that serving those in need in a complex society is a difficult intellectual and spiritual achievement emphasizing the decision-making processes, intelligent love, and sacrifice (i.e., personal time, energy) implicated in daily nursing care (pp. 154-155). Standing by the suffering patient and facing pain and human misery requires moral courage in dealing with internal and external barriers to care and persistence in building resilience to emotional situations (Missouridou, 2017). On the other hand, compassion fatigue (CF) describes the "cost of caring" for the suffering individual (see Figure 1) in nursing and other disciplines (Cavanagh et al., 2020). Frontline healthcare workers in COVID-19 settings have been reported to be at risk for various mental health problems WHO, 2020) and CF (Alharbi et al., 2020;Ruiz-Fernández et al., 2020).
Contextual factors surrounding COVID-19, such as the ease of transmission, lack of immunity among global populations, delayed testing, limited medical equipment, the uncertainty of the pandemic trajectory and the general level of anxiety within the community all combine to place increasing pressure on health and welfare systems (Centers for Disease Control and Prevention, 2020). Disastersincluding disease outbreaks and epidemics-require a high level of emergent healthcare response that is often instituted without a focus on the psychological well-being of those providing the response (Albott et al., 2020). The combination of witnessing physical suffering and death along with the immediate threat to one's own safety has been reported to induce many negative feelings in frontline nurses (fear of being contagious and infecting loved ones or about their own death in isolation and burial without religious rites and ceremonies, grief and guilt) as well as elevated mental health scores (Ardebili et al., 2021;Kackin et al., 2021). On the other hand, nurses in COVID-19 settings, despite increased responsibility due to performing tasks previously assigned to other clinical team members such as physicians, dietary staff, and respiratory therapists (Jia et al., 2021;Schroeder et al., 2020), also report positive emotions (confidence, calmness, relaxation, happiness and psychological growth which may lead to compassion satisfaction (CS; see Figure 1) and personal and professional psychological growth Schroeder et al., 2020). Nonetheless, to the authors' knowledge, there has been no study focusing exclusively on the CF and CS of frontline nurses in COVID-19 settings. In Greece, Blekas et al. (2020) reported moderate stress among healthcare professionals working in COVID-19 settings but did not distinguish among the variety of professionals from different disciplines.
This study aims to add to the literature because, to the best of the authors' knowledge, there has been no study previously investigating CF and CS among frontline nurses during the COVID-19 pandemic. The aims of the study were fourfold: (1) to investigate the level of risk for CF for greek nursing care providers (2) to examine their levels of CS (3) to explore the possible effects of personal and work-related characteristics on levels of CF and CS and (4) to describe the experiences of front-line nursing care providers providing care in COVID-19 settings.

| Theoretical framework
The present research employed the theoretical model of CF and CS developed by Stamm (2005Stamm ( , 2010 to explain the consequences of working with traumatized individuals. The origins of the model lie in the seminal work of Charles Figley and Beth Hundall Stamn who in the 1980s and 1990s attempted, among multiple other researchers, to refine the concepts of CF and secondary traumatic stress (STS) and developed the Compassion Satisfaction and Fatigue Test, the first selfhelp instrument focusing on CF. This instrument was later revised and evolved into the Professional Quality of Life Scale (Stamm, 2010).
According to the Compassion Fatigue and Satisfaction Theory, CF is composed of two subsets of symptoms: Job burnout (BO) and

Term
Definition of Term

Compassion fatigue
The overall experience of emotional and physical fatigue that social service professionals experience due to the chronic use of empathy when treating patients who are suffering (Figley, 2002).

Compassion Satisfaction
An individual's sense of achievement regarding his or her efforts to help another person (Figley, 1995).

Burn-out
A syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed and characterized by three dimensions: (a). feelings of energy depletion or exhaustion, (b). increased mental distance from one's job, o feelings of negativism or cynicism related to one's job, and (c). reduced professional efficacy (ICD-11).

Secondary Traumatic Stress
The natural and consequential behaviors and emotions that result from exposure to trauma experienced by a significant other or client and the stress that emerges from wanting to help (Figley, 1995).
F I G U R E 1 Definition of terms STS symptoms. Stamm (2010) defines BO as lingering feelings of hopelessness and fatigue that interfere with the professional's ability to perform effectively at work. Symptoms of BO may include feelings of being trapped, overwhelmed, "bogged down," and unsatisfied with one's work. On the other hand, STS is defined as being "preoccupied with thoughts of people one has cared for." Professionals report feeling exhausted, trapped, "on edge" or "infected" by other's trauma (Stamm, 2010, p. 21). Symptoms may include fear, sleep difficulties, intrusive images, and avoiding listening to other's traumatic narratives. However, the Compassion Fatigue and Compassion Satisfaction Theory does not solely focus on the negative consequences of helping others but also attempts to capture the positive feelings derived from compassionate help, that constitute the dimension of CS. Instead of developing fatigue due to exposure to suffering and traumatization, professionals may develop high morale and resiliency in adversity while experiencing pleasure and a sense of personal fulfillment and satisfaction.

| Cultural considerations
The first COVID-19 case was diagnosed in Greece on February 26, 2020.
Contact tracing was initiated on the first and all subsequently confirmed cases, with all contacts being tested and isolated. On March 23, a nationwide restriction of movement was enforced, whereby citizens could leave their house only for specific reasons and with a special permit.
Despite the economic costs of the devastating measure of lockdown, the epidemic curve was successfully flattened. According to the National Public Health Organization (2020), Greece had 126,373 confirmed cases and has suffered 3785 deaths (mean age of death, 79 years) on December 15, 2020. A second national lockdown measure announced on November 7, seems to successfully, for now, curb the epidemic curve.
Nonetheless, the impact of the COVID-19 pandemic in Greece is better understood in relation to its current socioeconomic status.
The Greek society has suffered a decade of austerity (Stylianidis & Souliotis, 2019) while the necessary, but at the same time socially disruptive measure of nationwide lockdown, appears to have a great impact on the well-being of individuals, families, and young people (Marketos, 2020). Furthermore, the public health system was chal- intensive care beds will be available.

| METHODS
In our mixed-methods study, a convergent parallel design was employed to investigate CF in nurses working in COVID-19 units (Creswell & Plano Clark, 2017). In this design, quantitative and qualitative data are collected at the same time, analyzed separately, and then the results are mixed during the interpretation of the data. During this last phase, the researchers looked for convergence, divergence, contradictions, or relationships between the qualitative and quantitative results. When used in combination, quantitative and qualitative methods complement each other and permit for a more robust analysis. Through this complementarity, the researchers sought to have the qualitative data enhance and elaborate on the quantitative findings. consent. An anonymous self-administered questionnaire was then distributed to nursing care providers (registered and assistant). Upon questionnaire completion, semi-structured interviews were conducted with five participants from two COVID-19 units who were available during that shift for an interview. The interviews' duration was approximately 30 min. An introductory question (What motivated you to work in a COVID-19 unit?) generated lively discussions about participants' experiences. This was followed by specific questions: Can you describe your experience in a COVID-19 unit? What are the advantages and the challenges of working in a COVID-19 unit? Can you describe some of the difficulties you encounter in your work in the COVID-19 unit? How do you cope with these difficulties?

| Procedure and ethical considerations
What are the advantages of working here? Questions were openended, with probes facilitating rich accounts.

| Functional assessment of chronic illness therapy spiritual wellbeing scale 12
The Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale-12 non-illness (FACIT-Sp-12) was used to assess nurses' spirituality over the last 7-day period. This 12-item scale is used to MISSOURIDOU ET AL. | 3 measure three dimensions of spirituality ("meaning," "peace," and "faith"), and provides a total score. Responses are given in a 4-point Likert scale ranging from 0, which corresponds to "not at all," to 4, which corresponds to "very much." Higher scores in the total scale and in the three domains indicate higher spirituality. The Cronbach alpha coefficient of the Greek version of FACITsp-12 was 0.77 for the total questionnaire, 0.70 for the "meaning" subscale, 0.73 for the "peace" and 0.87 for the "faith" subscale (Fradelos et al., 2016).

| Traumatic Life Event Questionnaire
The Traumatic Life Events Questionnaire (TLEQ) is a self-report questionnaire assessing the occurrence of a range of potentially traumatic events (Kubany et al., 2000). The TLEQ records detailed information about lifetime trauma history, including both impersonal (natural disaster, car accident, etc.) and interpersonal events (being attacked, while growing up: physically punished, witnessing family violence, being physically harmed by an intimate partner, unwanted sexual contact). Participants indicated a "yes" or "no" response to 16 potentially traumatic events. Prior studies have established good psychometric properties of the TLEQ (Kubany et al., 2000). The Cronbach alpha coefficient of the Greek version of TLEQ in the present study was 0.66 for the total questionnaire.

| Professional Quality of Life Scale
The Professional Quality of Life Scale (ProQOL V) is a 30-item selfreport measure on a 5-point scale (from never to very often) and consists of three discrete scales: CS, BO, and CF/STS that do not yield a composite score (Stamm, 2010). The Greek translated ProQOL version was employed for the purpose of the study (Misouridou et al., 2020). The Cronbach's alpha value was found to be 0.67 for CS, 0.68 for BO, and 0.84 for CF.

| Data analysis
A descriptive analysis was used to identify samples' characteristics.
Quantitative data was entered into SPSS v23 for analysis. T-tests and multiple linear regression analysis were used to explore the possible effects of personal and work-related characteristics on levels of CS, and CF/STS. Variables with p ≤ 0.05 were considered significant.
As regards qualitative data, inductive content analysis was used to explore participants' experiences in COVID-19 units following the principles of conventional content analysis (Hsieh & Shannon, 2005).
The steps implicated in this process include: (a) reading repeatedly data to achieve holistic understanding, (b) deriving codes using the exact words that capture key concepts, (c) attaching labels to emerging codes, (d) organizing codes into subcategories and categories, (e) developing a tree diagram which organizes codes, subcategories, and categories into a hierarchical structure, (f) developing definitions of codes and categories, and (g) identifying key themes emerging from categories. To ensure the credibility of findings, three researchers read independently participants' answers, and a consensus was reached on the identified themes, categories, and sub-categories. Confirmability of results was enhanced by data triangulation (Begley, 1996) and researcher triangulation. A reflective approach entailed thinking through any preconceptions about the data and any preliminary understandings borne out by the data (Barry et al., 1999).

| Demographic and work-related characteristics
One hundred and five nursing care providers (73 registered and 32 assistant nurses) completed the questionnaire. The sample was predominantly female (83%) and married (51%). The mean age was 37.9 ± 10.5 years. All registered nurses had a Bachelor's degree in nursing. Nineteen registered nurses (18%) had also acquired a Master of Science in nursing. The demographic characteristics of the sample are presented in Table 1. Table 2 presents the work-related and personal characteristics of participants. The majority of respondents (70%) described their working environment as very good or excellent while 89% thought that the staff always/most of the time worked as a team. Interestingly, 60% reported that they had never felt a desire to leave the unit or that it did not concern them although their placement at the COVID-19 unit was not their choice. Participants considered their physical health as very good (77%) but a considerable number of them reported having experienced one or more traumatic events in their life course (see Table 2). The most common traumatic life events were the death of a loved one (42.9%), injury or illness of a loved one (41%), natural disaster (29.5%), and car accident (21.9%) or any other accident (16.2%).
Participants with secondary education (vs. university education:  Table 5. Nurses with higher scores in meaning (p = 0.024) and faith (p = 0.040) were found to have higher levels of CS, whilst lower peace was found to correlate with higher BO (p = 0.007) and STS (p = 0.001). Also, the existence of traumatic life events (total number of traumatic events, regardless of their intensity) was found to be associated with higher levels of STS (p = .0.044). These independent variables explain the 29.3% of CS, 26.2% of BO, and 29.1% of STS variability. The independent variables (traumatic life events and spirituality) were adjusted for demographic and work-related characteristics. The multiple linear regression analysis results for ProQOL subscales are presented in Table 6. "I was scared mostly at the beginning and not so much for myself but for others. I was afraid that we may not do the right thing, that we may not operate properly because there was a lot of different information from many sources. These were the sources of my avoided any type of contact to protect themselves. At the same time, participants chose to separate themselves from others as a way of self-quarantine so as to avoid feelings of guilt and selfblame in case any of their family members or patients were infected by the virus.

| Integration of qualitative results
"Some people regard us heroes and others send us into exile.
My husband feels very proud of me! He is a police officer working for the greek security protective forces. But we do not have any vulnerable family members and we keep distances from every-one…" (I3) "At the hospital, everyone avoided us in the beginning and kept us at a distance. We also faced racism, intensely, in our families. At the same time, we put ourselves in isolation in our families. I personally slept on a sofa in the living room in order not to get in touch with my mother because she was in a high-risk group. Anyway, we tried to put ourselves in self-quarantine so as to protect those around us. Even in our social circle, there was racism. My friend, for example, asked me not to visit her. She told me "no, don't come!" because I worked in a COVID-19 unit. All the others who were around made room for me to pass. We faced that, yes. And I think we will face it again, but okay it does not scare us. At least it did not affect me.  "Protocols help greatly and we follow them faithfully." (I1) "We (i.e., nurses) are responsible to dress all personnel. We are responsible for infection control in the hospital setting." (Ι2)

Self-motivation
Participants described different levels of motivation in relation to working in a COVID-19 unit. Nonetheless, educational preparation and group cohesion enhanced their self-motivation and boosted their self-confidence.
"Being here is a great opportunity. I am very lucky. We all put our knowledge and do something good. The job would not work out if we were not so combatworthy." (13) "One colleague is watching the other. If someone makes a mistake we help him. It is simple, but it helps. We keep the area of our unit clean, if someone enters from a ward, they will not enter the unit.
Our colleagues tell us 'you make me feel safe as a guest.' Similarly, I feel safe in here. We know each other. I know we will talk and find a solution. Experience does not matter. As long as the new colleague has critical thinking. (12)

| Category 3: Compassion satisfaction
This category comprised two sub-categories: (a) satisfaction from meaningful nursing care and (b) personal/professional growth and self-care.

Satisfaction from meaningful nursing care
Understanding the challenges during the process of COVID-19 care, participants felt a powerful urge to help the COVID-19 patients and described the satisfaction they get as "meaningful" (I3) and "unique" (I5). Oral hygiene, wound care, assistance with nutrition, fluid, and elimination needs were described as means to relieve the emotional burden of quarantined patients and their traumatic experience of isolation.
"When you come in and talk to them, it is a great reward. Especially when you see them walking away from the hospital. It is the gratitude we receive, our reward, our recognition by the patients…." (I2) "Patients want constant contact. Isolation triggers their psychological problems. They want to hear you and see you all the time" (I5)

Personal/professional growth and self-care
According to participants, enhanced personal accomplishment facilitated personal growth. They also described that they gradually acquired a strong sense of personal identity and self-knowledge which was described as important in the encounter with patients.
Having more confidence both in themselves and in their role enabled Overall, the results of the present study are similar to those of Buselli et al. (2020) conducted during the present pandemic and other studies included in the meta-analysis of Cavanagh et al. (2020) and conducted before the COVID-19 pandemic. A possible explanation is that, despite the high transmission capacity of the SARS-Cov-2 (three of the participants in the present study had been tested positive), the present pandemic is associated with a significantly lower death rate and disease burden in comparison to SARS and MERS (Munster et al., 2020). Furthermore, the BO element of CF is influenced greatly by organizational factors (Stamm, 2010).  and CF reflect a "positive reinforcement profile" (Stamm, 2010). Individuals with this profile, despite the moderate scores in CF, carry no significant concerns about being able to accomplish their work.
Furthermore, higher levels of CS are found to be correlated with lower scores in stress, anxiety, and depression (Li et al., 2020) and in relation to an organizational climate characterized by trust, collaboration, respect, and shared responsibility, echoing principles of clinical governance (American Nurses Credentialing Center, 2020), point to a good person-environment fit (Inoue et al., 2021).
Furthermore, the qualitative results of the present study reveal participants' feelings of satisfaction and self-accomplishment when describing how they overcame the fear experienced during their transition into the COVID-19 unit. Through the strenuous journey of learning to provide compassionate care in a COVID-19 unit while protecting themselves, they acquired a strong sense of personal and professional identity. Additionally, through the struggles associated with assigning meanings to traumas they are exposed to, professionals may have the opportunity to grow beyond their pre-exposure level of psychological functioning . In this way engaging in an empathic relationship with COVID-19 patients may lead to opportunities for growth and a new appreciation of life, spirituality, and relationships despite the initial intense emotional impact (Lin et al., 2020 partly a result of their own personal history when exposed to the stress and the tensions present in their interactions with traumatized individuals (Missouridou, 2017). Missouridou (2017) stresses that self-awareness, acknowledgment of personal loss history and unresolved issues as well as acceptance of personal limitations constitute necessary equipment for a "wounded healer" in a genuine encounter with those in need. In this way, spirituality (Timmins & Caldeira, 2017) could be a precious compass in the long-term journey of resolving feelings of grief and loss and of building a strong professional identity.

| LIMITATIONS
Certain limitations of the present research should be taken into account. A major limitation of the study is that it may have been too early to see the real impact of the pandemic on frontline nurses. Galanis et al. (2020) have found that longer working time in quarantine increases nurses' BO. Furthermore, the sample was drawn from only two public hospitals and therefore no generalizations can be made to other healthcare contexts in Greece or internationally.
Additionally, the small sample size of the qualitative data and the analytic method employed partly due to the need for actionable information and timely integration of mixed-method results in the context of a public health emergency did not allow for in-depth exploration of participants' experiences.

| IMPLICATIONS FOR PSYCHIATRIC NURSING PRACTICE
As the second wave of the pandemic disrupts our family and social lives and there are predictions for following waves in the future, the findings of this study indicate the need for the development of educational and supportive interventions to prepare nursing care providers to cope with the emotional content of their work in the face of the present and future pandemics. Although CF scores in the present study were average, they certainly suggest a potential for an increase in CF if not mitigated. Psychiatric-mental health advanced practice nurses can support frontline nurses and contribute to providing mental health crisis interventions (Lesley, 2020). Screening nursing care providers and targeted interventions to those with high scores on CF and other mental health outcomes may protect both "wounded healers" and functioning healthcare systems stretched to their limits. Severe depressive and acute stress symptoms related to unacknowledged CF should be clinically evaluated. Additionally, organizational support and a supportive workplace culture (American Nurses Credentialing Center, 2020) are crucial to enable nursing care providers to talk about their feelings of frustration and grief in COVID-19 healthcare settings since they often do not feel prepared to provide care in the context of a public health emergency (Albott et al., 2020). Adequate preparation before entering the field and continuous education may empower nurses in actualizing their valued role and societal mission.
Care during the emotionally laden moments of COVID-19 treatment may be a source of suffering, anguish, and stress for nursing care providers but also an arena of personal maturity and self-actualization. "The doctor is effective only when he himself is affected" (Jung, 1989, p. 134). During a journey of self-healing, wounded healers have the courage to alleviate the other's suffering only to discover the way out of Plato's cave (Choder-Goldman, 2020), which is the process of transforming mute, immobilizing, and incomprehensible trauma and loss into knowable, expressible and meaningful experience facilitating personal and professional development and formation of profoundly authentic identities. In times of an international workforce crisis, nursing care providers should be adequately prepared to face the dynamics of trauma to understand the nature of suffering experienced when individuals and families face the dual burden of COVID-19 and stigmatized isolation and thus be able to help them restore purpose and meaning while at the same time protect themselves from absorbing or internalizing unmanageable emotions which may lead to CF (Missouridou, 2017). Caution is needed not to develop a dependency on the social and emotional intensity of the working milieu to meet unmet and social intimacy needs. Ultimately, the present syndemic invites contemporary human beings to reconstruct their lives and the way they relate to others and to think over personal and collective assumptions. Furthermore, it constitutes a challenge for organizations that give precedence to moral obligations to patients, families, and the public over corporate and commercial values and "wounded healers" who have the courage to pour "oil and wine" in the wounds of those in need.