Learner Outcome: The learner will demonstrate sufficient understanding of compassion fatigue and burnout by achieving a score of 70% or better on a post-test.
1 Contact Hour will be awarded with successful completion.
Criteria for Successful Completion: Read entire study, complete evaluation questions and achieve post-test of 70% or more
There is no conflict of interest among anyone with the ability to control content of this activity.
The Ohio Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. (OBN-001-91)
This independent study was written by Jessica Dzubak, MSN, RN
This is not intended as legal or professional advice. If you or someone you know needs help, please contact a licensed mental health professional.
Compassion Fatigue: You Are Not Alone
Jessica Dzubak, MSN, RN
Compassion fatigue. Burnout. Secondary stress. We have heard the terms in the break-rooms or in the locker room, and we read about them in the literature. Sometimes it is very easy for us to identify it in others. We have all seen that colleague who snaps at their patients or has lost their spark.
But are we just as good at identifying it in ourselves?
Compassion fatigue continues to be a growing concern among healthcare professionals, including nurses at all levels of care. However, healthcare workers are not the only ones prone to compassion fatigue. The literature suggests it primarily affects “the helping professions”, such as psychotherapy, social work, veterinary medicine, law enforcement and education (Abcug, 2017; Hunt, 2017; Turgoose, Glover, Barker & Maddox, 2017). Research found that approximately 50% of people, across professions, are burned out (Seppälä & King, 2017). Many professional associations have pages dedicated to compassion fatigue, such as the American Bar Association and the American Veterinary Medicine Association.
You don’t have to be a professional to experience compassion fatigue, secondary trauma or burnout. One rural health department identified the risk of these adverse effects in the lay people in the community who receive naloxone kits and are trained to administer in the event of an overdose emergency (Aguilar-Amaya & Gutierrez, 2019). With Ohio ranking second for highest rate of drug overdose deaths involving opioids in 2017, the public dispensing of naloxone kits in the community is becoming commonplace (National Institute on Drug Abuse, 2019). In addition to members of the community being affected, first responders are being hit exceptionally hard. A fire chief in West Virginia, in an area hard-hit by drug overdoses, has begun implementing measures to increase resiliency and prevent compassion fatigue for her first-responder staff, including on-site massage therapy, mindfulness training, and the hiring of a mental health counselor (Bloomberg Cities, 2018).
The effects and consequences of compassion fatigue and burnout can be so profound that even the patients suffer, including decreased satisfaction with their care and an increase in errors made by health professionals (Valentine Upton, 2018; Lachman, 2016). Nurses and healthcare providers must be aware of the concepts of compassion fatigue and burnout in order to recognize the signs in themselves and in their colleagues. Nurses have an ethical responsibility to self just as much as to others (American Nurses Association, 2015, p. 19). The ANA Code of Ethics (2015) pushes nurses to concern themselves with their own health, wellness, and safety. It has long been established that mental health is equally important as physical health, and nurses must remain diligent in tending to their own mental wellness.
What is Compassion and Why is it Important:
“…a multidimensional process comprised of four key components: (1) an awareness of suffering (cognitive/empathic awareness), 2) sympathetic concern related to being emotionally moved by suffering (affective component), (3) a wish to see the relief of that suffering (intention), and (4) a responsiveness or readiness to help relieve that suffering (motivational)” (Jazaieri, et al., 2012)
“to suffer together” “the feeling that arises when you are confronted with another’s suffering and feel motivated to relieve that suffering” (Greater Good Magazine, 2019, para. 1).
“Nursing’s most precious asset” (Valentine Upton, 2018, p. 2)
Research shows us that humans are “wired to empathize” (Keltner, 2012, para. 7). The same parts of our brains that light up when we experience pain are also activated when we witness other people in pain (Keltner, 2012). Compassion takes us beyond empathy and into the realm of wanting to help. It can be incredibly stressful when a nurse is witnessing a negative situation or the suffering of his/her patient, yet he/she cannot do anything to help. Sometimes, every effort can be made to save the patient, remedy the situation, or fix the problem – yet a negative outcome occurs anyway.
Nurses go into the profession because of their inherent desire to help and support others, regardless of circumstance, socioeconomic status or culture (American Nurses Association, 2015). In order to provide this level of care, nurses must display a certain degree of compassion and empathy.
Nursing is unique in that it touches people in all walks of life, from newborn babies to criminals imprisoned for life. Each and every patient we touch deserves the same level of compassion and respect. This constant demand to remain calm, respectful and compassionate can become overwhelming if the nurses are not taking the time to treat themselves with the same level of kindness and care.
Nursing is stressful, and life is stressful. We must learn to manage ourselves before we can even begin to manage others. We must also learn to recognize when things start to change. A decrease in job satisfaction or increased difficulty in managing “difficult” patients require attention. Giving these troublesome things a bit of attention does not mean you are self-indulgent, selfish or weak. It means you are human and are taking the steps to manage issues that could worsen and impact your career and well-being.
Compassion fatigue vs. Burnout
Compassion fatigue and burnout, are they the same?
Per the American Institute of Stress (AIS), there is a “clear difference.” The AIS explains the key difference being that compassion fatigue has a “more rapid onset” and burnout is something that develops and “emerges over time”. Additionally, compassion fatigue is thought to have a faster recovery, but only if it is recognized and managed early (American Institute of Stress, 2018).
Burnout: Jenaro, Flores and Arias (2007) explain burnout as ‘a syndrome composed of emotional exhaustion, depersonalization, and reduction of personal accomplishments and is displayed as feelings of hopelessness, difficulties in dealing with work, and poor work performance’ (Jenaro, Flores, & Arias, 2007). These emotional components result in difficulties carrying out job duties, hopelessness in improving the situation, and a decrease in effectiveness in the workplace (Stamm , 2010).
In the latest version of the International Classification of Diseases, ICD-11, the World Health Organization (WHO) has added burnout as an “occupational phenomenon” (World Health Organization, 2019). Burnout is not to be confused with a medical condition.
Compassion Fatigue: Compassion fatigue can be described as either a preoccupation or a re-experiencing of a patient’s or client’s traumatic event(s), which can decrease the caregiver’s aptitude or interest in bearing the suffering of other people (Mathias & Wentzel, 2017). Compassion fatigue can also be described as “a state of detachment and isolation experienced when healthcare providers repeatedly engage with patients in distress” (Lee, McCarthy Veach, MacFarlane, & LeRoy, 2015, para. 1). Another respected definition, stated by Dr. Frank M. Ochberg, is “basically … a low-level, chronic clouding of caring and concern for others in your life – whether you work in or outside the home. Over time, your ability to feel and care for others becomes eroded through overuse of your skills of compassion” (Ochberg, n.d.., para 3).
Often, the term secondary stress or secondary trauma stress can be used instead of compassion fatigue. Secondary stress is defined as: “the emotional duress that results when an individual hears about the firsthand trauma experiences of another” (The National Child Traumatic Stress Network, n.d., para 1). Nurses and many others in the ‘helping professions’ both hear and witness other people’s stress and trauma on a sometimes daily basis. Therefore it is understandable to see how this stress can become overwhelming.
When discussing compassion fatigue, it is important to recognize compassion satisfaction, or “gratification obtained when doing one’s work to the best of one’s ability” (Mathias & Wentzel, 2017, para. 16). Another definition is “…the feeling of pleasure that results from ably executing one’s duties”. (Mathias & Wentzel, 2017). Compassion satisfaction is what we want to feel every day when we walk out of a shift. We want to feel like we did good, treated our patient’s to the best of our ability, and like we made a difference. We want that pleasure and gratification, not because we are self-involved but because it makes the negative aspects worth it, and because it reminds us of why we do this work. So what makes it so hard to do this?
Compassion fatigue, secondary stress, and burnout, while often reduced to simplistic definitions, are not simple concepts. In fact, they are complex and multifaceted. Both affect the nurse’s ability to function effectively, both personally and professionally. The quality of the care provided is decreased in both situations (Mathias & Wentzel, 2017). Regardless of the combination of symptoms, any of them can decrease one’s ability to provide top-quality care. In some cases, symptoms can be so detrimental that even the safety of the care is compromised.
The “cumulative stress” those in the caring professions face can ultimately lead to these physical, emotional, social and spiritual effects (Sinclair, Raffin-Bouchal, Venturato, Mijovic-Kondejewski, & Smith-MacDonald, 2017).
|Boredom||Increased blood pressure|
|Cynicism||Loss of compassion|
- More sick days
- Higher turnover rate
- Decreased productivity
- Patient dissatisfaction
- Increase in errors
(Valentine Upton, 2018; Sheppard, 2015)
The American Bar Association (2017) provides another comprehensive list of detailed symptoms and behaviors linked to compassion fatigue:
- Perceiving the resources and support available for work as chronically outweighed by the demands
- Having client/work demands regularly encroach on personal time
- Feeling overwhelmed and physically and emotionally exhausted
- Having disturbing images from cases intrude into thoughts and dreams
- Becoming pessimistic, cynical, irritable, and prone to anger
- Viewing the world as inherently dangerous, and becoming increasingly vigilant about personal and family safety
- Becoming emotionally detached and numb in professional and personal life; experiencing increased problems in personal relationships
- Withdrawing socially and becoming emotionally disconnected from others
- Becoming demoralized and questioning one’s professional competence and effectiveness
- Secretive self-medication/addiction (alcohol, drugs, work, sex, food, gambling, etc.)
- Becoming less productive and effective professionally and personally
Prevalence and Statistics:
- Burnout is among the leading patient safety and quality concerns (The Joint Commission, 2019)
- Up to 85% of healthcare workers experience compassion fatigue
- Higher levels of compassion fatigue in younger nurses and/or those with fewer years of experience
- 6% of all nurses reported feelings of burnout (emergency department nurses = higher risk)(The Joint Commission, 2019)
- “Very new” nurses to the acute care setting = high levels (Valentine Upton, 2018)
- Female nurses have a higher incidence
- Age: 40-49 year old nurses had “significantly lower compassion satisfaction” and higher rates of burnout (Sacco, Ciurzynski, Harvey, & Ingersoll, 2015).
Why does compassion fatigue hit nursing so hard? One study points out that interviewees in the study reported the feeling of being “undervalued” and “being taken for granted by patients who have unrealistic expectations of the nursing role” (Valentine Upton, 2018). “It is important to look at these personal growth benefits without judgment and be honest with yourself regarding what you hope your job will provide as these personal benefits because it is when your work doesn’t provide us this gain, you become vulnerable to emotional injuries which are often experienced as secondary trauma and compassion fatigue” (Tobey, 2019, p. 7).
Reflection: Have you experienced caring for a patient(s) who have “unrealistic expectations” of your role as the nurse? What were these expectations? How did you handle the situation?
With an increased emphasis on patient satisfaction scores, nurses are being stretched thin to accomplish their nursing tasks safely and meet all of other patient’s needs (Bachman, 2016). Most nurses will tell you they truly enjoy this part of their job, making a patient feel more comfortable during a stressful time or even just providing a shoulder to cry on. But over time, this willingness to help can cause problems if stress and emotions aren’t managed properly.
As nurses, we become so focused on alleviating our patient’s stress and pain that we fail to address our own.
Organizational Compassion Fatigue
Compassion fatigue doesn’t just affect individuals. It can spread and begin to affect an organization as a whole. The Compassion Fatigue Awareness Project (2017) describes the following as organizational symptoms of compassion fatigue:
|· high absenteeism
· constant changes in co-worker relationships
· inability for teams to work well together
· desire among staff to break company rule
· outbreaks of aggressive staff behavior
· inability of staff to meet deadlines and complete tasks
· lack of flexibility
· negativism toward management
· reluctance towards change
· inability to believe in improvement
A combination of these factors can lead to a less-than-desirable work environment. With the steady prevalence of workplace bullying, lateral violence, and workplace violence, healthcare workers should be looking at the correlation between compassion fatigue, burnout and violence. The literature shows that there is a connection between healthcare workplace bullying and burnout (Bambi, Foa, De Felippis, Lucchini, & Rasero, 2018; Giorgi, et al., 2015). Workplace and social support have been linked with lower levels of burnout and greater satisfaction and productivity (Seppälä & King, 2017).
While educators must be careful not to scare or discourage students about nursing, an honest discussion about the demands of the job is warranted. Students should be aware of resources they have as well as learn coping skills and stress management skills early on. Studies show that students even experience compassion fatigue during their nursing school experience (Jack, 2017).
The study goes on to say “At times it seemed that the students cared more for the patients than they did for themselves, as they became more and more involved in the challenging situations which led them to place high expectations on themselves” (Jack, 2017, para. 23).
The reality of nursing can be overwhelming, and educators are in a challenging position. They need to disseminate crucial information while also preparing nursing students for the “real world.” Educators must teach the clinical information as well as the practical. In order to do this, educators must find innovative ways to communicate with their students and foster a culture of safety. One way to do this is to regularly have opportunities for debriefing.
The importance of debriefing cannot be understated (Schmidt & Haglund, 2017; Wanninger, Riley, Hofer, & Swift, 2019; McCorkle, 2016). Debriefing allows students to talk about experiences, whether positive or negative, review events in a non-judgmental way, and learn from the opportunity. It also encourages the student nurse to continue this as they transition to professional practice. Talking with a colleague, manager or mentor after a stressful incident can alleviate some of the stress and anxiety, and resources can be obtained if necessary.
We must instill in our nursing students that while stressful things may occur, feeling compassion fatigue and burnout are not “just part of the job.” A 2016 study found that nursing students experience a high-level of stress, but the majority of them (92%) do not typically or frequently make time to personally debrief or unwind after a stressful situation (Homan, 2016).
Debriefing is also critical for seasoned, established nurses and others in the helping professions. Research supports debriefing, showing that it has a positive relationship to compassion fatigue and burnout (Miller, 2016). Additionally, debriefing may increase the perceived level of support in an organization or among coworkers, providing another resource to combat compassion fatigue.
A 2017 study examined whether or not a “sacred pause” at the time of a patient’s death impacted resilience and levels of closure (Kapoor, Morgan, & Siddique, 2018). While the study was not large enough to conclude that this ritual actually prevents or lowers rates of burnout, it did find that participants reported more closure, less cumulative grief and distress, increased resiliency and professional satisfaction among the healthcare team (Kapoor, et.al., 2018).
Training and Treatment at Work
- De-briefing sessions
- Bereavement interventions
- On-site counseling
- Create a culture of support among leadership
- Encourage discussions on stressors, critical incidents, and staff experiences
- Support groups
(Boyle, 2011; Lachman, 2016)
The Joint Commission released the following strategies to promote nurse resiliency and identify burnout or compassion fatigue (The Joint Commission, 2019).
· Provide education for nurses, preceptors and nurse leaders to:
-Identify behaviors caused by burnout and compassion fatigue
-Become aware of their personal stressors and triggers.
-Take part in self-care activities/techniques (such as sleep, fitness and eating habits).
· Improve clinician well-being by measuring it, developing and implementing interventions, and then re-measuring it.
· Provide nurses with opportunities to reflect on and learn from practice and other practitioners (e.g., positive role models).
· Develop or utilize current tools for staff to use to anticipate opportunities and problems.
· Work with your internal team to assess if your current electronic health record (EHR) system may be customized so that it optimally supports nursing workflow.
· Hold regular staff meetings. Include discussions regarding new organizational policies, processes and outcomes from higher leadership meetings. Engage nursing input in staff meetings by posting an agenda and asking for additional items the nurses would like to discuss or present.
· Cultivate a health professional culture that is based on altruism, setting a good example, mentoring, leading, coaching and motivating others.
· Recognize nurses in a meaningful way. Since individuals interpret recognition differently, find out from nursing staff how your organization can best demonstrate that it is invested and interested in recognizing nursing staff for the work that they do.
The Joint Commission (2019)
That sounds like me. Does this mean I am a bad nurse?
No. Suffering from compassion fatigue and/or burnout does not mean you are a bad nurse or that you should start searching for a new career. When you have a fight with a loved one, you don’t immediately give up on the relationship – you search for a solution or compromise. The same concept applies; except the person we are fighting with is ourselves. In some ways, this can make it even harder to solve. Humans have difficulty showing themselves the same level of kindness and compassion that we show others. Those in the healthcare field are unfortunately accustomed to abuse, disrespect, and undesirable working conditions. Yet, despite all of that, we expect ourselves to ultimately become immune to the stressors yet still keep the same level of enthusiasm on the job.
We have all heard the old adage; you can’t pour from an empty cup.
I think I’m burned out. What do I do now?
- Talk with a mentor
- Change directions
- Visit a counselor
- Practice mindfulness
- Make time for exercise and quality sleep
- Resiliency training
- Take a vacation
(Duarte & Pinto-Gouveia, 2016; American Institute of Stress, 2018)
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