MANY HEALTHCARE professionals face stress and burnout on the job. This is especially prevalent in nurses, with rates as high as 40%.1 Healthcare workers are exposed to difficult situations and circumstances, leading to a predisposition for compassion fatigue that can manifest as physical or psychological health problems. These permeate the nursing profession and contribute to burnout, job dissatisfaction, and staff turnover. This article explores strategies to recognize the early signs and symptoms of compassion fatigue and offers support for individuals and units struggling with it.
Background and related issues
Compassion fatigue is a term originally coined in 1992 by Carla Joinson, who noticed that nurses coping with frequent heartache had lost their ability to nurture patients.2 An attempt would later be made to redefine it as secondary traumatic stress disorder.3
Regardless of the name, new graduates must be aware of the risk of compassion fatigue to prepare them for exposure to all facets of the profession. The risk may be amplified in certain specialties, such as end-of-life care, emergency nursing, and critical care. Challenging assignments and physical exertion are also prime examples, which can be exacerbated by limited breaks, longer-than-scheduled hours, and repeatedly switching between day shift and night shift. Other risk factors associated with nursing include feeling unable to discuss professional challenges due to an unsupportive environment.
Compassion fatigue is often confused with related concepts such as moral distress and burnout. Moral distress occurs when a nurse knows the right course of action but is obstructed from acting on it by institutional constraints.4 Burnout is associated with emotional exhaustion and relates to the cumulative effects of job stress.4
The onset of moral distress and burnout can be gradual over time. In contrast, the onset of compassion fatigue may be more abrupt; for example, when the nursing staff is called away from bedside assignments to a rapid response situation in another unit, adding to the responsibilities of the shift.4
Compassion fatigue describes the symptoms that result from providing empathetic support to patients, their families, and other caregivers. It is one of the reasons providers disengage, experience noticeable changes in practice, and choose to leave the profession.4 In any given shift and setting, nurses are exposed to the complexities of care.
Many stressors place a caregiver at risk for compassion fatigue, including the unpredictable course of a terminal illness, unexpected cardiac events, family disputes, repeated readmissions, and the need to support patients facing death without loved ones. Many nurses feel as though they have failed after a patient's death or an unsuccessful resuscitation event. When consistently involved in scenarios in which their patients do not survive, nurses will begin to question their own skills and abilities.4
Nursing students at risk
The signs of compassion fatigue may be seen as early as nursing school. Nursing students in educational programs typically focus on individual patients, learning their stories, pondering their illnesses, and, at times, becoming disillusioned with the limitations of clinical interventions. As students, nurses learn that healthcare providers cannot save everyone, despite their best efforts.
During clinical rotations, students first observe professionals exhibiting signs and symptoms of burnout. As graduate nurses, they experience a roller coaster of emotions as they navigate through their first codes, first patient deaths, and the first time they witness a patient receive a terminal diagnosis. These new nurses begin to understand that a shift can start well but end in frustration or despair. They may be poorly prepared to let it go at the end of the day.
Physical and emotional toll
A 2018 study of staff and physicians working in acute care settings reviewed incidences of posttraumatic stress disorder symptoms, moral distress, compassion fatigue, and burnout as institutions attempted to foster a psychologically healthy workplace.5 After implementing an approach that enabled peers to assist one another with heavier workloads, sick calls decreased by 46% within a year.
Stress and burnout in healthcare professionals are associated with severe physical and mental health problems, including fatigue, insomnia, hypertension, depression, and anxiety. These stressors also affect professional performance and have been associated with suboptimal patient care.1
One 2016 study noted that nurses experiencing compassion fatigue may dread going to work; have difficulty concentrating; feel nervous, anxious, or pessimistic; have low self-esteem; or lash out at coworkers. At first, these signs can be brushed off as a bad day or a tough shift, but they may indicate compassion fatigue if the behaviors continue or intensify.6
In a 2017 analysis on the consequences of compassion fatigue, the participating healthcare providers reported difficulty engaging with patients compassionately or empathically. This adversely affected their job performance and their patients' trust, ultimately corrupting the meaning of their work (see Signs of compassion fatigue).4
Rising levels of fatigue
Due to the pressures of modern nursing, such as inadequate staffing and increased clinical responsibilities, the American Nurses Association (ANA) reported a rise in unacceptably high levels of fatigue in healthcare professionals. Inadequate sleep can also have major health and safety implications for both nurses and the patients in their care.7
Besides logging more clinical hours and patient interactions, nurses often field complaints and act as mediators between other disciplines and patients. Nurses acting as preceptors are susceptible to stress from both their patients and the new nurses for whom they are responsible during orientation. Ongoing compassion fatigue places nurses at risk for losing passion for their work.8
Hospitals that provide opportunities for confidential counseling can help prevent compassion fatigue. Employees are encouraged to be transparent about personal and coworker-related stressors and speak up in an environment they trust will support them. Nurses may choose to explore their institution's health and wellness program or continuing-education department for programs and courses on meditation, reflective care, or coping skills. Similarly, support from professional organizations such as the ANA may be found online. These organizations offer approaches to reduce the physical and emotional consequences of morally complex situations, providing expert tips and strategies to build resilient teams.7
Nursing professional development practitioners and staff educators are well placed to mitigate risks in experienced nurse preceptors, strategizing with unit leadership to assign new orientees systematically to avoid overburdening a preceptor with back-to-back coverage. Teams can head off compassion fatigue in daily unit huddles by discussing difficult patients and exploring ways to work together instead of facing these situations alone. On an individual level, nurses can reduce risks with an increased awareness of risk factors and by utilizing coping strategies such as regular exercise or reflective journaling (see Strategies to prevent compassion fatigue).
Early recognition and intervention
Nurses spend a great deal of time at the bedside caring for patients in difficult times. Hospital administrators and nursing leaders are integral to the early identification of nurses at risk for compassion fatigue. By working together to expand support services and develop a caring work environment, nurses may be able to improve job satisfaction, enhance patient safety, and decrease staff turnover.