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Nurses and Compassion Fatigue
© Laurie Barkin RN, MS
In caring for people who are ill, injured, and dying, nurses routinely bear witness to others' pain, loss, and suffering. In addition, hospital-based nurses work closely with family members who often feel anxious and fearful for their loved one's future. Although empathy allows many nurses to experience great satisfaction in their work, repeated exposure to others' emotions may lead to compassion fatigue--a term often used synonymously with "secondary traumatic stress". Despite nurses' routine exposure to loss and tragedy, their reactions to these have not been systematically addressed. (1)
It is difficult to assess how many nurses develop compassion fatigue. In a recent review of seven studies of secondary traumatic stress among nurses working in forensics, pediatrics, emergency medicine, hospice, ICU, and oncology, rates of secondary stress symptoms ranged from 25% to 78%. (2) A study of emergency nurses, found that nearly 86% had moderate to high levels of compassion fatigue. (3)
In contrast to physicians who are taught to cure disease, nurses care for patients and help them cope with illness or disability. Nurses enter a person's life during a time of crisis. By orienting patients to hospital culture and explaining what to expect during hospitalization, nurses help patients gain some semblance of control and order, thereby quelling anxiety and creating a relationship of trust. Such a relationship helps patients and families to express their concerns and to ask questions, especially ones they may be reluctant to ask their doctors. In the best of circumstances, nurses create the conditions that allow patients to speak from the heart. In doing so, nurses and patients sometimes experience moments of profound connection that both cherish.
In the hospital, without access to their usual support systems, patients often become depressed, fearful, and anxious. The onset of compassion fatigue can arise from empathizing with these emotions and feeling powerless to help. This happens in the context of workplace environments made increasingly stressful by high acuity, myriad new medications, adapting to new technology, litigious concerns, work hours, staffing, and poor professional relationships.
The most empathic and idealistic of us respond by intensifying our caring, trying to be all things to all people. When these nurses fail at this impossible task, they feel guilty and miserable. Other nurses respond by becoming indifferent and distant, busying themselves with tasks and technology. This reaction may be similar to the "silencing response" as described by Baranowsky in which caregivers redirect, shutdown, minimize, or neglect the traumatic material brought by another to the care provider. (4) When nurses respond to compassion fatigue by creating emotional distance, their patients, in turn, may feel neglected or abandoned.
During the five years that I worked as a psychiatric liaison nurse on the surgical/trauma unit at San Francisco General Hospital with people who had survived motor vehicle accidents, bullets, knives, fists, falls, and fires, I listened to hundreds of trauma stories. In the course of conducting thorough psychiatric evaluations, I asked my patients about prior traumatic events in their lives. More upsetting than the circumstances necessitating hospitalization were my patients' stories of untreated childhood trauma. These included stories of children who witnessed parental suicide and domestic violence, children who were sexually abused and worked as prostitutes, and children who endured punishment at the hands of sadistic parents.
For the first few years, I took pride in my work with these patients. Many had never told their stories to another person. By listening deeply and without judgment I validated their experiences and thus, their humanity. In our work together, I helped them identify words that best described their feelings, taught them relaxation techniques to manage these feelings, and coached them in constructing a coherent narrative to give shape to those feelings.
But such witnessing comes with a price. After a few years, I began to experience some discomforting symptoms: nightmares, palpitations, shortness of breath, anxiety, and an inordinate fear for my children's safety. Later I learned that my symptoms had a name: vicarious trauma, a component of compassion fatigue. Unfortunately, appeals that I had made to the director of our consult service to allow staff process time were dismissed. When it became clear to me that I needed to take care of my own mental health, I resigned my position.
Nursing school does not prepare nurses for the experience of witnessing pain and suffering. Although nurses value a holistic approach to patient care--one that emphasizes prevention and health maintenance - many of us wait for a crisis to ensue before we take our own medicine. (3) Not surprisingly, our bodies bear the brunt of our stress. This may be expressed in irregular eating and sleeping, musculoskeletal tension, respiratory problems, substance abuse, and decreased immune system functioning. Too many of us teeter too close to the precipice of chronic illness. It is not surprising that a study by Welch found that 35% of nurses sampled were clinically depressed. (5)
It stands to reason that happier nurses have more to give their patients than those depleted by compassion fatigue. With so much time and energy spent at work, efforts to create a supportive workplace environment should be paramount. Nurse administrators can support nursing staff members by regularly allocating time for nurses to discuss how they are coping with the stress of caregiving. They can encourage staff members to practice good self-care such as mindfulness meditation and self-compassion.(6) And they can use psychiatric liaison nurses to teach good communication skills, lead support groups, and consult with individual nurses, particularly newer staff members. Nurses must also take responsibility for their own care. The Academy of Traumatology/ Green Cross has proposed the following standards of self-care: do no harm to yourself in the line of duty while helping others, and, attend to your physical, social, emotional, and spiritual needs as a way of (providing) high quality services to those who look to you for support as a human being. (7)
References
1. Boyle, DA., Countering Compassion Fatigue: A Requisite Nursing Agenda. Posted 7/15/11; The Online Journal of Issues in Nursing. 2011;16(1)
2. Cheryl Tatano Beck, Archives of Psychiatric Nursing volume 25 #1, 2011
3. Hooper C, Craig J et al. Journal of Emergency Nursing (2010) Sept; 36(5): 420-7. Epub 2010 May 18.
4. In Treating Compassion Fatigue Editor: Figley, CR., Brunner-Routledge. New York. 2002.
5. Welsh, D. (2009) Predictors of depressive symptoms in female medical surgical nurses. Issues Mental health Nursing; 30:320-326.
6. Neff, Kristin.Self-Compassion for Caregivers. May 23, 2011. Published on Psychology Today (http://www.psychologytoday.com/node/64851
7. Academy of Traumtology/Green Cross Proposed Standards of Self-Care.
Laurie Barkin, RN, MS, is a psychiatric nurse consultant to the University of California, San Francisco.
She is the author of The Comfort Garden: Tales from the Trauma Unit.
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