Secondary Logo

Journal Logo

Department: Performance potential

The ART of maintaining the “care” in healthcare

Todaro-Franceschi, Vidette PhD, RN, FT

Author Information
doi: 10.1097/01.NUMA.0000465407.76450.ab
  • Free

Poor professional quality of life (PQOL) leads to difficulty with staff retention, lateness, absenteeism, and low morale—all of which result in an unhealthy workplace, ultimately affecting patient care and outcomes. We constantly hear that strong leadership is a key ingredient for a healthy work environment. But how can you support staff members who seem to be burnt out? And how do you keep going when you feel like you're running on empty?

Identifying compassion fatigue and burnout

Compassion fatigue and burnout—syndromes related to poor PQOL—have become global problems in healthcare. Have you ever suddenly felt overwhelmingly sad or heart heavy? Or have you noticed staff members who, out of the blue, become teary-eyed or overly emotional? Compassion fatigue—cosuffering with others—has many contributing factors, including feeling unprepared to care for those who are dying, death overload, and moral distress. Compassion-fatigued individuals feel emotionally exhausted but they keep going, caring for others even though it hurts them. If unresolved, compassion fatigue can contribute to the development of burnout.

Burnout develops gradually and is most likely the result of being dissatisfied with one's work. In some ways, burnout appears to be a defense mechanism similar to pulling one's hand away from something hot to prevent getting burned. Over time, there's an involuntary change in the way one goes about being in the world. Burnt out caregivers become detached, disengaged, disenchanted, and dispassionate; they go about their work in a robotic, rather than humanistic, manner. Having people working in healthcare who no longer seem to care is dangerous because they ultimately go along to get along, becoming “silent voices” and “silent witnesses” to a variety of things that aren't conducive to health and healing.1 When you have burnt out staff members, attaining a culture of safety is virtually impossible.

In addition to unresolved compassion fatigue or moral distress, a cadre of other factors can contribute to the development of burnout, including lack of resources, inadequate staffing, poor communication, incivility, and ineffective management to name a few. With the current chaotic state of healthcare, is it any wonder that nurses are considered the most at risk for burnout?

Although a growing body of research indicates that compassion fatigue and burnout lead to diminished quality of life, many individuals are unaware that they're at risk or may actually be compassion fatigued or burnt out. Leaders working with staff members who suffer from poor PQOL are themselves at increased risk for these conditions. That's why awareness and intervention are important to ensure both a healthy workforce and quality patient care.

Boosting awareness

There has been much written on self-care strategies, and staff wellness programs have become the norm. However, trying to address PQOL issues through self-care and wellness programs alone may not be sufficient. For example, if burnout is the problem, individuals may have difficulty finding the motivation to engage in self-care strategies or wellness programs.

ART is an easy-to-apply awareness model developed to help nurses and other caregivers enhance PQOL.1 ART stands for:

  • Acknowledging a wound or feeling
  • Recognizing choices and, with intention, choosing and taking purposeful action
  • Turning toward self and others to reconnect with ourselves and our environment in ways that foster contentment.

The ART model can be applied individually or collectively to reaffirm the meaning and purpose in our work and lives.

Acknowledge your feelings

The first step in ART is being more mindful of your moments as you live them. While working, note how you're feeling and what you're thinking. Are you in the moment or thinking about something in the past or future? Try to be attentive to the now: How do you feel? Are you angry, irritable, fatigued, sad, or happy? You may recognize that your feelings fluctuate during the day or, conversely, seem “stuck.”

After you acknowledge your feelings, ascertain what's contributing to how you're feeling. Make note if it's a negative pattern and, if so, identify the root cause(s) of why you're feeling like you do. There are so many factors that may be adversely affecting a nurse leader's PQOL, such as lack of resources, incivility, poor communication, staff members who are frequently late or absent, problems with retention, and incompetent (or uncaring) patient care. When you figure out root causes, prioritize them if there are more than one.

Recognize choices, take purposeful action

I teach undergraduate, graduate, and doctoral-level nursing, and I hear all of the time from unhappy nurses who say that they have no choice and essentially feel as if they have no voice. They may feel constrained by their respective employers, or perhaps they feel the need to remain where they're working for the employee benefits. The key to unlocking this sense of helplessness is to understand that even when you choose to do nothing, it's still a choice.

Take a hard look at what's contributing to your diminished PQOL after you've identified it and then recognize the choices you have. List them and make two columns next to them—one for advantages and one for disadvantages. Then look at the cost-benefit ratio. After you've done this, make a choice and take purposeful action to realign yourself with the nature of your work in meaningful ways to instill the joy back into it. Most of us spend a significant part of our life working; we should love what we do.

Turn toward yourself and others

This step shouldn't be considered a final one, but rather an ongoing reminder to remain connected with yourself and your environment, which includes people, places, and things. Those of us who go into service professions choose to do so because we care and want to assist individuals to actualize their potential. In essence, we want to improve their quality of life. If we lose our connection to that sense of purpose, or feel for whatever reason inept at what we do, it has widespread repercussions, which affect everyone's quality of life. How we go about our work is important and integral to this fact: we're important.

Look for things you don't normally notice. Be attentive to opportunities to draw health and happiness toward you by connecting with loved ones, nature, or a good book or music—whatever you enjoy. Find 1- or 2-minute blocks of time for mindfulness exercises. Try focusing on your breathing for a minute or so. Or you can focus on something in nature or a piece art for a brief period of time, making sure to note aspects that you wouldn't normally see. You'll be amazed how it helps center you.

We're in this together

Effective leaders know that employees want to be heard, understood, and respected for what they bring to the workplace. This means that leaders need to really “see” their staff members as individuals, not just as employees. Compassion should be part of the leadership equation. Successful leaders are able to handle the toxicity of different situations in ways that let employees know they're valued as human beings. The benefits of compassionate leadership can't be overrated; when employees feel valued, it leads to enhanced work performance, which translates to a better quality of patient care. It's a win-win situation.

You can apply ART in your own practice and augment the use of this model with simple, short exercises during staff meetings. To begin, take the key points of the model and post them on the unit board for staff reflection. Create an opportunity during a staff meeting to talk about the general aspects of compassion fatigue and burnout to increase awareness of the serious nature of these syndromes. Then use case examples to help staff members apply the model to their own situations. If the area in which you work is one where death and dying are frequent occurrences, a death preparedness assessment may be helpful to determine if education and debriefing support are necessary.

If you have staff members who are experiencing compassion fatigue and/or burnout—and chances are good that you do—it's essential to make them aware of it and provide them with the resources to help them heal. Knowing when you and/or your staff members need assistance to maximize health and happiness is key. Remember, we're human beings, not robots. In healthcare, our PQOL and quality patient care are inextricably interwoven. It's time to attend to our PQOL; we didn't go into healthcare not to care.


1. Todaro-Franceschi V. Compassion Fatigue and Burnout in Nursing: Enhancing Professional Quality of Life. New York, NY: Springer; 2013.


Foundation for a Mindful Society. Mindful at work.

Stamm B. The ProQOL measure in English and non-English translations.

Todaro-Franceschi V. Quality caring.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.