Compassion in nursing involves a deep and empathic regard for the suffering of a patient and the desire and engagement to ease that suffering (Slatten, Carson & Carson, 2010). Empathy may take the form of counter-transference or the vicarious experience of the patient’s suffering (Boyle, 2011). Compassion entails the use of self enabling the nurse to establish a connection and a therapeutic relationship with the patient in order to (Smart et al., 2014). However, the repetitive practice of compassion can lead to fatigue, a phenomenon more common in settings such as oncology, palliative care, hospice, trauma, and emergency services. Constant preoccupation with patients and families in pain and witnessing patients die despite interventions often induces guilt, powerlessness, and frustration (Melvin, 2012; Fetter, 2012). It depletes energy and the capacity for self restoration. Compassion fatigue is defined as the outcome of a “progressive and cumulative process that is causes by prolonged, continuous, and intense contact with patients, the use of self, and exposure to stress” (Coetzee & Klopper, 2010, p. 237). It is better understood in terms of its stages and warning signs, both of which are discussed below. More importantly, knowing the needs of caregivers at high risk for this occupational hazard assists in identifying appropriate and effective coping strategies that will protect the health and wellbeing of the staff.
Stages of Compassion Fatigue
Compassion fatigue develops in three stages. During the phase of compassion discomfort, there are subtle changes such as reduced passion, dedication, and enjoyment of work as the nurse used to have (Coetzee & Klopper, 2010). Instead, the nurse feels constantly tired to the point that he or she realizes the need to take time off to rest. The nurse may also begin to manifest with reduced attention span, memory, and sharpness in clinical judgment (Lombardi & Eyre, 2011). More importantly, the nurse starts to feel uncomfortable in situations requiring the use of self in order to fulfill patient needs. These symptoms are, however, temporary and taking time off to rest can mitigate the symptoms and restore the nurse’s capacity to care (Smart et al., 2014).
When unrecognized and unmanaged, compassion discomfort can progress to compassion stress. In this stage, the nurse becomes aware that changes have become pervasive with effects now noted in physical, social, emotional, spiritual, and intellectual functioning (Coetzee & Klopper, 2010). The initial symptoms may also be magnified. For example, worsening memory loss and an inability to focus may interfere with task performance. Output may also suffer because of the frequency of illness. At this time, the nurse has reached the limits of his or her endurance leading to feelings of being overwhelmed. To try to maintain equilibrium, the nurse begins to consciously avoid instances that require the use of self such as in empathizing with or alleviating a patient’s suffering (Lombardi & Eyre, 2011). There may also be irritation when such demands arise. After some time and stress levels continue to rise, the nurse may feel only complete boredom with his or her professional tasks and responsibilities (Melvin, 2012).
Again, when compassion stress is not understood for what it represents and is ignored, it will evolve into compassion fatigue. Signs and symptoms intensify further to an alarming level of dysfunction (Coetzee & Klopper, 2010). The nurse may become careless and unresponsive to the needs of patients that may compromise patient safety. He or she may show insensitivity, apathy, heartlessness, and indifference to peers and patients alike. The emotional state reaches a level of instability nearing breakdown (Slatten, Carson & Carson, 2010). In this stage, the nurse has utilized all her energy with nothing left to spare even for the self, i.e. fatigue. Lack of awareness as to why there is deterioration in professional functioning contributes to confusion and helplessness (Slocum-Gori et al., 2011). The typical consequence is turnover because rest ceases to become effective. The nurse leaves the unit, organization, or profession in search of another work setting, facility, or career path.
Warning Signs of Compassion Fatigue
Compassion fatigue can affect the physical, emotional, social, spiritual, and intellectual functioning of the nurse or caregiver. The physical effects may start out as weariness and then intensifies into loss of strength and endurance, diminished output and performance, and increasing physical complaints such as diarrhea, headaches, and insomnia leading to frequent sick calls (Fetter, 2012). At the peak of fatigue, the nurse generally complains of lack of energy and burnout, the latter occurring when there are other factors contributing to stress such as difficult patients, high workloads, interdisciplinary conflict, limited resources, inadequate staffing, lack of supervision, and unending paperwork (Slatten, Carson & Carson, 2010). A nurse with compassion fatigue is also noted to develop a higher likelihood for involvement in accidents and the resulting injuries.
On the other hand, emotional warnings signs include reduced enthusiasm and desensitization later on developing into irritability and feelings of being emotionally overwhelmed (Lombardi & Eyre, 2011). In the third stage, affect escalates into apathy and breakdown fuelling the desire to quit the job. These emotional changes underlie the social effects of compassion fatigue. At the outset, the nurse feels unable to give help to patients, a dysfunction that evolves into the inability for compassion (Lombardi & Eyre, 2011). It eventually leads to indifference to and a lack of concern for patients.
Spiritual effects pertain to discernment that underlies critical thinking and judgment. The caregiver or nurse with compassion fatigue suffers from lapses in judgment that was not the case before and which increases in severity to a total inability for spiritual awareness (Slocum-Gori et al., 2011). Later on, the nurse displays a lack of interest in reflection and contemplation that contribute to poor judgment. Lastly, compassion fatigue also affects intellectual processes namely attention, concentration, ordered thinking, and interest in the task (Lombardi & Eyre, 2011). Taking the various effects together, compassion fatigue renders the nurse largely ineffective and compromises the health and wellbeing of patients. There are tools established to assess the presence and severity of compassion fatigue among the staff that nurse managers can use to identify those in need of resources and assistance (Slatten, Carson & Carson, 2010).
Needs of the Caregiver
A greater attention to self-care is important in the prevention of compassion fatigue. Nurses at risk for this occupational hazard need to have sufficient exercise, sleep, rest, leisure, and nutrition that are the physiologic precondition for a strong immune system enabling the health professional to withstand the stresses at home and at work (Boyle, 2011). In addition, nurses’ experiences of loss must be acknowledged as valid given the connections they established with the patient who died. Disenfranchised grief is when the nurse feels the reality of the loss but he or she cannot openly express it because it is not recognized or deemed appropriate (Jonas-Simpson, 2013). They need support in processing negative events and managing stress to prevent overarching mental health problems such as secondary traumatic stress disorder and depression. For example, the nurse might blame herself for not knowing or doing enough for the patient. Support may be in the form of counseling and other forms of therapy, debriefing, education and training, or mentoring (Boyle, 2011).
Coping Strategies
Having a self-care plan ensures the nurse is proactive about his or her occupational health. Mindfulness is one coping strategy that nurses can use to remain effective in the face of stress and negative emotions. It is a cognitive-behavioral technique that entails limiting the focus of one’s attention to the present when other thoughts intrude (Stanton & Dunkley, 2011). It is not avoidance or repression. Rather, mindfulness promotes openness to experiencing stressful thoughts and emotions but without the need to respond. For instance, likening these thoughts to a train passing by while one watches on or noise that can be turned down does not require effort in blocking them but they remain in the background while the individual focuses on the present (Stanton & Dunkley, 2011).
It is also important for the nurse to be aware of what triggers compassion fatigue, reflect on the effectiveness of current responses, and learn about alternative responses such as seeking the help of a peer support group (Boyle, 2011). As such, the caregiver expands the tools and resources available for combatting stress and compassion fatigue. Grounding and containment skills are also useful in times of distress. It entails awareness of the body’s limits or tolerance in terms of arousal and instituting control measures to keep it within safe levels (Boyle, 2011). Such measures include deep breathing exercises and use of the senses to allow grounding in the physical environment. Lastly, methods of relaxation and outlets for stress that nurses can use include meditation, journal writing, art therapy, massage, and listening to music.
Conclusion
Compassion fatigue is a debilitating occupational hazard that also endangers patient safety. It is important to acknowledge this phenomenon and nurses’ needs that need to be met on the job for prevention purposes. To establish effective individual and workplace interventions, it is also necessary to understand compassion fatigue in terms of its course of progression, and warning signs in the areas of physical, intellectual, emotional, social, and spiritual functioning. Greater awareness of individual responses to stress and negative events, and knowledge of the resources and practices that can help in symptom management are invaluable in combatting compassion fatigue.
References
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Fetter, K.L. (2012). We grieve too: One inpatient oncology unit’s interventions for recognizing and combating compassion fatigue. Clinical Journal of Oncology Nursing, 16(6), 559-561. doi: 10.1188/12.CJON.559-561.
Jonas-Simpson, C., Pilkington, F.B., MacDonald, C., & McMahon, E. (2013). Nurses’ experiences of grieving when there is a perinatal death. Sage Open, 2013(3). doi: 10.1177/2158244013486116 .
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Slocum-Gori, S., Hemsworth, D., Chan, W.Y., Carson, A., & Kazanjian, A. (2011). Understanding compassion satisfaction, compassion fatigue and burnout: A survey of the hospice palliative care workforce. Palliative Medicine, 27(2), 172-178. doi: 10.1177/0269216311431311.
Smart, D., English, A., James, J., Wilson, M., Daratha, K.B., Childers, B., Magera, C. (2014). Compassion fatigue and satisfaction: A cross-sectional survey among U.S. healthcare workers. Nursing and Health Sciences, 16(1), 3-10. doi: 10.1111/nhs.12068
Stanton, M., & Dunkley, S.M. (2011). First steps in mindfulness skills. Nursing Times, 107(6), 22-24. Retrieved from http://www.nursingtimes.net/Journals/2013/01/18/t/e/p/150211First-steps-in- mindfulness-skills_NEW.pdf
