Compassion Fatigue and the Hardship of Caring

Maria Turner

May 20, 2019

Kimberly Shea, PhD, RN, still remembers the last patient she saw as a hospice nurse — a young woman with pancreatic cancer who died while Shea was helping her off the toilet.

"It was a very painless death," Shea, from the University of Arizona College of Nursing in Tucson, said, "but it took every ounce of energy I had to not just run out of that house away from this thing that I didn't want to see one more time."

Kimberly Shea

Shea didn't run out of the house — she had the young woman's husband to support — but she knew things had to change. "I feel like I just fell off the edge of the earth," she told Medscape Medical News. "I didn't know what was going on."

But she did know that she loved her job and was committed to her patients and their families. If there was a patient she hadn't had time to check on during the day, she would call when she got home.

Then, after about 10 years as a hospice nurse, Shea started to suffer from severe anxiety. "I knew I loved the work, but I started to feel that I wasn't cut out for it," she explained.

I feel like I just fell off the edge of the earth. I didn't know what was going on.

Shea tried everything. She was running 10 miles every other day, eating a vegetarian diet, even seeing a hypnotist, but none of it was really working. Finally, she tried medication — paroxetine 20 mg — but things went from bad to worse.

"I couldn't get off the couch; I was afraid of everything," she told Medscape Medical News. "I told my husband to put away the guns."

After she lowered her paroxetine dose and stopped seeing patients, things began to get better. Shea started working as a research assistant, asking people about their experiences in care, but even that turned out to be too much. "I would even get anxious talking to people on the phone," she said.

What Shea didn't realize at the time was that she was struggling with something that many nurses suffer from to some extent: compassion fatigue.

"Loss of the Ability to Nurture"

The most concise way of thinking about compassion fatigue is "the loss of the ability to nurture," but symptoms range from physical and emotional to cognitive, said Marlene Steinheiser, PhD, RN, director of nursing education at the Infusion Nurses Society (INS).

Marlene Steinheiser

Gastrointestinal disturbances, headaches, and sleep disturbances are all common, as is feeling drained and irritable. Nurses also report feeling scattered and not remembering things, she told Medscape Medical News.

But symptoms can depend on the care setting. Steinheiser has been researching compassion fatigue in skilled nursing facilities where nurses care for older adults and experience death routinely. "Death is normalized because that's what older people do; they die," she pointed out. And nurses look at the accompanying sadness as "just part of the job."

Even if they know what it is, "nurses are reluctant to admit to compassion fatigue because the core of nursing is compassion. It sounds like failure," she added.

Compassion fatigue emanates from the relationships we develop with our patients and their families.

"It's important to understand that burnout and compassion fatigue are different things," said Deborah Boyle, MSN, RN, who will present with Steinheiser during an educational session on compassion fatigue and burnout tomorrow at the INS 2019 Annual Conference in Baltimore.

Deborah Boyle

"You get burnout from organizational factors of your workplace," Boyle told Medscape Medical News, such as "a manager who is not supportive, a team that doesn't work well together, or constant overtime. Compassion fatigue emanates from the relationships we develop with our patients and their families."

In the late 1980s, compassion fatigue and secondary trauma started to be talked about in professions like policing and firefighting, but nurses were never mentioned, said Boyle.

Yet nurses are "at even more of a risk for compassion fatigue," she pointed out. "You have to go back into that room and pick up the pieces after people have been given devastating news."

The term was first applied to nurses in 1992 (Nursing. 1992;22:116, 118-9, 120), but it is still not widely recognized, or even understood, in the wider nursing community, said Steinheiser.

"Nurses are expected to just move on" when a patient dies. But if the emotional toll such events can take on nurses is not addressed, the risk for compassion fatigue increases, she explained.

Still, even when resources like managerial support for grief counseling exist, nurses need to understand their importance, and not think, "I can fix this myself," said Steinheiser.

"I Can Fix This Myself"

This was all too true for Shea, who had access to a counselor but did not go to see him because she was concerned that he "was taking on the weight of everybody," and wondered: "How is he going to understand what I am going through?"

She ended up doing a degree in nursing informatics, "but it wasn't who I was. I loved patients," she said, adding that "I didn't know much about technology."

It was only recently that she recognized her experiences as a severe form of compassion fatigue.

"Maybe if I knew compassion fatigue was a thing and it wasn't that I was unable to handle my job, that it wasn't a flaw in me," it could have helped, she said.

Shea eventually found her way back to the world she loves by doing research on telehealth and palliative care. "It seemed impossible to combine these two things but they did combine," she told Medscape Medical News.

Keeping Nurses Healthy

Holly Carpenter

"Nursing is the best job in the world, but it's also one of the most difficult jobs in the world," said Holly Carpenter, senior policy advisor at the American Nurses Association (ANA).

"Self-care is one of the most important things you can do as a nurse," she told Medscape Medical News. "If you are not healthy and safe, it is going to be hard to care for others."

After the release of the ANA Health Risk Appraisal for 2013 to 2016, the ANA Enterprise launched Healthy Nurse, Healthy Nation, a free online initiative for nurses that focuses on five areas — physical activity, nutrition, rest, quality of life, and safety — and is a mix of tips, challenges, resources, and discussion forums, plus there is a health, safety, and wellness survey that nurses can use to report their health concerns.

Nurses can join the initiative individually, but organizations are also encouraged to join. "Nurses can't do everything by themselves, their employers have to do it with them," Carpenter explained. They have to understand the needs for optimal staffing and injury-prevention devices and they have to value the work that their nurses are doing.

And nurses need to start speaking out, said Boyle.

"Your administrators are not going to do anything about it unless you say that it's a problem," she explained. But it can take creative interventions to get administrators to listen. For example, she advises nurses to invite the people in charge of the budget to "walk in their shoes" for half a day.

Experiential interventions can make a difference, she told Medscape Medical News. "You can complain and you can ask, but until the person's thought process changes, you are going to come up against a brick wall."

There are also low-cost interventions that Boyle has seen work in various hospital settings. One hospital introduced a journal in the nurses' lounge that allowed nurses to express their feelings and keep track of each other. Another hospital had a group huddle with all staff, secretaries included, at the beginning of each shift.

"This is all the psychosocial stuff that we didn't get to talk about in nursing school," she said. "We need more training and more communication skills."

"Self-care is not selfish-care," said Boyle. "It's what makes you a better nurse."

Infusion Nurses Society (INS) 2019 Annual Conference. To be presented May 21, 2019.

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