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 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
Similarly, compassion fatigue tends to present with these symptoms:
Sadness & grief
Increased psychological arousal
Changes in beliefs, expectations, assumptions
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 a 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 1