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Compassion fatigue

The cost of caring

Boyle, Deborah A. MSN, RN, AOCNS, FAAN

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doi: 10.1097/01.NURSE.0000461857.48809.a1
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EMPATHETIC CARING and interpersonal skills are at the core of nursing.1 Compassion requires an inner conviction and resiliency that sends the message, “I see and feel your pain.”2 But while we in the nursing profession highly value compassion, it can also get us into trouble.

Simply put, compassion fatigue is the cost of caring for others in emotional pain.3 It's been studied in first responders such as police, firefighters, and paramedics, yet it remains underrecognized, poorly understood, and minimally researched in nurses, who also witness tragedy in their daily work. Like first responders, nurses are secondary survivors of others' health crises. This article discusses what we know about compassion fatigue, including how to recognize and combat it.

Defining compassion fatigue in nurses

Nursing involves exposure to trauma, death, disfigurement, debility, and despair. This exposure accumulates over months and years.

Over two decades ago, compassion fatigue was first addressed in the nursing literature. Based on observations of ED nurses, compassion fatigue was described as the loss of the ability to nurture characterized by apathy and cynicism.4 The first book published on the topic cited the prevalence of compassion fatigue in counselors and mental health providers, and it was associated with secondary traumatic stress disorder.3,4 Today, however, little more is known about compassion fatigue within the ranks of nursing.5

What makes compassion fatigue in nurses different than that experienced by other helping professions is the constancy and proximity to tragedy over time.6 Nurses can't remove themselves from their source of distress. Additionally, they may be caring for multiple patients with devastating illnesses. Compassion fatigue may also result when a nurse reexperiences traumatic events, similar to flashbacks, which stem from reminders of past patients or stressful events from the nurse's personal life. (See Is it burnout or compassion fatigue?)

Compassion fatigue is a state in which the compassionate energy that's been expended has surpassed restorative capabilities.7 It emanates from witnessing suffering and feeling impotent to do more to help.8 Most important, repeated exposure to stressful events occurring in patients and families with whom the nurse has developed a special relationship over time leads to emotional exhaustion.9 With no outlet for emotional expression, nurses often “bottle up” their feelings. Feeling dispirited, nurses become short-tempered, fatigued, and resentful of the demands made on them. They find themselves unable to respond to the needs of their patients and withdraw from emotionally charged scenarios.

Consequences of compassion fatigue

Compassion fatigue has physical, emotional, social, spiritual, and professional implications. (See Indicators of compassion fatigue.) Chronic exhaustion, insomnia, and other somatic symptoms may occur. Sadness, apathy, cynicism, frustration, and judgmental responses may become the norm. Elements of depression and anxiety are exhibited. Isolating oneself from others and no longer enjoying activities that previously brought joy is another indicator of compassion fatigue. Spiritually, nurses may question their beliefs within the context of the significant loss they witness. Why do bad things often happen to good people? Why are some patients and families burdened with so much affliction?

A nurse's performance may be influenced in various ways. Both productivity (on a daily basis and in terms of sick days) and efficiency (work execution and the association with errors) may be impaired. Some nurses decide to leave a current job or leave nursing for a different career.

Numerous interventions can be employed to deal with compassion fatigue.10 They generally fall under three categories: self-awareness, work setting strategies, and self-care.

Self-awareness

Any effort undertaken to increase self-awareness about compassion fatigue represents an important first step to manage it. Ask your family what their impressions are of you after the workday ends. Have they noticed a change in you? Are you able to separate work from home? Also consider who your main sources of support are. Are they good listeners? Do you use them routinely as a sounding board? Feedback from those close to you can provide important insight into how work is influencing your personal life. You may not be aware of this association.

Work setting strategies

Numerous work setting interventions can help nurses deal with compassion fatigue. The first step is to determine what work setting resources are available.10 Employee-assistance programs may offer educational programs in addition to counseling that address stress reduction, work-life balance, and the use of effective communication strategies. Lobbying for employee-assistance personnel to come to the unit (rather than expecting the nurse to go to them) sends a strong message of concern for nurses' emotional well-being. Support groups can be developed and facilitated by counselors or pastoral care colleagues. Debriefing sessions after emotionally charged events can help nurses address their sense of loss. They also give nurses a forum for discussing what they were able to do to rather than focussing on missed opportunities. Complementary approaches such as chair massage, aromatherapy, journaling, prayer, quiet time, and mindfulness meditation integrated into the workplace are other options that can reduce work-related stress.

Take care of yourself

If nurses continue to run on empty, they can't expect to successfully maintain caring professional and personal lives. A good way to consider optimum self-care is to practice responsible selfishness.11 Draw a circle and divide it proportionately according to where you spend your time over a week: work, family, social time, hobbies, and activities that bring you joy. Most of us probably allocate only a small sliver of time to take care of ourselves, so a well-formed self-care plan is most likely in order. A self-care plan must embrace all aspects of wellness, hardiness, and resilience, including nutrition, exercise, stress reduction, and time for social activities, hobbies, and spiritual health. You must assume responsibility for these behaviors much like you ensure time to eat and sleep; self-care is just that important.

Hazardous to your health

The multiple demands of our hectic lives, coupled with stressful professional responsibilities, make nursing potentially hazardous to your health. While compassion fatigue has historically been understudied, underrecognized, and undertreated, it's likely that this phenomenon will receive much-needed attention in the coming years as the retention of caring, compassionate, and tenured nurses will become even more highly valued in our constantly changing healthcare environment.

Indicators of compassion fatigue7-10

  • Physical: chronic fatigue, exhaustion, insomnia, aches and pains (headaches, muscle tension), gastrointestinal complaints
  • Emotional: sadness, apathy, cynicism, oversensitivity, frustration/irritation, depression, anxiety, blaming/judgmental, mood swings, lack of joyfulness, poor concentration, memory impairment, self-medication with food, alcohol
  • Social: isolation, loss of interest or enjoyment in activities previously found desirable
  • Work: avoidance or dread of working with certain patients, decreased productivity, increased errors, turnover, job dissatisfaction, decreased efficiency, increased use of sick days, choosing to leave nursing as a career
  • Spiritual: existential questioning.

Is it burnout or compassion fatigue?

Essential to countering compassion fatigue is recognizing it. First and foremost, compassion fatigue must be distinguished from burnout. While nurses can experience both, these are two distinct phenomena. Burnout is associated with workplace stressors such as manager unresponsiveness, lack of camaraderie and teamwork, staffing shortages, working long hours, intense workloads, conflicts with other nurses and healthcare providers, and time pressures. Compassion fatigue, on the other hand, emanates from the stresses nurses experience from their relationships with patients and families.5

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