The Double-Edged Sword: Compassion vs. Self-Protection

[NatalieBridges]

Sometimes I wonder how to maintain a balance.

Just the other day I watched a man in his early forties, who had come to the hospital after an accident, bleed to death. With his leg wrenched off, a mess of shreds of flesh and coagulated blood, he had reached the end. The doctors took his wife to the bedside and calmly but firmly explained that there was nothing else they could do. The damage was too severe, the injury too great. The dripping blood collected in a pool underneath him like a morbid summary of the sad tale.

I watched for a few seconds like an unattached observer, noticing the inconsolable wife and other family members with a haze of self-protection between us. With only a dormant ting of grief, I watched as the wife laid her body over her husband, begging and pleading into the air for him to live. Her desperate but vain requests fell upon a silent room as she screamed and wept. Her tears wet his face but he didn't move, already drifting in the middle place between alive and dead. Finally he passed away slowly and quietly and the family was left with some privacy to grieve. After such a commotion, the silence was deafening.

Functioning as the charge nurse that day, I was aware of the situation but because of the hectic pace of the unit at that time, I didn't have the mental energy or space to soak it in fully. I cognitively understood but I held back my emotions for the sake of the job, for the sake of keeping the unit functioning at the highest level. Patients needed to be admitted from the ER or OR, nurses required help with bedside procedures, and some of our other patients were declining at a rapid pace, requiring all hands on deck as we hung blood pressure medications and put in chest tubes. If you've ever been the charge nurse, you understand the feeling of the weight of the hospital world on your shoulders, the responsibility of life and death weighed around your neck. When you're the charge for the trauma ICU, with everyone in the hospital calling you to fix a problem or make room for a patient, in many ways those are accurate assumptions.

There's a fine line between entering into the emotions of the situation and preserving yourself for the sake of the job. A conundrum common to any area within the hospital realm. Nursing can be a diabolical and equivocal profession for this very reason: the maddening crux of self-protection and compassion. It's a double-edged sword that boasts both danger and power.

On one hand, I consider myself to be an extremely sensitive person who relates to my patients and families on an emotional level. In my job working with families, I sit and listen as they vent about frustrations or griefs. I cry with them as we turn off the machines and let their family member drift into breathless silence. My heart aches inside of me as families have to make impossible decisions about the future of a loved one's care. Few choices are straightforward and easy, and most require all they have left emotionally, mentally, and physically. Sleep, proper nutrition and self-care become obsolete as families focus whole-heartedly on the task at hand, the healing or demise of their loved one. I've gone home and cried helplessly because of a devastating patient situation, the grief and loss too much to bear. Seth has listened as I relate some of the horribly unfair circumstances that are inherent in a broken, fallen world. I function in deep compassion for my patients and families, empathizing with them over their heartbreaking situations.

Regardless of the specific area, nurses are not strangers to the unlucky, unfair circumstances that plague humanity. From oncology to NICU to outpatient clinics, we all encounter the unexpected test result, the unbelievable diagnosis, the unexpected and tragic turn of events. We experience on the ground level variations of pain and loss that many people can't comprehend. We are exposed to some of the most triumphant and desperate situations, watching people defy the odds or succumb to the inevitable. Nursing is a highly emotional profession with the pendulum swinging between hope and loss, pain and victory, life and death.

On the other hand, I felt completely unattached to the man dying that day, knowing that if I let myself indulge, a deluge of tears would follow. I went to a party after work that night and as my mother asked me, "how was your day?" I related the incidences in a matter-of-fact tone that seemed to shock her. I realized abruptly that it wasn't normal for someone to say they watched a patient bleed to death, while sipping iced tea at a wedding shower. In my callousness and self-preservation, I hadn't even stopped to wonder at my own disillusionment with the situation.

But as nurses, we can't always allow ourselves full depth of emotion at a certain time. It's one of the disadvantages and hard boundaries that come with the job. If I imagined Seth lying in the bed as the patient and me, the desperate wife, weeping over him, I surely wouldn't have been able to continue with the day. I would've been overwhelmed with inconsolable grief at simply the thought. I would've sat down dejectedly at the bedside and ignored the other duties required of me.

Nurses get very extensive training in assessment skills, safe medications practices, and the scope of our license. But treading the fine line between emotional indulgence and self-protection is something you have to learn on your own, in your own way, so that you can go back to work the next day and be satisfied with your profession. Everyone comes to that place, the place of peace with difficult circumstances, at their own pace and in their own fashion. And it changes as you move through various stages of life. You constantly have to reevaluate yourself, your calling, and your emotional reserve to adapt to the situations before you.

Sometimes I'm amazed at my ability to push my emotions aside and continue in the job of saving lives. Sometimes I'm surprised as I can't seem to stop ruminating over a seemingly routine but difficult situation. I shock myself with how I react to some predicaments and not others, or the degree to which I react.

It's an impossible double-edged sword, the blade of self-protection and compassion. It gleams at you, waiting for you as you walk into work everyday. You wield it as best you can, trying to make the wisest choices, but sometimes it cuts you when you least expect it. Then you remember it's both your weapon and your downfall, and you grow in respect for it.

We pick it up before a shift and lay it down afterwards, but we all know it's never far from us.

[AdamantiteEnigma]

Yes, one has to be careful. Compartmentalization has a way of coming back to us in force. And at the worst of times. I've learned over my time so far not so much as to indulge as you say - rather accept the circumstances for what they are. Had to take a hard look at myself when I attended a friend's wedding and found myself an oversized, blubbering, inconsolable mess. It did take me a while to realize where the emotional spillage came from. Feelings I had regarding individual cases; things I'd safely tucked away, came back with a vengence yelling, "Hello there... remember me?"

[toomuchbaloney]

Beware of cumulative loss and grief.

[tokmom, BSN, RN]

It is a double edge sword. See my quote in my siggy line. It is there for a reason. Our personalities that make us great nurses are also our Achilles heel.

Having been to the dark side of burnout and compassion fatigue and left the profession for close to 5 years, I'm a huge proponent for debriefing and as many team building exercises at work. Off work, it is imperative to nurture one's soul and refill that glass of hope and strength. Meditate, take up a relaxing hobby, journal, talk to family. Do anything that invigorates. It may seem selfish initially, because our personalities that make us who we are, keep us from caring for ourselves first.

We do this at work all the time. We miss lunch to take care of pt's or even skip a bathroom break until it cannot be denied. At home, we feed and care for families. Only when there is a moments peace do we even dare to think of ourselves. We give...give...and give until we are void of emotion or energy.

Managers need to realize that compassion fatigue and burnout are very much alive and well in the nursing world and they need to address it promptly. Nursing students actually start out with mild burnout, but are they taught coping skills? From what research I have done, that answer is NO.

I did my capstone paper for my BSN on compassion fatigue and burnout. The more I researched, the angrier I became with the level of head turning in the profession. Managers don't care, the medical profession doesn't care, and we certainly know the bean counters don't give a hoot, because many have never worked a day in their life on a floor, witnessing tragic and sudden death.

So...who needs to care? We do. All three million of us need to voice our disdain for the lack of programs to assist nurses with burnout and compassion fatigue. Not only does it affect the nurses, but the patients with decreased satisfaction scores and increased sentinel events. Maybe if we quit beating each other up over what degree everyone has, and started supporting each other, we could greatly lesson the causalities of compassion fatigue and burn out.

OP, I'm sorry you had to witness such a sorrowful event, and kudos to you for being a trauma nurse. I have recognized my limitations of where I can work for my own emotional health. I could never deal with that kind of stuff on a daily basis. I would see my kids, husband and family members fighting for their lives. Please be kind to yourself. You seem to be an amazing nurse who truly cares about your patients and your staff. (((hugs))).

[jadelpn, LPN, EMT-B]

Emotional indulgence is a difficult place to be in nursing practice.

No matter what the intent, it can be seen as a nurse making parts of a patient and family experience about the nurse as opposed to the patient/family.

There is no reason why a nurse has to take the full brunt of an agonizing situation. If there is a grief counselor, palliative care, social work--these are all members of a health care team who can help a nurse sort out family support.

As a charge nurse, OP, I see you as a level headed, lets think about what needs to be done next kind of a nurse. Which is so important of a charge nurse. As a charge, you have the ability to get other members of the team involved in the after math of some significant patient issues. Use your nurses where their strengths are. If you have a seasoned nurse who can support a family until social work comes, then by all means, do some shuffling. Make it a pact that no one goes in alone. Support each other through the tough cases.

Then your conversations outside of work can be non-work related, or to the tune of "I have an amazing team who rocks! We are fortunate".

[nurseprnRN, BSN, RN]

Dear OP, please change your posting name to something anonymous stat, and if that's really you in that picture, your avatar as well. You're a new member so the mods can help you. There are numerous, numerous threads on why this is critically important.

The last time I had really serious burnout from being close to a patient and family was a long time ago, but I clearly remember the feeling of going in to the ICU the day after he died and being assigned to another patient in the same room I had spent so many weeks in. I did it for the day, but then I put in for 2 week's vacation. I got some good counseling from other nurses and a social worker, and learned that professional boundaries are important for a good reason.

We can be empathetic and connect on emotional levels, but we have to be sure we can't lose our ability to do what we have to do. I did lose my ability to do what I had to do when this dear man died. I had to regroup and work out a way to retain myself, because without that I wouldn't be able to be any good to anyone. You will get there, but you have to make as conscious a decision to learn how to do this as the one where you decided you had to learn normal chemistries or blood gases or ACLS protocols to do what you do.

[HouTx, BSN, MSN, EdD]

Wonderful post - but I agree with GreenTea ... identifiable avatar+ user name + specific clinical details = potential for professional disaster!!! Please change this.

There is a growing body of psych literature on "Cumulative Stress Disorder" as a subset of PTSD. It has certainly been identified as a contributing factor to burnout also. Smart organizations are implementing mechanisms (e.g., Critical Incident Stress Debriefing) to provide support to clinicians as a matter of routine practice after any sort of significant event such as the one OP described. This is much more effective than simply offering EAP programs because clinicians tend to think of this (seeking emotional/psych support) as wimpy behavior and evidence that they can't hack it. Weakness is considered professional failure.

I encourage everyone to raise this issue at their place of employment. Even if organizational support is lacking, a department can implement their own CISD program on a smaller scale. Here's a link to a how-to article (http://www.info-trauma.org/flash/media-e/mitchellCriticalIncidentStressDebriefing.pdf)

[jadelpn, LPN, EMT-B]

Your local Fire Department can help, as well as your police department. Most have established peer support and critical incident debriefing as part of their team support. They could be a great resource for starting a program at your facility.

[TriciaJ, RN]

If your hospital has a pastoral care department, they may be a good resource. It was my favourite department in the hospital where I used to work. They were johnny-on-the-spot for so many things; I can never thank them enough.