“The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet” Remen
Nurses are routinely exposed to difficult and traumatic situations. They are short staffed, have increasingly sicker patients, face aggression and bullying, and angry bosses. Nurses often lack support and appreciation. Wow…you might think I’m exaggerating, but just ask any nurse and you’ll get a similar response.
Being a nurse demands toughness, intelligence, and flexibility to handle unpredictable and dangerous situations every day. Even though nurses are used to high stress, long term exposure to these conditions can eventually cause burn out.
Burn out is just a generic word, but this generalization hides a deeper problem. Sometimes stress is accompanied by emotional trauma; a more serious and debilitating chronic condition.
Burnout has many nuances and stages, and is usually associated to emotional trauma. In order to understand and treat stress effectively, we need first to look at a stress blueprint to better understand how emotion can affect trauma.
We can divide post traumatic disorders in three categories:
- Burn out
- Vicarious traumatization
- Compassion fatigue
These three components have much in common, and a person can have one, or a combination of the three. These categories define causes, associations, and residual effects of untreated stress.
Compassion fatigue for example is associated with an individual’s reaction to emotional stress created by a “patient and caregiver relationship”. General burnout out may be caused by work related stresses and have little to do with emotions.
Traumatic emotional stress is a serious matter. All individuals, no matter how resilient can fall pray to emotional trauma because emotional trauma has a cumulative effect. Effective help can be difficult to find, but you can be your own light in the darkness.
It is easy to tell when nurses are burned out. The signs are clear – irritability, tired faces, forgetfulness, fatigue, and depression. It is possible to have burn out that is emotion free; a person can simply be tired and overworked but no emotions are involved. But emotions are sometimes beneath the surface without you or anyone ever know.
Burn out affects some individuals differently according to their personalities. Stress levels are higher for some due to their predispositions. Researchers have come up with 5 personality types to illustrate this point; they are called the big five .
- Openness to experience
These personality types are further affected by two variables:
Work-related attitudes. For example, nurses who fosters false expectations or unrealistic health outcomes for their patients can be more vulnerable to emotional stress then others. For example, they can become emotionally affected if the patient doesn’t get well as the RN’s expectations. Another example is the nurses’ vision, values and beliefs which include philosophy of care. These concepts may also not play out as planned and can lead to frustration and burnout.
Work-related characteristics. This one has to do with the individual’s inability to control a unfavorable working environment. Employers trying to save money might create difficult working conditions such as not replacing old and faulty equipment, or not addressing staff shortages. There are other overwhelming job related stresses which are inherent to nursing and out of anyone’s control. Some of these are:
- Increased patients-to-nurse ratios
- Increased patient acuity and complexity
- Lack of leadership and peer support
- Lack of autonomy at the point of care
Number 1 – 2 falls into the job related/patient related category. These two sources of stress are less controllable because they are related to natural conditions such as – patients are getting sicker and more acute, or that: plain and simple, nursing is a hard job. Such conditions are usually easier types of stress to cope with. They are in a sense inevitable and will always exists along with the profession, therefore accepted as part of the job.
However, number 3 – 4 are man made and therefore have a tendency to be more noxious and capable of causing emotional damage to nurses. For example, due to workplace re structuring a nurse is sent to another unit she is not familiar with.
Disruption of work culture and environment causes stress. This stress is further aggravated by insensitivity of management who sees nurses as simple workers having no regards for their hard work and emotional stress loads. The lack of support and empathy from employers bring a far more damaging level of stress than natural causes because because it is fabricated, therefore avoidable. They are perceived as abuse, which can further complicate things.
Stress levels can also create a feedback loop. The more stressed nurses are, the more stressed the working environment becomes. This conditions can be evidenced by the emergence of several side effects secondary to stress, that in turn lead to further burnout. These are:
- Lack of sleep
- Poor diet
- Interference with personal life
- Poor pay
- Lack of appreciation
- Poor management
Compassion fatigue can also be called secondary traumatic stress. Compassion fatigue has been described as a “natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other – stress result from helping, or wanting to help, a traumatized or suffering person” 
Compassion fatigue also affect doctors, psychiatrists, mental health workers, and EMT’s. Compassion fatigue can last for a few days, or can be a chronic problem.
Most studies agree that Compassion fatigue is a phenomenon born out of the therapeutic relationship between the patient and health care provider. The suffering and trauma experienced by the patient triggers a multi level response in the provider.
A study shows that nurses working in ER, ICU, pediatrics and forensics have high rates of compassion fatigue ranging from 25% to 78%. Among emergency nurses, 86% were found to have moderate to severe levels of compassion fatigue.
In order to better understand the complexities of compassion fatigue, a model based on 5 elements was suggested [9, 10]. These 5 elements are related to personal attitudes, individual responses and skills, and personality traits that help us better understand the complex web that emotional stress can create.
- Emphatic ability
- Emphatic response
- Residual compassion stress
- Halting compassion fatigue
- Resilience and hope
- Joy of compassion
Emphatic ability – Some of us have a natural ability to feel what others are experiencing. They are able to put themselves on the other person’s shoe. This is called empathy, a skill that allow us to get in touch the trouble of others as if they were our own.
Empathy is the ultimate form of assessment because by understanding how others feel you are able to determine their true needs.
People choose health care as a profession because in some way or another they care about others. Your ability to connect to your patients is important and it should allow for better therapeutic outcomes.
Emphatic response – This refer to provider’s compassion and empathy possible beneficial effects for patients. Can the provider’s empathy produce a better outcome? Or, will the provider absorb all the stress and pain from the patient and become sick himself?
Empathy can be cultivated or be a natural response from our sense of duty to others. The ability to have empathy doesn’t necessarily mean that we are using it wisely. Nor it means that by having an emphatic health care worker will translate into better care for patients.
Being exposed to raw emotion from patients is a highly unstable affair and without a clear understanding and training, it can cause more harm than good for the provider. Being empathetic is a positive trait but its skillful use will determine the impact to patients and providers – that bring us to our next element.
Residual compassion stress – When a provider is truly interested in the well being of a patient, he/she open up the doors of communication. There has to be openness where energy is free, unstable and raw. In order to understand others we have to go in and hang out outside our comfort zone. Few individuals possess the high skill necessary to handle this situations well without accumulating residues.
Residual stress aggravated by a certain personality types are called “the savior type syndrome”. These individuals feel personally responsible and feel that the suffering of others has to be resolved. These individuals get involved in a highly personal level and are most at risk to develop stress due to a “caring the world on their shoulder” type attitude.
Halting compassion fatigue – Is the ability to identify compassion fatigue and its triggers and have the resolve to stop it or get off the runaway train. This is the ability to develop protection mechanisms.
Everyone has a different approach. Sometimes it means stepping out of the patient’s room for a moment; other times is to simply have an automatic system that shut off the tendency to being sucked in into the emotional vortex. Visualizations or affirmations such: “when I put the scrub I’m a different person and I’m not affected by anything”.
Resilience and hope – Can be characterized by the ability to be empathetic, to fully participate with the patient, to engage in the pain and suffering and not be affected by any of it. The results are usually good for the patient too.
This is an aspect I feel more comfortable with and know it is possible to achieve. The ability to fully transform the patient pain and suffering into a positive energy if you will. This stage requires deep understanding and awareness.
It requires a person to be fully present, engaged and being personable without involving one’s ego. Someone who cares but do not take personal responsibility for everything. At the end of the day, all that transpasses, stays behind at work and doesn’t create residues.
Joy and compassion – is the ultimate positive outcome between patient and caregiver. Joy and compassion is achieved when you do a good job at being empathetic; the end result is joy. That is, you actually enjoy doing your job.
You have produced joy out of a miserable situation (congratulations!). You altered someone’s energy and produced joy where there was suffering. This experience is transformative for both patients and caregivers.
The ability to transform heavy and dense emotions into positivity. How can this be done? It will depend on your level of commitment to others, and your ability to be present and aware in difficult situations, and the ability not to get the ego involved.
My own experience with compassion fatigue
Compassion fatigue can strike anyone. No matter how resilient and able to keep emotional distance from your patients; anyone can get hit. There is a “cumulative effect” in dealing with emotions.
I am tolerant and resilient to emotions on the floor. I can get involved as I need but I’m usually able to keep things at a distance. One day however I was feeling down and tired. Mostly tired of seeing the same never ending drama from patients.
I went to work and I felt uncomfortable. It felt as if I could feel the pain of all my patients at the same time. I felt that their status were related to me in some way. It was a scary and unpleasant sensation. I felt like leaving that place and never coming back. Luckily it didn’t last for long. But for some people it can be a chronic struggle.
To better understand vicarious traumatization it helps to do a little review. So, we’ve learned that burn out can be just about any stress a nurse is exposed to; or the sum of all stresses combined.
Compassion fatigue is a specific emotional trauma involving compassion and care when patient and caregiver are involved in the intimacy of care given and care received.
Vicarious traumatization can be seen as all other emotional traumas caused by a array of difficult situations created by either patients and their problems, workplace and job requirements.
Vicarious traumatization is usually associated with a long term exposure to difficult and traumatic events; that at certain point trigger a negative emotional response in the provider. This variety of stresses in the workplace often resonate with a internal trauma the worker is vulnerable to.
The exposure to graphic accounts of human cruelty, trauma, and suffering, as well as the healing work within the therapeutic relationship that is facilitated through emphatic openness (compassion fatigue) may leave healthcare providers, including nurses, vulnerable to emotional and spiritual consequences.
Some values can be identified as triggers or possible factors influencing some individuals to be victimized by vicarious traumatization:
- Futility of care
- Unnecessary invasiveness
- Abuse from patients
- Individual’s history
Futility of care – Today, with advances in technology we can extend the life of dying patients. But the outcome is the same; the patient end up perishing one way or another. Vicarious traumatization happens when a nurse witness unnecessary suffering and is not able to do anything about it because the decision making is outside of her scope or practice. This also happens with countless procedures patients must endure when the outcome certain – the patient will die.
Unnecessary invasiveness – Is when you realize patients are getting treatments they don’t need and are exposed to extra pain and suffering for no reason. i.e. chemotherapies, unnecessary colonoscopies, intubation.
Abuse from patients – Today, nurses suffer from a stream of abuses from patients. Assault, verbal abuse, stalking, and general lack of respect and appreciation. Behavior is one of the most difficult aspects of stress related to patient care. Patients bring their personal and physical chaos to the RN and want it to be fixed immediately. As patients realize this scenario will not play out so easily, they threatened RN with lawsuits or calling the state to voice their grievances.
Individual’s history – This is when your personal history of abuse and childhood trauma is triggered by the emotional stresses you experience at work. For example a person who’s been sexually abused in the past might be particularly vulnerable to be traumatized if being stalked by a patient. Anxieties from the past play a central role in stress development.
3 Ways to cope with compassion fatigue and burnout
#1 You are in charge
The best way to avoid being traumatized by emotional stress is to avoid stress altogether. Yes, whenever possible remove yourself from a stressful situations. This may not always be possible but most people don’t even think there is an option. Develop the get off the runaway train concept.
If there is a train coming your way, you don’t think – you get out of the way. The same principle apply to everything in life, including stress in nursing. Simply don’t expose yourself to danger unless there is no other option.
Fore example: If you’re assigned a aggressive patient and he is causing you emotional stress; switch this patient with another nurse. This is commonly done. Patients can fire you, but you have the right to refuse care in some instances.
If you feel you’re being emotionally abused by your employer (and that is one of the hardest problems to solve) you may also try to address this problem. The majority of people never try anything; they just complain to others at the break room or push through and hope the problem will go away.
The get off the runaway train can be done enve if you can’t get out of the way. You can pace yourself. You can take a day off, you can take breaks, call in sick, you can acknowledge that a situation is hurting you and the simple fact of admitting it to yourself will make a difference. In a way, that is like getting out of the way but still deal with the stressful situation at hand.
#2 Train yourself to handle emotional stress
Prepare mentally – People prepare for nursing for years, but there is often little preparation to handle psychological stress. Training involves practice and determination.
Often emotional stress, is a reflection of something we already have inside. Because we are all human and can’t separate the suffering of others from our own. Chances are we’re more affected by emotional stress when we feel depressed or vulnerable ourselves.
Sometimes is good to keep an emotional distance, but other times is best to embrace a stressful situation 100%. Sometimes, the closer you get to pain and suffering the less you’ll feel it because you get fully in touch with it. The discomfort and fear we experience is usually created by us by trying to avoid something – we create a battle with ourselves.
The fight we create trying to escape, produces friction and stress. The simple act of thinking of pain creates pain. But what if we embrace it and get close until we’re able to see that we still there and there is nothing to fear. Once you come full contact with your fears they tend to disappear.
Another problem is our level of acceptance in regards to negative outcomes. Patients have dire situations; deteriorating health and a negative prognosis. They come to us expecting improvements, but in many cases there is little that can be done for these patients. To watch this hopeless situation unfolds can be very painful.
I noticed this principle in action with hospice patients. When someone has a terminal diagnosis and instead of fighting a losing battle they embrace death, something positive happens as a result of this acceptance.
The outcome is better and studies have shown that these patients live longer sometimes being discharged from hospice. Their end of live is transformed into a rich experience rather than a painful battle. We can apply these same principles of acceptance to our duty of being exposed to human trauma and unfortunate patient outcomes.
Prepare physically – Being physically prepared makes a big difference in your ability to handle stress. If your body is weak, everything becomes a burden, even taking a walk around the block. Studies have shown that intense physical activity stimulated the brain in many ways. I recommend exercising vigorously and with frequency to avoid burnout. Remember, your mind and body are the same, strong body strong mind. I think lifting weights for nurses is a great idea. Start today.
Practice tonglen  – Tonglen is one of the richest and bravest practices that you can apply in care. Tonglen means giving and receiving; and is the practice of being present to our suffering and the suffering of others at the same time. We must first get in touch with our own fears, in order to take care of others.
Tonglen is the realization that in order to help others we must relate and be kind to our own suffering, frustration and fears.
By understanding and being in touch with our own fears and frustration we can feel powerful in the presence of the overwhelming suffering of others. What comes next is our willingness to transform fear and alienation into compassion through mercy and cultivation of openness. The practice of tonglen is quite simple.
The practice consist in seating next to a person who is suffering and practice breathing. You breathe in all the heavy and tarry black sooty pain first. On exaltation your breathe out well purified white light energy. This is an ancient Buddhist practice that consists of assisting people who are suffering. You simply stay near the person and work with your breath. Here’s a good introduction to tonglen.
Practice awareness meditation – There are many types of meditation. However, with awareness meditation you focus on the breath. The idea is that you continually focus on something to remain in the present moment. The breath is good because it is as real as it gets. You know you are breathing, and there are several signs you know it is real. You feel your chest rise and fall and you can hear the breathing. Ultimately your breath is your life. So it is a great idea to use the breath as the focus of your meditation because it link us to our present moment. Learn more about meditation.
#3 Discovering the joy of compassion
Find that spark in yourself. There is a joy in taking care of others. You might know it already but just need a refresher. But we tend to forget about joy because we get burned out.
I don’t know what can bring you back into this space again. But there is one thing you can notice in yourself. When you put others first you feel good; when you think of yourself first you feel miserable.
The only person getting irritated is yourself. There is no irritation outside yourself. Just work to be done. We want to see what’s in for us. What about me. The ego has many tricks to convince us we’re right. We try to fight the systems; we are convinced that there is something wrong with the system and that is what is making us miserable.
You have to own your problems. You have to assume that all problems are our problems. Once you take ownership of your problems, their yours and now you can do whatever is necessary to take care of them. Don’t blame your boss or anyone else.
Your boss might be in more trouble than you. At least you are walking around on the floor and doing great things for your patients. Your boss is stuck in front of a computer and having her boss yell at her even louder than she yells at you. The system is broken, and you are not going to fix it. You just have to sit with it.
Patient focused care
But there is a hidden gem in nursing, and you just have to uncover it again. Nursing is all about other people and not you. In nursing you have a great opportunity to get out of your head. The byproduct of focusing on the patient’s problems will result in your increased selflessness.
- Compassion Fatigue Awareness Project
- The American Institute of Stress
- Gifts From Within (An international non profit organization for survivors of trauma and victimization)
For further reading
- Reflecting on the Concept of Compassion Fatigue
- Empathic Communication
- Compassion Fatigue: Coping With Secondary Traumatic Stress Disorder In Those Who Treat The Traumatized
- Compassion Fatigue and Burnout in Nurses Who Work With Children With Chronic Conditions and Their Families
- Burnout contagion among intensive care nurses
- Maslach Burnout Inventory Manual
- Diagnosis and treatment of helper stresses, traumas, and illnesses
- Measuring Compassion Fatigue
- Stress causing psychosomatic illness among nurses
- Violence Against Nurses and its Impact on Stress and Productivity
- “Are You Way Too Stressed Out?” Survey Results
- International Comparison of Spending on Health, 1980–2009
- Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction
- Meditation: Tonglen or Giving and Receiving: A Practice of Great Mercy
- Emotional distance
- Compassion Fatigue: Psychotherapists’ Chronic Lack of Self Care
- Figley Institute workbook
- The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It
- Empathy from a nursing perspective: Moving beyond borrowed theory
- The Burnout Companion To Study And Practice: A Critical Analysis
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