Medication Errors and Critical Care Nurses

Moral Distress,
Compassion Fatigue,
and Perceptions About
Medication Errors
in Certified Critical
Care Nurses
Jeanne Maiden, PhD, RN, CNS-BC; Jane M. Georges, PhD, RN;
Cynthia D. Connelly, PhD, RN, FAAN

The primary purpose of this study was to examine the previously

untested relationships between moral distress, compassion fatigue,
perceptions about medication errors, and nurse characteristics in a
national sample of 205 certified critical care nurses. In addition, this study
included a qualitative exploration of the phenomenon of medication
errors in a smaller subset of certified critical care nurses. Results revealed
statistically significant correlations between moral distress, compassion
fatigue, and perceptions about medication errors in this group.
Implications for critical care nurses seeking to create work environments
conducive to the reduction of medication errors are explored.
Keywords: Compassion fatigue, Medication errors, Moral distress
[DIMENS CRIT CARE NURS. 2011;30(6):339/345]

Certified critical care nurses (CCRNs) care for patients
experiencing some of the most challenging illness states
in which life becomes extremely fragile and tenuous. Pro-
moting optimal patient outcomes requires careful mon-
itoring in this fast-paced and often chaotic environment.
Caring for patients amid distractions and competing
priorities becomes a normalized part of nursing practice
within the critical care environment.1 Stress is a common
phenomenon for nurses working in critical care settings
and often results in a variety of spiritual, psychological,
and functional outcomes. As CCRNs care for patients
in increasingly stressful contexts, it becomes important to
study phenomena related to stress, such as moral distress
(MD), compassion fatigue (CF), and medication errors.
Little is known about the interaction of these phenomena
in the CCRN population. The primary purpose of this
study was to examine the previously untested relation-
ships between MD, CF, perceptions about medication
errors (PMEs), and nurse characteristics (NCs) in a na-
tional sample of 205 CCRNs. Second, this study qual-
itatively explored the phenomenon of medication errors
in a smaller subset of CCRNs. The specific aims of this

DOI: 10.1097/DCC.0b013e31822fab2a November/December 2011 339

Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Medication Errors and Critical Care Nurses
study were to (1) describe the levels of MD, CF, PMEs,
and NCs in a national sample of CCRNs; (2) examine the
relationships between MD, CF, PMEs, and NCs in this
group; and (3) obtain a deepened understanding of the
CCRN experience of MD, CF, and PME.
BACKGROUND AND SIGNIFICANCE
The Critical Care Environment: Moral Distress
The critical care environment may create a situation that
becomes detrimental to the very staff charged with the
patients’ care.2,3 Frequently, the expectations of patients,
families, physicians, and/or institution are in conflict.
Nurses’ proximity and presence at the bedside and inter-
actions with the patient and family regarding care choices
and treatments may cause distress, either for the patient/
family or staff.4 Moral distress may be a consequence of
maintaining the nurse-patient relationship.
Jameton5 defined MD as ‘‘knowing the right thing
to do, but institutional constraints make it impossible to
pursue or carry out the right course of action.’’ As de-
scribed by Elpern and Balk,6 ‘‘moral distress involves the
perception that core personal values and ethical obliga-
tions are violated’’ that can result in psychological dis-
equilibrium. Research on MD conducted with CCRNs7-16
has found unit staffing patterns, carrying out orders for
unnecessary tests on terminally ill patients, deception
through failure to take an action, and failure to tell the
truth regarding actions not in the best interest of the pa-
tient contribute to nurses’ MD. Notably there is evidence
that MD may be manifested in avoidance or withdrawal
behaviors, resulting in compromised patient care.15,16
The Critical Care Environment:
Compassion Fatigue
Compassion fatigue describes a state of emotional, phys-
ical, social, and spiritual exhaustion leaving the indi-
vidual fatigued, overwhelmed, helpless, and hopeless
about one’s situation or life, causing a pervasive decline
in the person’s desire, ability, and energy to feel and
care for others.17,18 The majority of research on CF has
been conducted with emergency response personnel in-
cluding police officers, firefighters, psychology, and
select nursing specialties17-22 and is documented as an
acute reaction to high-stress situations.17 Some authors
have used the term ‘‘secondary traumatic stress disor-
der’’ to identify reactions following exposure to high-
stress situations. The negative consequences associated
with secondary traumatic stress disorder include efforts
to avoid thoughts or feelings about the event, avoidance
of activities or events reminding the person of the event,
anger, difficulty sleeping and concentrating, and hyper-
vigilance.17 Given the high stress that routinely occurs in
340 Dimensions of Critical Care Nursing Vol. 30 / No. 6
Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
the critical care environment, CCRNs may be at risk for
developing CF.
Medication Errors: An Indicator of Unsafe
Practice and Work Environment
Patient safety encompasses a wide variety of patient care
processes and outcomes, including the safe use of med-
ications.23,24 The Institute of Medicine noted that pre-
ventable adverse drug events or harmful medication errors,
that is, any error occurring in the medication-use process,
occur in 1% to 10% of hospital admissions and account
for a $3.5 billion cost.25 In 2005, the overall combined
reporting of sentinel events (unexpected occurrence in-
volving death or serious physical or psychological injury,
or the risk thereof) revealed that almost 10% were due to
medication errors.26 Notably, medication errors are a
major source of overall medical errors and have been
identified as a patient safety priority by state and federal
regulatory and funding agencies.25,27,28 This study
sought to explore nurses’ PMEs, specifically the reasons
that medication errors occur and the reasons that such
errors are not reported.
Patient safety encompasses a
wide variety of patient care
processes and outcomes, including
the safe use of medications.
Summary
Given the enhanced potential for MD and CF among
CCRNs, it can be posited that these factors may play a
role in the detection or nonreporting of medication er-
rors. This study was undertaken to provide an exami-
nation of the relationships between these variables, with
the ultimate goal providing a knowledge base for decreas-
ing medication errors in the critical care environment.
METHODS
Study Design
The study design consisted of a mixed methods in which
a quantitative survey was administered to a national group
of CCRNs, followed by a small qualitative focus group
of a subset of participants. A mixed-methods approach
uses one data set to provide a supportive secondary role
in a study based primarily on the other data type.29 In
this study, qualitative data from a small subset of partic-
ipants were used to supplement the quantitative survey.
This design was chosen to provide new information and

add richness to the survey data and provide validation of
the quantitative findings.
Sample
The sample consisted of 205 CCRNs who were members
of the American Association of Critical-Care Nurses
(AACN) and involved in patient care delivery within the
previous 12 months. Two hundred five CCRNs com-
pleted and returned the mailed survey. Following receipt
of the quantitative mailed surveys, a small subset of the
sample, consisting of 5 CCRNs with current bedside
clinical practice, were recruited to participate in a 1-time
focus group.
Procedure
A purposive sample of CCRNs with current member-
ship in AACN was recruited for the study. Permission
to use the AACN mailing list and approval from the
University of San Diego institutional review board were
obtained. All participants gave written, informed con-
sent. For the quantitative phase, survey packets contain-
ing study materials were mailed to 1000 CCRNs, using
preprinted mailing labels purchased through the CCRN
list rental service. A preaddressed, postage-paid enve-
lope was included to return the study materials. Follow-
ing receipt of the quantitative mailed surveys, a subset
of the sample, consisting of 5 CCRNs with current bed-
side clinical practice, were recruited to participate in a
1-timefocus group regarding the study foci of MD, CF,
and perceptions of medical errors.
Measurement
The following materials were mailed to potential partic-
ipants for completion: a demographic questionnaire to
document NCs, the Moral Distress Scale, the Professional
Quality of Life Scale (ProQOL), and the Medication Ad-
ministration Error Survey.
Nurse Characteristics. A demographic questionnaire
asked participants to record such relevant NCs as age, sex,
employment status, marital status, religious affiliation, unit
tenure, nursing tenure, and intent to leave current position.
Moral Distress Scale. For the purposes of this study,
moral distress was defined as, ‘‘(An) individual knowing
the correct course of action to take, but because of real
or perceived institutional constraint or barrier it is im-
possible to carry out the correct course of action.’’5
Moral distress was measured by the Moral Distress Scale,
a 38-item, 7-response Likert-type scale.7 Scale content
validity and reliability (! = .86) have been reported.7 In
the current study, Cronbach ! = .97.
The Professional Quality of Life Scale30-34 is the
third and current version of the Compassion Fatigue
Self Test first developed by Figley.17 The ProQOL is
Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Medication Errors and Critical Care Nurses
a 30-item, 5-response Likert-type scale designed to as-
sess how the respondent is affected emotionally and psycho-
logically by events associated with the workplace.33 The
ProQOL consists of 3 subscales: compassion satisfaction,
burnout, and CF/secondary trauma. Construct validity
and reliability coefficients ranging from .71 to .90 have
been reported.31-34 In the current study, Cronbach ! = .81.
The ProQOL consists of 3 subscales:
compassion satisfaction, burnout, and
compassion fatigue/secondary trauma.
Medication Administration Error Survey is a 77-item
survey developed by Wakefield and colleagues35 to assess
nurses’ perceptions of (1) reasons medication errors oc-
cur, (2) reasons medication errors are not reported, and
(3) an estimated percentage of actual medication errors
reported. The category, ‘‘reasons medication errors oc-
cur,’’ includes 5 subscales: physician communication,
medication packaging, nurse staffing, pharmacy pro-
cesses, and transcription related. The category, ‘‘reasons
medication errors are not reported,’’ includes 4 subscales:
disagree with the institution’s definition of medication
error, reporting effort, fear, and administrative response.
Participants are asked to indicate a level of agreement with
each statement based on a 6-point Likert scale (1 = strongly
disagree to 6 = strongly agree). Construct validity and
reliability have been reported with Cronbach coefficient
! ranging from .53 to .78 for the subscales.35
RESULTS
Descriptive Statistics
Completed surveys were returned from 205 CCRNs.
Participants were primarily female (90%) and married
(73.6%) and worked full time (74.4%). Mean age was
47.49 years (range, 27-64 [SD, 7.91] years), had been
in practice for an average of 23.3 years (range, 4-42
[SD, 8.49] years), and worked on their unit for an aver-
age of 13.61 years (range, 0.08-38 [SD, 8.45] years).
Fewer than 10% (9.5%) were considering resignation.
Respondents reported an elevated level of MD (mean,
3.89 [SD, 1.36]) and a low level of CF (mean, 13.82
[SD, 6.55]).
Table 1 contains the mean scores for perceived rea-
sons for medication error and reasons for not reporting
errors by subscale. As is illustrated in Table 1, on a 1-
to 6-point scale, with 1 signifying ‘‘strongly disagree’’ and
6 indicating ‘‘strongly agree,’’ physician communication
and medication packaging were reported as the most
November/December 2011 341
 Medication Errors and Critical Care Nurses

nurse staffing (F1,196 = 6.64, P G .01) by intent to resign.

TABLE 1 Perceived Medication Error Subscales
Mean Scores Certified critical care nurses endorsing intent to resign
reported higher mean CF scores (mean, 17.37 [SD,
Mean (SD) 7.01]), and greater agreement on nurse staffing was the
Reasons medication errors occur reason for medication error (mean, 4.19 [SD, 1.00])
than those not intending to resign (mean, 13.46 [SD,
Physician communication 3.9 (1.04)
6.38]; mean, 3.47 [SD, 1.17]), respectively. A statisti-
Medication packaging 4.0 (1.17) cally significant moderate relationship was found
Nurse staffing 3.6 (1.17) between MD and CF (r = 0.21, P = G .001). Thus, the
Transcription related 2.7 (1.50) more morally distressed the CCRNs felt, the higher their
perceptions of CF.
Pharmacy process 2.6 (1.17)
Reasons medication errors are not reported
Correlational Statistics
Disagree with definition 3.5 (1.14) A correlational matrix is presented in Table 2 that sum-
Reporting effort 3.8 (1.40) marizes the relationships between and among the study
Fear 4.1 (1.20) variables of MD, CF, selected NCs, and the perceived
reasons that medication errors occur, including physician
Administration response 3.8 (1.24)
communication, medication packaging, inadequate nurse
Scale of 1 = strongly disagree to 6 = strongly agree. staffing levels, transcription-related problems, and phar-
macy process.
important reasons that medication errors occur, with a Reasons Medication Errors Occur. Participants who
mean of 3.9 (SD, 1.04) and 4.0 (SD, 1.17), respectively. reported increased levels of MD also reported a greater
For reasons that medication errors are not reported, perception that physician communication is a major
fear (mean, 4.1 [SD, 1.20]), reporting effort (mean, 3.8 reason for medication errors. Medication packaging as
[SD, 1.40]), and administrative response (mean, 3.8 a perceived reason for medication error occurrence was
[SD, 1.24]) received the highest endorsement. positively correlated with years in practice. Moral dis-
tress, CF, intent to resign, and the perception of in-
Relationships Between Variables adequate nurse staffing as the reason for medication
There were statistically significant differences between errors were positively correlated. Moral distress and
the mean scores of (1) CF (F1,195 = 6.32, P G .01) and (2) CF were positively correlated with the perception that

TABLE 2 Pearson Product-Moment Coefficients for Reasons Medication Errors Occur Subscale Scores,
Moral Distress, Compassion Fatigue, and Selected Nurse Characteristics
PC MP NS TR PP MD CF IR YP UT Age

PC V
MP 0.46a V
a
NS 0.39 0.26a V
TR 0.33a 0.13 0.37a V
a a a
PP 0.46 0.25 0.30 0.43a V
a a b
MD 0.24 0.06 0.34 0.20 0.12 V
b b
CF j0.02 j0.09 0.15 0.15 j0.005 0.21a V
a
IR j0.02 j0.04 0.18 j0.002 0.006 0.10 0.18b V
b
YP 0.12 0.15 0.003 j0.05 0.13 0.002 j0.05 j0.09 V
b
UT 0.10 0.13 0.04 0.14 0.17 0.02 0.08 j0.08 0.51a V
b a
Age 0.08 0.12 j0.06 j0.08 0.14 j0.02 0.00 j0.08 0.84 0.44b V

Abbreviations: A, age; CF, compassion fatigue; IR, intent to resign; MD, moral distress; MP, medication packaging; NS, nurse staffing; PC, physician communication;
PP, pharmacy process; TR, transcription related; UT, unit tenure; YP, years of practice.
a
P = .01.
b
P = .05.

342 Dimensions of Critical Care Nursing Vol. 30 / No. 6

Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

transcription-related problems are a reason for error oc-
currence. Years on unit and the respondent’s age pos-
itively correlated with the perception that pharmacy
process is a major reason for medication errors.
Medication packaging as a
perceived reason for medication error
occurrence was positively correlated
with years in practice.
Reasons Medication Errors Are Not Reported. A
correlational matrix is presented in Table 2 that summa-
rizes the relationships between and among the study
variables of MD, CF, selected NCs, and the perceived
reasons that medication errors are not reported, includ-
ing disagreement with an institution’s definition of
medication error, reporting effort, fear, and administra-
tive response. Moral distress and CF were positively cor-
related with disagreeing with the institution’s definition
of medication error and fear as reasons for not reporting
medication errors. Moral distress was positively corre-
lated with reporting effort and administrative response as
reasons for nonreporting.
Qualitative Data
Following the collection of the survey data summarized
above, a focus group with 5 participants drawn from
the larger sample was conducted. By asking open-ended
questions to this small group, the researchers sought
to give an added richness to the survey data and pro-
vide validation of the quantitative findings. The discus-
sion questions presented to this group were: ‘‘How has
your work environment implemented medication error
reduction strategies?’’; ‘‘What is the central issue re-
lated to nursing medication errors?’’; What feelings have
you experienced related to medication errors?’’; ‘‘Was
there any resource available to discuss these feelings?’’;
‘‘What measures could help reduce medication errors
for nurses?’’; and ‘‘How has the increased attention to
medication errors affected your professional practice?’’
Following the focus group discussion, the participants’
statements were transcribed and studied for central, re-
curring themes.
The themes that emerged from this discussion were
congruent with the quantitative data: the need for ‘‘pro-
cess and work practice changes’’ to enhance safe medica-
tion administration was emphasized strongly. In regard
to the feelings experienced by CCRNs in relation to
medication error, participants quickly raised the theme
of ‘‘negative emotions.’’ Descriptors such as ‘‘horror’’
Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Medication Errors and Critical Care Nurses
were used when describing a medication error made by
another staff member, along with ‘‘frustration’’ and
‘‘anger’’ at the way the error was handled by admin-
istration. ‘‘Devastation,’’ ‘‘fear,’’ and ‘‘the worst thing
that might happen’’ were themes discussed regarding
other nurses’ errors. Some participants described nurses
who felt so badly about a medication error, they con-
sidered leaving nursing. Other nurses were described as
sad, but rationalized their actions or felt justified, given
the context in which the error occurred. These themes
of strong negative emotions and the intent to resign
resonate with the quantitative data from this study and
suggest a previously unexplored dimension to the ex-
perience of critical care nursing.
IMPLICATIONS FOR CRITICAL CARE NURSES
We conducted this study to examine a previously un-
derstudied phenomenon, specifically, the relationships
between MD, CF, PMEs, and NCs. However, the im-
plications of these data go far beyond this seemingly
clear-cut purpose. The relevancy of this study to the day-
to-day work of critical care nurses is deeper than we
anticipated. Although it is intuitive that nurses who feel
higher CF might also experience higher MD, this study
is the first documentation of this correlation in critical
care nurses. The further correlation of these phenomena
with such variables as intent to resign and the perception
that medication errors are related to workplace processes
(eg, poor physician communication, transcription errors,
pharmacy process) displays a pattern of critical care
nurses working in circumstances that would seem to pro-
mote burnout and turnover, rather than prevent it.
Why Do Medication Errors Occur?
Data from this study demonstrate that medication er-
rors do not occur in a vacuum. They occur in a complex
context in which issues such as physician communica-
tion, nurse staffing levels, and even medication packaging
are reported as significant reasons that errors occur. Such
a ‘‘situational’’ explanation for medication errors is in
direct opposition to other explanations that tend to cen-
ter on individual nurses as ‘‘bad’’ or ‘‘careless.’’ Concur-
rent with this view of individual blaming is the creation
of a work culture in which medication errors go unre-
ported, because of such highly charged emotions as fear,
horror, and punitive administrative response.
The Critical Care Environment Transformed:
Beyond Blame
Data from this study clearly show that a transformation
is needed in the environment of the critical care unit.
That a nationally recruited sample of CCRNs reported
elevated levels of MD is a sufficiently important piece of
November/December 2011 343
 Medication Errors and Critical Care Nurses
data by itself to suggest that existing processes in critical
care environments require further study. The usual re-
sponse of ‘‘it goes with the territory’’ is often given for
the highly stressful work environments that CCRNs in-
habit. But data from this study suggest that institutional
processes promote medication errors and that fear pre-
vents nurses from reporting errors, while simultaneously
fostering MD. Is there an alternative to an environment
of blame?
The creation of work settings in which errors are
viewed as part of larger systemic problems, rather than
individual failure, is a recent development in health care.36
The application of such models to the critical care envi-
ronment, however, would require a shift in consciousness
on the part of all personnel, including physicians and
administrators. Some health care organizations are
adopting a more lateral, ‘‘blame-free’’ culture. Such work
cultures involve the promotion of open, honest communi-
cation across all disciplines and levels of staff, with an
emphasis on professional accountability.36 We propose
that given the findings from this study, the testing of such
models in the critical care environment is certainly war-
ranted. Medication errors remain a patient safety priority,
and until the context in which these errors occur is changed,
it seems unlikely that such errors can be reduced.
The Voice of the Critical Care Nurse
Findings from this study suggest that the voice of the
critical care nurse may often go unheard. Indeed, the
status of CCRNs in the context of current power struc-
tures provides a setting that isolates and often leaves the
nurse feeling inadequate or morally bad as the result of a
medication error. Future study of the critical care work
environment needs to focus on the effects of punitive
responsesVincluding blaming and marginalizationVof
nurses following a medication error. As Georges and
colleagues37 note, the investigation of power relations in
the environments in which nurses work constitutes an
important focus for future research, if real change is to
occur. The voices of CCRNs participating in this study
told us quite clearly that the current model of individual
blame and shame for medication errors is no longer
working. These voices validate the existence of what
Georges38 terms the ‘‘unspeakable’’Vthat is, the un-
spoken violence done to both nurses and patients as a
result of a work environment that seeks to blame indi-
viduals for systemic problems.
CONCLUSION
This study has been an initial effort to capture the con-
textual factors that influence medication error in critical
care. Moral distress and CF emerge as contributing
factors requiring further study in relation to the pre-
344 Dimensions of Critical Care Nursing Vol. 30 / No. 6
Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
vention of medication error. Findings from this study
support building a transformed work culture in which
error reporting is actually commended, instead of pun-
ished. The adoption of a nonpunitive, blame-free culture
that promotes active reporting of medication errors
could ultimately result in the elimination of errors. The
direct involvement of CCRNs in the creation of such
environments is essential. As nurses, we are, ultimately,
responsible for finding a voice and creating the most
healing environments possible, both for ourselves and
for our patients.
References
1. Ulrich B, Lvandero R, Hart K, Woods D, Leggett J, Taylor D.
Critical care nurses’ work environments: a baseline status
report. Crit Care Nurse. 2006;26:46-57.
2. American Association of Critical-Care Nurses. Position state-
ment on moral distress. http://www.aacn.org/moraldistressposition.
Accessed January 10, 2009.
3. Morris P, Dracup K. Time for a toll to measure moral distress?
AJCC. 2008;17(5):398-401.
4. Peter E, Liaschenko J. Perils of proximity: a spatiotemporal
analysis of moral distress and moral ambiguity. Nurs Inq. 2004;
11:218-225.
5. Jameton A. Nursing Practice the Ethical Issues. Englewood Cliffs,
NJ: Prentice-Hall; 1984.
6. Elpern EH, Balk RA. Trouble in ICU: diagnosing moral dis-
tress. Chest Physician. 2008;3:8-9.
7. Corley MC, Elswick RK, Gorman M, Clor T. Development
and evaluation of a moral distress scale. J Adv Nurs. 2001;33:
250-256.
8. Meltzer LS, Missak-Huckabay L. Critical care nurses percep-
tions of futile care and its effect on burnout. Am J Crit Care.
2004;13:202-208.
9. Sundin-Huard DH, Fahy K. Moral distress, advocacy, and burn-
out: theorizing the relationships. Int J Nurs Pract. 1999;5:8-13.
10. Wilkinson JM. Moral distress in nursing practice: experience
and effect. Kansas Nurse. 1988;63(11):8.
11. Elpern EH, Covert B, Kleinpell R. Moral distress of staff nurses
in a medical intensive care unit. Am J Crit Care. 2005;14(6):
523-530.
12. Asch DA. The role of critical care nurses in euthanasia and as-
sisted suicide. N Engl J Med. 1996;334:1374-1379.
13. Pauly B, Varcoe C, Storch J, Newton L. Registered nurses’
perception of moral distress and ethical climate. Nurs Ethics.
2009;16(5):561-573.
14. Corley MC, Minick P, Elswick RK, Jacobs M. Nurse moral
distress and ethical work environment. Nurs Ethics. 2005;12(4):
381-390.
15. Corley MC. Moral distress of critical care nurses. Am J Crit
Care. 1995;4:280-285.
16. Guiterrez K. Critical care nurses’ perception of and responses
to moral distress. Dimens Crit Care Nurs. 2005;24:229-241.
17. Figley CR, ed. Compassion Fatigue: Coping With Secondary
Traumatic Stress Disorder in Those Who Treat the Trauma-
tized. Florence, KY: Brunner Mazel; 1995.
18. McHolm F. Rx for compassion fatigue. J Christ Nurs. 2006;23(4):
12-19.
19. Robins PM, Metzer L, Zeliskovsky N. The experience of sec-
ondary traumatic stress upon care providers working in a
children’s hospital. J Pediatr Nurs. 2009;24(4):270-279.
20. Beaton R, Murphy S. Working with people in crisis: research
implications. In: Figley CR, ed. Compassion Fatigue Coping With
Secondary Stress Disorder in Those Who Treat the Traumatized.
Florence, KY: Brunner Mazel; 1995:51-81.
 Medication Errors and Critical Care Nurses

21. Stewart DW. Casualties of war: compassions fatigue and health
care providers. Medsurg Nurs. 2009;18(2):91-94.
22. Mrayyan MT, Hamaideh SH. Clinical errors, nursing shortage
and moral distress: the situation in Jordan. J Res Nurs. 2009;
14(4):319-330.
23. Hughes R. ed. Patient Safety and Quality: An Evidence-Based
Handbook for Nurses. Rockville, MD: Agency for Healthcare
Research and Quality; 2008. AHRQ Publication 08-0043.
24. Kalisch BJ, Aebersold M. Overcoming barriers to patient safety.
Nurs Econ. 2006;24:143-148, 155.
25. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human:
Building a Safer Health System. Washington, DC: National
Academies Press; 2000.
26. Joint Commission on Accreditation for Healthcare Organi-
zations. National Patient Safety Goals. 2005. http://www.
jointcommission.org/patientsafety/NationalPatientSafetyGoals.
Accessed December 8, 2009.
27. Natasha N, Huminski L. How we cut drug errors. Mod Healthc.
2006. http://0-proquest.umi.com.phineas.ptloma.edu/pqdweb?
index=. Accessed December 8, 2009.
28. Armitage G, Knapman H. Adverse events in drug administration:
a literature review. J Nurs Manag. 2003;11(2):130-140.
29. Creswell J, Plano-Clark V. Designing and Conducting Mixed
Methods Research. Thousand Oaks, CA: Sage Publications; 2007.
30. Stamm BH. The Concise ProQOL Manual. 2nd ed. Pocatello,
ID: ProQOL.org; 2010.
31. Boscarino J, Figley C, Adams R. Compassion fatigue following
the September 11 terrorist attacks: a study of secondary trauma
among New York City social workers. Int J Emerg Ment
Health. 2004;6(5):57-66.
32. Maytum JC, Heiman MB, Garwick AW. Compassion fatigue and
burnout in nurses who work with children with chronic conditions
and their families. J Pediatr Health Care. 2004;18(4): 171-179.
33. Wee D, Myers D. Compassion satisfaction, compassion fatigue,
and critical incident stress management. Int J Emerg Ment Health.
2003;5:33-37.
34. Aycock N, Boyle D. Interventions to manage compassion fatigue
in oncology nursing. Clin J Oncol Nurs. 2009;13(2):183-191.
35. Wakefield BJ, Uden-Holman T, Wakefield DS. Development
and validation of the medication administration error report-
ing survey. In: Henriksen K, Battles JB, Marks E, Lewin DI,
eds. Advances in Patient Safety: From Research to Implemen-
tation. Vol. 4: Programs, Tools, and Products. Rockville, MD:
Agency for Healthcare Research and Quality; 2005. AHRQ
Publication 05-0021-4.
36. Walton M. Creating a ‘‘no blame’’ culture: have we got the
balance right? Qual Saf Health Care. 2006;13:163-164.
37. Georges JM. Biopower, Agamben, and emerging nursing
knowledge. Adv Nurs Sci. 2008;31(10):4-12.
38. Georges JM. Evidence of the unspeakable: biopower, compas-
sion, and nursing. Adv Nurs Sci. 2011;34(2):130-135.
ABOUT THE AUTHORS
Jeanne Maiden, PhD, RN, CNS-BC, is associate dean, professor,
and MSN program director at the School of Nursing at Point Loma
Nazarene, University in San Diego, California.
Jane M. Georges, PhD, RN, is associate professor at the Hahn
School of Nursing at the University of San Diego, California.
Cynthia D. Connelly, PhD, RN, FAAN, is professor and director
of nursing research at the Hahn School of Nursing at the University
of San Diego, California.
The authors have disclosed that they have no significant relationship
with, or financial interest in, any commercial companies pertaining
to this article.
Address correspondence and reprint requests to: Jeanne Maiden, PhD,
RN, CNS-BC, Point Loma Nazarene University, School of Nursing, 3900
Lomaland Dr, San Diego, CA 92106 (jeannemaiden@pointloma.edu).

How
to Reach Us
We want to hear from you, so please feel free to get in touch. For best response, use the
numbers and addresses listed below so you will quickly reach the people who can help you.
Have comments, questions, or reactions to articles in Dimensions of Critical Care Nursing?
Write to us or send an e-mail to Vickie Miracle, EdD, RN, at vmiracle@aol.com. Please include
your mailing address.
Want to submit a manuscript? See author guidelines on http://www.dccnjournal.com, our
Web site. If you have questions about a topic, send a topic query letter to Vickie Miracle, EdD,
RN, at 424 Eastgate Village Wynde, Louisville, KY 40223, or an e-mail at vmiracle@aol.com.
Want to subscribe? Or have problems with your subscription or billing, or need to change
your address? Call 1-800-638-3030.
Want to see our Web site? Visit us on the Internet at http://www.dccnjournal.com to access
the Critical Care Connection, our online CE offerings, reference library, and much more.
Thanks for your interest in Dimensions of Critical Care Nursing. We will make every effort
to be sure that you are satisfied with the service you get from us.
DOI: 10.1097/01.DCC.0000406385.17864.ab

November/December 2011 345

Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.