Beyond Burnout: What is Compassion Fatigue?
Burnout and compassion fatigue are often seen together in nurses stressed to the limit. Find out what this common condition is, what the common symptoms are, and strategies on how to overcome it.
Jennifer Castaneda, RN, BSN, HCT, didn't know what was wrong, but she knew that she didn't want to work at the bedside anymore. When she was younger, her future profession was preordained. Many of her family members worked in the medical field. Now she stood at a precipice, and she couldn't figure out what was wrong with her life.
Jennifer was the typical angry person, she admitted by phone interview. She was divorced twice, self medicating with alcohol, and constantly pushing people she cared for out of her life. "I got really great compliments from my patients. I got awards for my compassion," she states. No matter how bad her life got outside of the hospital, she never stopped being super nurse. She says, "I would end up giving more. The more my life was out of order, the next day I tried harder."
She couldn't pick out a specific patient that made her realize the trouble she was in, but she does remember one patient that added fuel to a raging fire. He was post open heart, and had every appliance he could possibly have: chest tube, foley, external pacer, and telemetry wires. Unfortunately, he didn't have a great deal of family support, and he was always on the bell, asking nurses for small things. It got to the point that all of the nurses on the floor would take turns because their frustration levels were so high.
Jennifer tried her hardest to be there for her patient, but what he was asking for drained her. Eventually, the patient got out of bed himself and fell, slipping on his feces, and increasing his stay by two weeks. She was devastated, and management didn't make it any better. "It turns out that it was not written in notes that he was never specifically told to not to get up," she states. "Nurses got into trouble for not documenting. I thought at that moment that 'I'm done'. The nurse who was singled out was our best nurse. We had worked as a team."
This caring, compassionate, hard working nurse left the profession because she just couldn't give anymore of herself or sacrifice her life outside the hospital. Was she weak? Was she a complainer? Was she just someone who couldn't hack it?
No. In fact, she was suffering from a condition known as compassion fatigue and, like many nurses, was unaware of it.
The nursing profession has many challenges, but the twin specters of burnout and compassion fatigue are among the most crushing. Although there is a difference between these two conditions, they are related. They are devastating nurses across the country. According to the American Association of Colleges of Nursing, 13 percent of newly licensed RNs were working in a different career within one year of their licensing, and 37 percent indicated they were ready to change jobs. The turnover rate in nursing is one of the highest at 13.9 percent. Something is making nurses leave the bedside, and it isn't only lack of staffing or trouble with management. It is emotional stress that contributes to the mass exodus. Compassion fatigue affects thousands of nurses who don't know they are suffering from it. This does not mean they are tired of caring. It means they have taken too much onto their shoulders and don't know how to find their way out.
Empathy and Compassion
When most nurses hear the phrase compassion fatigue, they think that it means tired of caring, based on the words used to describe it. To most nurses, this is an insult. Never, under any circumstances, would nurses stop caring about their patients. Most nurses would go above and beyond for their patients, and that's part of the problem. Dr. Kate G Sheppard PhD, RN, FNP, PMHNP-BC, FAANP, Clinical Associate Professor, and PMHNP Specialty Coordinator for Community and Systems Health Science Division at the College of Nursing at University of Arizona suggests a different term for this common occurrence. She related in a phone interview that, "Every nurse said to me at some point that they may have compassion fatigue but they still have compassion. I have urged experts to a different term: emotional saturation. You're just full. Your shoulders are not big enough to take take all this on."
Most of the confusion stems from the difference between empathy and compassion. Although nurses are encouraged to have both, the definition of each is important to understanding compassion fatigue. Empathy is feeling what someone else is feeling. It is putting yourself in their shoes. Compassion takes it a step further and urges the caregiver to do something to fix the problem. Dr. Sheppard explains it this way: "Empathy is understanding that a patient is cold. Compassion is getting the patient a blanket." Compassion is the impulse within nurses that urges them to fix the problems of their patients. Unfortunately, some things are not their responsibility to fix or cannot be fixed, When this happens, nurses have an emotional reaction that they have no outlet for. They are told they will simply get used to it.
Burnout vs. Compassion Fatigue
It is so easy to dismiss a nurse's distress as burnout. In fact, burnout and compassion fatigue are usually seen in combination, but they are not the same thing. Dr. Maryann Abendroth Ph.D., RN, Assistant Professor at Northern Illinois University School of Nursing & Health Studies states in an email interview that, "Burnout is generally associated with work overload. . . . Symptoms of burnout can start gradually and worsen over time. Like burnout, compassion fatigue symptoms are associated with emotional exhaustion; however, nurses experiencing compassion fatigue are traumatized due to bearing witness to those who are suffering. Burnout may be a precursor or a risk factor for compassion fatigue, which has a more sudden and acute onset than burnout."
Dr. Sheppard agrees, "Compassion fatigue is overarching. Within it is both secondary traumatic stress and burnout. They go hand in hand. Burnout is from the environment. Burnout is not having the correct items when needed. I've rarely met someone with compassion fatigue that doesn't have burnout." Burnout describes stress that comes from conflicts with management, the incivility of doctors, and chronic short staffing. Compassion fatigue is crossing the boundaries between professional compassion and personal compassion for your patients. It means giving too much of your emotions and expecting too much of yourself.
Compassion Fatigue: A Perfect Storm
Many professions experience the phenomenon of compassion fatigue, but nurses are particularly susceptible due to the nature of the job. Dr. Abendroth states, "Part of the art of nursing is to be empathic and sensitive to the physical and emotional needs of our patients. Yet this calling can take its toll. Specifically, nurses who often define themselves as 'being their job' may be at particular risk because they may easily begin to blur the professional/personal boundaries between themselves and their patients." Compassion fatigue is often triggered by this blurring of emotional boundaries between the patient's needs and the nurse's.
Nurses at risk for compassion fatigue tend to believe that they are the only ones who can care for their patients. How can I take a lunch when something may happen to my patient? Patients will go south whether nurses take care of themselves or not. Lunch may actually help the nurse achieve the distance needed. Dr. Sheppard is familiar with this phenomenon: "Nurses at risk tend to think, 'I have to go check on MY patient.' They stop taking their breaks, because who's going to watch THEIR patient? This is total enmeshment with the patient, and the nurse can't walk away." Sometimes nurses are reminded of other people when taking care of a patient, such as a parent or a child. This can lead to further blurring of the emotional lines, making the need to fix that patient mean so much more than is healthy.
Do you have compassion fatigue?
It is possible that a large population of the nursing profession suffers from compassion fatigue. As with all conditions, it is important to recognize the symptoms before making a definitive diagnosis. The Online Journal of Issues in Nursing published an article by Dr. Brenda Sabo, RN, Ph.D., under the title "Reflecting on the Concept of Compassion Fatigue" which thoroughly describes the symptoms of both burnout and compassion fatigue.
According to this source, burnout symptoms include:
- Anger & frustration
- Negative reactions towards others
- Physical complaints
- Psychological problems
- Cognitive issues
- Relational disturbances
Similarly, compassion fatigue tends to present with these symptoms:
- Sadness & grief
- Somatic complaints
- Increased psychological arousal
- Changes in beliefs, expectations, assumptions
- Witness guilt
- Decreased intimacy
- Physical complaints
- Psychological distress
- Cognitive shifts
- Relational disturbances
As demonstrated, both burnout and compassion fatigue have similar symptoms. However, compassion fatigue displays more of an emotional component than the frustration of burnout. Experts agree, though, that the two are often found together.
One way to screen yourself for compassion fatigue is to take a test known as the ProQOL measure. It is used by therapists and experts to diagnose compassion fatigue, but it is also an excellent self test to determine if you are suffering from this condition.
Treating Compassion Fatigue
For so many nurses, this situation seems hopeless. They feel like failures because they can't "hack it." They run from the bedside in droves, because they are so overwhelmed by the dual punch of burnout and compassion fatigue. All these professionals want to do is care for others, and it feels like they can't do what they were trained to do. When these thoughts and emotions run unchecked, it is likely to lead to clinical depression, personal complications, and career changes.
Fortunately, the outlook is not so bleak, and you can do several things to restore your ability to function as a bedside nurse. One of the first steps you need to take is setting boundaries. What is a boundary? Dr. Sheppard explains, "Boundaries are saying I will take care of myself and I will take my breaks as scheduled. I am drawing a limit. Work will not push me and take that away from me. Boundaries are what you won't discuss with patients or family members, such as religion and sexual practice."
For instance, many nurses won't take food offered by a patient. When the patient presses, nurses come up with excuses. Finally, the nurse takes the food and throws it out. This is a perfect example of breaking a boundary, a boundary set by the nurse who does not want to eat potentially contaminated food. In this situation, it is easy to dispose of the food, but when you cross boundaries and allow yourself to become more emotionally involved than you should, compassion fatigue results. Set boundaries that state you can't fix everyone, you will make mistakes, and that it's okay. You are not superhuman, and you don't have to be.
Another way to combat compassion fatigue is adequate self care. Although this sounds like psychological double talk, the core essence of it is vital to restoring your sanity. Dr. Sheppard recommends positive self talk. "Mindfulness and self compassion are key. Look how you talk to yourself. Would you talk like that to a colleague? Identify one example of when you berated yourself. Turn it around and imagine using the same words to the colleague. You never would say that. Get better at noticing the self talk. Apologize to yourself when you slip up."
Self care can include many aspects of your life. Seeing a therapist isn't an admission of failure, but it is a way to learn boundaries and positive self talk. Socializing with friends and colleagues can help to vent the emotions that you are keeping inside, helping you to avoid living in a self imposed bubble. Journaling is another way to vent emotions, and you don't have to run the risk of judgement. You can also try meditation and mindfulness, both at work and at home. You can find ways to take care of yourself, release the need to save everyone, and find a way to make nursing work for you.
Nurse Jennifer Castaneda did leave the bedside, but she learned valuable lessons from her time as a nurse. "My friend said to me, 'You're really angry.' I even took an anger management class, and it was a very positive experience for me. It taught me about self care. It taught me that I was giving it all at work, but that didn't make it okay to hurt myself. I was not saving anyone by sacrificing all my energy to them. I needed to learn when to say I can't."
She is much happier now, even though she no longer works in nursing. Jen is in a supportive relationship, doesn't abuse alcohol, and has made a life of helping others, particularly nurses. "I now help women develop strong boundaries, extreme self-care, and getting their needs met in relationships. I guess now I am not surprised that I have clients that are nurses, too." She runs the website www.jennifercastaneda.com. In this role, she teaches self care through the use of hypnosis and positive interpersonal relationships. She has gone through the dark of burnout and compassion fatigue, coming out on the other side a happier person.
"I am happy I became a nurse, and I am happy with what I am doing now," she states. "I just wish I would have known what compassion fatigue was and how to handle it in the first place. It may have made the difference in my life and career."
Overcoming Compassion Fatigue: A Practical Resilience Workbook; Martha Teater, MA, LMFT, LPC, LCAS, and John Ludgate, Ph.D.
Back from Burnout: Seven Steps to healing from Compassion Fatigue and Rediscovering (Y)our Heart of Care; Dr. Frank Gabrin
To Weep for a Stranger: Compassion Fatigue in Caregiving; Patricia Smith
Trauma Stewardship; Laura van Dernoot Lipsky and Connie Burk
Compassion Fatigue and Burnout in Nursing; Vidette Todaro-Franceschi
Abendroth, M., (Jan 31, 2011) "Overview and Summary: Compassion Fatigue: Caregivers at Risk" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 1
American Association of Colleges of Nursing; Nursing Shortage
Lombardo, B., Eyre, C., (Jan 31, 2011) "Compassion Fatigue: A Nurse's Primer" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 1, Manuscript 3.
ProQOL Measure; The ProQol Measure In English and Non-English Translations
Sabo, B., (Jan 31, 2011) "Reflecting on the Concept of Compassion Fatigue" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 1, Manuscript 1Last edit by Joe V on Jun 17, '18
About Lynda Lampert, RN
Joined: Apr '06; Posts: 99; Likes: 656
Freelance Medical Writer; from US
Specialty: 4 year(s) of experience in telemetry, med-surg, post op, ICUFeb 16, '15Occupation: Critical Care Transport Nurse and Paramedic Specialty: ICU and EMS ; From: US ; Joined: Mar '07; Posts: 257; Likes: 650Been there, done that. I LOVE the high acuity, technology, and independence of the ICU. It was the unrealistic family members, physicians that didn't want to discuss the real prognosis, and ultimately what we "do" to chronically ill and debilitated people at the end-of-life that drove me to my breaking point. I took a long look at what I liked, what I didn't like, and what my options were. I moved from the ICU into surface transport (ambulance). Here I am still caring for critically ill patients, but for no longer than 3-4 hours. I am not able to form the "bond" that ultimately led to my emotional distress. I am so glad that I made the move. I LOVE my job now and and think of anything I'd rather do!!!Feb 16, '15Occupation: Nursing Assistant Personnel Specialty: none ; From: US ; Joined: Mar '14; Posts: 110; Likes: 142thank you. what a great article!Feb 17, '15Occupation: MedLeg Consul/Educator/WHNP-FNP Specialty: 35 year(s) of experience in Education, FP, LNC, Forensics, ED, OB ; From: US ; Joined: Jun '05; Posts: 108,748; Likes: 28,312Excellent Article. Thank you very much.Feb 17, '15Occupation: allnurses Content/Community Director Specialty: Peds, Med-Surg, Disaster Nsg, Parish Nsg ; From: US ; Joined: Jun '06; Posts: 25,360; Likes: 18,483Thank you for the excellent article. This topic hits many nurses right in the heart.Feb 18, '15Occupation: Nurse Practitioner Student Specialty: 8 year(s) of experience in MED-SURG Certified ; From: US ; Joined: Feb '15; Posts: 22; Likes: 24This has always been a problem and I agree that we all are struggling with creating and maintaining a boundary to keep us from having emotional distress. We just seem to have trouble finding out where that limit is. I've seen these among Army nurses in the ER in a deployed setting or in an outreach program in a third world country. There are times where we have to face the reality that we cannot 'fix' everything and that we should remember to 'fix' ourselves too. I hope every nursing program has something like this to remind prospective students to this reality and its implications in nursing care. Thank you for this article.Feb 19, '15Occupation: RN From: US ; Joined: Dec '12; Posts: 4; Likes: 3This was a great article. Thank You.Feb 19, '15Joined: Jan '15; Posts: 211; Likes: 511Thanks, this was a very good article. It defined a few terms for me that I had heard used interchangeably, which should not have been. I appreciate it!Feb 20, '15Joined: Jan '09; Posts: 15; Likes: 2love this article. unfortunately, many of us minimize the importance of self-care until it's obvious that we're struggling...and by that point, it's often too late.Mar 12, '15Joined: Apr '11; Posts: 14,652; Likes: 34,138At one point in my early career, I took care of 7 terminal patients in a row over the course of bout 6 months. This was before hospice was widely available, so I saw a lot of struggle and suffering of both patients and families at point of death.
For instance a 12 y.o. girl with rampant cancer who was in awful pain and actually apologized to her nurses when they would have to reposition her, because she saw how terrible they felt for increasing her pain during the procedure! She died on Easter morning at sunrise.
A man with several respiratory dx. who had more than a few crises with trying to breathe; all we knew to do at the time was turn him on his side to see if that would ease him. It took him one entire eight hour evening shift to finally pass. Three family members and one nurse (me) in his room (at home) trying to catch our collective breath FOR him, hovering on the edge of death WITH him. We all cried with relief when he ceased his efforts and died. It was tremendously stressful for all involved.
After that, I felt like I had been stripped raw and had nothing left to give.
I found a part-time job with rehabbing injured and baby wildlife. Though the survival rate for the critters was a paltry 20%, somehow the successes felt triumphant. Releasing them back to the wild was a cause for celebration, and very healing for me.
Several years later I was able to return to work as a nurse, feeling refreshed and no longer as vulnerable. I got a job at a small hospital as a medication nurse on an ortho/spinal-cord post-op unit. The staff was superior and as staffing at the time was ALWAYS sufficient, with very reasonable ratios. We actually could be professionals AND have a lot of FUN with each other.
Since the advent of hospice I no longer dread working with what had previously been referred to as 'terminal cases', and feel honored to attend to a dying patient and their family.Dec 23, '15Joined: Dec '15; Posts: 3; Likes: 2Thank you so much for a great read! As a nursing student, we are being taught the s/s of burnout, but I have yet to experience it. I graduate in May, and am hoping to eventually work in ICU. I love that this was such an honest post about the reality of nursing!Last edit by AN Admin Team on Dec 23, '15Dec 23, '15From: US ; Joined: Feb '14; Posts: 9,535; Likes: 18,073Good article.
Sometimes it is the health care employer that is contributing to the poor boundary development, poor self care, and behaviors which result in both compassion fatigue and burnout. Policy, practice, and expectations are often in conflict with the real emotional needs of the struggling health professional. Many nursing employers are not empathetic to those needs and their indifference escalates the process.
When nurses have buckets of caring to give only to have their employers knock holes in the buckets, they must find easily and readily acceptable ways to refill lest they continually function on empty. Nurses functioning with that reality are often viewed as the professionals who "eat the young".
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