Most nurses enter the field of nursing with the intent to help others and provide empathetic care for patients with critical physical, mental, emotional, and spiritual needs. Empathic and caring nurses, however, can become victims of the continuing stress of meeting the often overwhelming needs of patients and their families, resulting in compassion fatigue. Compassion fatigue affects not only the nurse in terms of job satisfaction and emotional and physical health, but also the workplace environment by decreasing productivity and increasing turnover. We begin this article with a case study of a reactive nurse who did not seek help for her continuing stress. This is followed by a review of Watson’s theoretical perspective related to compassion fatigue. Next we delineate symptoms of, and describe interventions for addressing compassion fatigue. We conclude by presenting a case study of a proactive nurse who avoided developing compassion fatigue and a discussion of future research needed to better prevent and ameliorate compassion fatigue.
Key words: Compassion fatigue, nursing, self care, skills enhancement, professional growth, role of Psychiatric Mental Health Clinical Nurse Specialist (CNS), employee assistance programs, pastoral care, nurse residency programs, relaxation centers, mentors
Compassion fatigue has been defined as a combination of physical, emotional, and spiritual depletion associated with caring for patients in significant emotional pain and physical distress (Anewalt, 2009; Figley, 1995). Although many definitions of compassion fatigue are now found in the literature, Joinson (1992), a nurse, was the first to describe the concept in her work with emergency room personnel. She identified compassion fatigue as a unique form of burnout that affects individuals in caregiving roles.
Compassion fatigue has been described among cancer-care providers, emergency room personnel, chaplains, and first responders, among others. This fatigue may impact nurses in any specialty when, in the process of providing empathic support, they personally experience the pain of their patients and families. We will begin this article with a case study of a reactive nurse who did not seek help for her continuing stress. This will be followed by delineating symptoms of, and describing interventions for addressing compassion fatigue. We will conclude with a case study of a proactive nurse who successfully avoided developing compassion fatigue, and a discussion of future research needed to better prevent and ameliorate compassion fatigue.
We authors are both Psychiatric-Mental Health Clinical Nurse Specialists (CNSs) employed by a large teaching hospital system in the Midwestern part of the United States (US). We have served as consultants to nursing leaders and caregivers. As consultants we have observed the effects of compassion fatigue on professional nurses. We have helped nurses overcome compassion fatigue by strengthening their interpersonal and communication skills, by guiding nurses in the process of self-assessment so as to gain insight into stressors that contribute to their compassion fatigue, and to help them develop their own recovery plans.
Case Study of a Reactive RN
Nurse #1 attended nursing school and planned a career in cardiac nursing. Her mother had experienced multiple cardiac events and hospitalizations throughout most of her life. During Nurse #1’s childhood years, her mother had multiple admissions for congestive heart failure. Each admission became more difficult for her mother. The nursing staff and the family became very familiar with each other during these repeated admissions. This situation motivated Nurse #1 to pursue a career as a cardiac nurse.
After graduation Nurse #1 began working on a busy Telemetry Unit. Several patients on this unit experienced multiple admissions to the unit. Nurse #1 seldom took breaks; she quickly acquired the skills needed to work on this unit and soon became a leader on the unit. Within a short time span three of her primary patients died. The patient census remained high and the workload remained intense. Nurse #1 began viewing her work as drudgery. She could barely arrive at work on time and rarely offered to be a consistent caregiver for a challenging patient. Her co-workers observed her changing behavior as she struggled to find some work-life balance. This changing behavior was also noticed by the nurse manager who attempted to adjust Nurse #1’s schedule to work twelve hour shifts. However, this adjustment took a toll on her physically and emotionally. After a period of time she started working in the outpatient clinic at the hospital. However, this new work environment did not diminish her over involvement with certain patients and their families. Although Nurse #1 attempted to adjust to this new setting, she still continued to care for patients with end-of-life, cardiac-disease processes. Eventually, she left this position to pursue a less stressful work environment.
Theoretical Perspectives Related to Compassion Fatigue
Watson’s theory of human caring (Neil, 2002; Watson, 2010) is grounded in the basic empathic relationship between the nurse and the patient; this theory advocates for relationship-based nursing (RBN). At the core of RBN is empathy and the communication of this empathy to the patient and the family. Empathy is defined as the ability to understand a patient’s feelings, understand the situation from patient’s perspective, and communicate this understanding to the patient.
...professional nursing practice thrives within the context of a caring, empathetic relationship between nurse and patient. However, this necessary empathetic relationship can also contribute to compassion fatigue if conscious steps are not taken to avoid and/or lessen this condition. Koloroutis (2007) identified three core relationships for transforming practice using RBN, including the nurse’s relationship with patients and families, the nurse’s relationship with self, and the nurse’s relationship with colleagues. The nurse’s relationship with self is a core concept in managing compassion fatigue. Nurses need to be assertive, to express personal needs and values, and to view work-life balance as an achievable outcome.This relationship with self is essential for optimizing one’s health, for being empathic with others, and for being a productive member of a work group within a healthcare facility.
Figley (1995) has explained that compassion fatigue is experienced by those individuals who help others in distress. These helpers may be subsequently traumatized through their efforts to empathize and show compassion. This often leads to inadequate self-care behaviors and increased self sacrifice in the helper role. Compassion fatigue has also been described as secondary traumatic stress (Figley, 1995) resulting from caring for patients in physical and/or emotional pain or stress. Unlike Post Traumatic Stress Disorder (PTSD) the caregiver does not physically experience the traumatic event but does experience the event emotionally by caring for the patient (Sabo, 2006).
Some symptoms of burnout and compassion fatigue are similar.However, the distinguishing factors include onset of symptoms and the effect upon the caregiver’s role. In burnout the onset is more progressive and may cause indifference, disengagement, and withdrawal from patients and the work environment. Compassion fatigue can be more acute in onset and may precipitate over involvement in patient care (Anewalt, 2009). In 1995, Figley commented that the presence of burnout could increase the likelihood of developing compassion fatigue.
In summary, professional nursing practice thrives within the context of a caring, empathetic relationship between nurse and patient. However, this necessary empathetic relationship can also contribute to compassion fatigue if conscious steps are not taken to avoid and/or lessen this condition.
Symptoms
Numerous authors have identified symptoms of compassion fatigue (Figley, 1995; Gentry, Baggerly, & Baranowsky, 2004). These symptoms can include work-related symptoms, physical symptoms, and emotional symptoms. The symptoms that may be seen in each of these categories are presented in the Table below.
| WORK RELATED | EMOTIONAL: |
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| PHYSICAL: | |
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Any one of the above symptoms could validate the occurrence of compassion fatigue. However, it is important to note that generally more than one symptom is demonstrated before a nurse is identified as having compassion fatigue.
Mental health professionals and/or nurse mentors, including nurse managers, clinical nurse specialists, and preceptors, can help to validate the presence of compassion fatigue. An essential first step in developing an intervention plan is awareness of the problem. In addition to assessing for factors presented in the Table, a basic assessment would include collecting the following information regarding the involved nurse:
- Description/evaluation of the nurse’s work setting and working conditions;
- Nurse’s tendency to become over involved;
- Nurse's usual coping strategies and management of life crises;
- Nurse’s usual activities to replenish self physically, mentally, emotionally, and spiritually; and
- Nurse’s openness for learning new skills to enhance personal and professional well being.
Interventions
Empathetic caring and interpersonal skills are at the core of the nursing role (Harmer & Henderson, 1962; Watson, 2010). However, the cost of providing this empathic nursing care can contribute to caregiver compassion fatigue. Often a nurse with compassion fatigue needs help and guidance from a mentor, consultant, supervisor, or professional counselor to assist with a personalized assessment and intervention processes. Once the assessment is complete a personal intervention plan can be developed as described below.
Talking about one’s concerns and feelings with an appropriate person can give support and hope to the caregiver and assist with the development of an action plan to address compassion fatigue. The first intervention step is to review the resources that are available in the workplace. Most hospitals now include an Employee Assistance Program (EAP) as part of the Human Resources Department. The primary purpose of EAPs is to provide employees with supportive counseling for personal and/or work-related issues. Talking about one’s concerns and feelings with an appropriate person can give support and hope to the caregiver and assist with the development of an action plan to address compassion fatigue. Often an EAP will present formal classes on relevant, life-learning topics, such as managing time, balancing a budget, caring for an elderly parent, communicating effectively, and reducing stress. These classes are designed to decrease stress, enhance work-life balance, and provide help for employees experiencing conditions such as compassion fatigue.
Seeking out a mentor, supervisor, experienced nurse, or a charge nurse who understands the norms and expectations of one’s unit may assist in identifying strategies that will help cope with the current work situation. Some examples of helpful strategies might include: changing the work assignment or shift; recommending time off or reducing overtime hours; encouraging attendance at a conference; or becoming involved in a project of interest. These actions have the potential to enhance the work environment and promote work-life balance.
...a mentor, supervisor, experienced nurse, or a charge nurse who understands the norms and expectations of one’s unit may assist in identifying strategies that will help cope... Pastoral Care Departments also offer a variety of activities to support nurses. The goal of pastoral care is to meet the spiritual needs of patients, families, and staff. Examples of supportive activities include facilitating reminiscence during times of loss or death; leading memorial services; offering prayer and comfort for patients, families, and hospital staff; and providing spiritual help through individual counseling and group programs.
Developing positive self-care strategies and healthy rituals are very important for a caregiver’s recovery from compassion fatigue. Healthy rituals are those activities that one participates in on a regular basis and that replenish personal energy levels and enhance feelings of well being. As nurses begin meeting the needs of others, they often neglect their own needs. It is important for the nurse to identify replenishing strategies that can promote physical, emotional, and spiritual well being. A commitment to taking care of one’s self includes having adequate nutrition, hydration, sleep, and exercise. The nurse may need to be encouraged to try a new approach to self-care, such as a yoga class, massage, meditation, or tai-chi. Our hospital system has promoted self-care for nurses through a Relaxation Center where nurses can go for brief periods of respite. At this Center nurses can receive reiki, light massage, or just relax in a quiet and comfortable setting. Our staff have enthusiastically expressed positive feedback regarding the Relaxation Center. Many nurses have acknowledged feeling less stressed and more able to manage at work after using the Center. They often bring ideas for relaxation back from the Center to their work group.
Another idea is to create a comfortable, relaxing environment in a designated place on the nursing unit. This can be done by transforming an available room into a relaxation area. Nurse can select a soothing color for the walls and assist in purchasing a small waterfall, comfortable chairs, a CD player, and/or a collection of relaxation CDs that can provide comforting stress relief.
As Psychiatric Mental Health CNSs we facilitate regular staff conferences to discuss complex patient situations that nurses find challenging. The day and time for these conferences are selected jointly by nurse managers and staff nurses. Both professional and ancillary staff members are invited to participate. These discussions may address the physical care of patients, pain management, behavioral issues, family dynamics, and/or work-related stressors. These forums are helpful in allowing staff an opportunity to express their concerns and feelings in a safe environment and then collaboratively work to address their concerns.
Two years ago our hospital system initiated a Nurse Residency Program. This one-year program for new graduate nurses is built on an evidence-based curriculum that meets national residency accreditation standards. The Program offers a twelve-month schedule focusing on orientation topics and issues confronting new nurses. Once a month the nurse residents meet to discuss a focused topic and to ‘reflect’ on the topic. These meetings provide an opportunity for new graduates to develop their critical thinking skills and share their thoughts and feelings. This Nurse Residency Program has helped us to mentor and precept new nurses and to assist them with a successful transition into their staff nurse role. This Program has helped the nurses to develop effective decision-making skills related to clinical judgment and performance and to gain clinical autonomy, thus enhancing their job satisfaction and increasing their retention. This Program also offers the opportunity to incorporate research-based evidence into practice so as to facilitate safe, quality nursing care, again enhancing the nurses’ feelings of competence and self-worth. It also offers an opportunity for nurses to begin formulating individual plans for developing their future careers.
Pastoral Care Departments also offer a variety of activities to support nurses. New-nurse support groups can also help to decrease stress and prevent compassion fatigue. Prior to the initiation of the Nurse Residency Program the authors facilitated monthly new-nurse support groups. These meetings were scheduled through the Staff Development Department toward the end of the nurse’s orientation. The sessions focused on identifying areas of concern for new graduates and assisting them with recognizing available resources within the hospital system. The problem solving process was emphasized during these group discussions. In general the evaluations were very positive. Most participants responded that they felt better overall and less stressed after leaving the group. Often requests were made for additional sessions.
Case Study (Proactive RN)
Nurse #2 was a nurse who exhibited anxiety and job dissatisfaction on a regular basis. She was often overwhelmed with her complex, patient-care assignments and expressed much sadness about her patients' social and emotional problems. She was frequently tearful and verbally acknowledged not wanting to come to work. In addition she was sensitive to feedback and felt a lack of support from some of her peers and supervisors. She had difficulty sleeping, worried about work on her days off, and talked openly about wanting to leave the hospital.
Nurse #2 talked often with several clinical nurse specialists who helped her focus on achieving a healthy work-life balance. They counseled her on positive self-care strategies and effective communication techniques and guided her in considering long-term career plans. Although attempts were made to help improve the situation on her unit, she continued to experience anxiety and dissatisfaction.
Despite her growing unhappiness, she identified a specific area of nursing in which she had always wanted to work. Arrangements were made for her to talk with the supervisor and schedule a shadowing experience in this area. She decided to transfer to this new area and has since made a positive adjustment. Being proactive in meeting her own needs and addressing work-related needs has resulted in Nurse #2 feeling more energized about her work assignment and more eager to come to work.
Future Research
It is vital that individual nurses, nursing leaders, and healthcare facilities work together to find the answers so as to prevent/alleviate compassion fatigue. Compassion fatigue needs to be studied in its entirety. We need to identify what specific characteristics and experiences precipitate this phenomenon among individuals employed in caring work and to investigate what personal qualities and traits might provide protection. Longitudinal studies are needed to investigate factors that contribute to the development of symptoms. These factors might include, among others, the nurse’s years of experience, level of education, and institutional support. Studies are needed to identify the effectiveness of interventions, such as those described in this article, for combating compassion fatigue in a variety of work settings. One could begin with a pre- and post-intervention questionnaire asking nurses to describe, for example, the effects of weekly patient care conferences on their stress and compassion levels. It is vital that individual nurses, nursing leaders, and healthcare facilities work together to find the answers so as to prevent/alleviate compassion fatigue. A new program at Ohio State University Medical Center is ‘caring for those who care for others’ using the Stress, Trauma, and Resilience (STAR) program (Herron, 2010). An initial finding from this program is that more support and resources are needed for caregivers who attempt to cope with stressful situations on a daily basis.
Conclusion
There are 3.1 million registered nurses in the US; they comprise the largest group of healthcare workers in the country (Health Resources and Services Administration, 2010). A nursing occupational hazard of providing empathic, relationship-based care to patients and families is the development of compassion fatigue. The impact of compassion fatigue on nurses can be profound. It may cause stress-related symptoms and job dissatisfaction among caregivers and decreased productivity and job turnover within the healthcare system (Medical News Today, 2010). In today’s economy compassion fatigue can be very costly personally and professionally for nurses and financially for institutions.
In today’s economy compassion fatigue can be very costly personally and professionally for nurses and financially for institutions. It is important for nurses to become knowledgeable about compassion fatigue symptoms and intervention strategies and to develop a personal plan of care so as to and achieve a healthy work-life balance. Equally as important is that healthcare systems invest in creating healthy work environments that prevent compassion fatigue and address the needs of nurses who are experiencing compassion fatigue. This article has described a variety of interventions to enhance wellness opportunities and decrease job stress. Caring for caregivers, whether on a personal or system level, provides the foundation needed for optimal patient and family care. Recognizing compassion fatigue symptoms and developing a personal plan of care will allow nurses to meet both their own needs and the needs of patients and families through an empathic relationship.
Authors
Barbara Lombardo, RN, MSN, PMHCNS-BC
E-mail: barbara.lombardo@uhhospitals.org
Barbara A. Lombardo, RN, MSN, PMHCNS-BC is a graduate of St. John College (BSN) and Case Western Reserve University Frances Payne Bolton School of Nursing (MSN) in Cleveland, OH. She has maintained a Clinical Instructor role at the Frances Payne Bolton School of Nursing for many years. Barbara has been a Psychiatric-Mental Health Clinical Nurse Specialist in Medical-Surgical Nursing at University Hospitals Case Medical Center (UHCMC) in Cleveland, Ohio for the past 28 years. She worked as a staff nurse in a VA Hospital and as a Clinical Instructor for Psychiatric Nursing. In the role of a CNS her primary responsibilities include: consultant to the healthcare team working with complicated, challenging patient/family situations; teaching during orientation and ongoing promotional classes; assisting in the Nurse Residency Program; and holding Patient Care Conferences and Interdisciplinary Rounds.
Caryl Eyre, RN, MSN
E-mail: caryl.eyre@uhhospitals.org
Caryl Eyre, RN, MSN is a graduate of the University of Wisconsin, Madison (BSN) and Case Western Reserve University Frances Payne Bolton School of Nursing (MSN). She has worked for over twenty years as a Psychiatric-Mental Health Clinical Specialist in Medical Surgical Nursing at University Hospitals Case Medical Center (UHCMC). Her areas of expertise include facilitating patient- and family-centered care and providing support to patients, families and staff. She is co-facilitator of a patient family advisory council. She teaches classes on communication, conflict resolution, and teambuilding to nursing staff. She and Barbara Lombardo have facilitated new nurse support groups for over 20 years at UHCMC.
© 2011 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2011
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