“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 exposed to all kinds of traumatic experiences. They are short staffed, caring for sicker patients while dealing with aggression, bullying and management abuses, often lacking support and appreciation.
Being a nurse demands toughness, intelligence, and flexibility to handle unpredictable and dangerous situations every day. Even though nurses get better at tolerating high stress, long term exposure to these conditions eventually can cause anyone to burn out.
Burn out is just a generic word used to label a variety of stresses, but this generalization hides a deeper problem. Sometimes stress is accompanied by emotional trauma, a serious and debilitating condition. Burn out has many nuances and stages, and usually involves emotional trauma. In order to understand and treat emotional trauma effectively, we need first to look at a stress blue print. Thankfully someone thought of one.
Health care stress can be though of as post traumatic disorders, and are better understood if divided 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 the patient and caregiver relationship. General burn out may be caused by work related stresses and have little to do with emotions.
This article takes traumatic emotional stress seriously. All individuals, no matter how resilient can fall pray to emotional trauma; because emotional trauma has a cumulative effect. Effective help is difficult to find, but you can be your own light in the darkness. Please keep reading.
It is easy to tell when nurses are burned out. The signs are clear – irritability; tired faces; forgetfulness; fatigue, and depression. It’s usually assumed that burn out is empty of emotions; a person can simply be tired and overworked but no emotions are present. But emotions are sometimes beneath the surface without you ever knowing.
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 expected by the RN. Another example of attitudes are nurses vision and values and beliefs which include philosophy of care. These concepts may not play out as planned and can lead to frustration and burn out.
Work-related characteristics. This has to do with the individual’s inability to control a working unfavorable environment. Employers trying to save money might create difficult working conditions such as old equipment or lack of staff. There are other overwhelming job related stresses that are inherent to nursing and are out of anyone’s control. Some of these are:
- Increased patients-to-nurse rations
- 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 nursing is a hard job plain and simple. Such conditions are usually easier stresses 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 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 these stresses could have been avoided. They are perceived as abuse.
Stress levels can also create a feedback loop. The more stressed nurses are, the more stressed the working environment becomes, thus creating more stress. This conditions can be evidenced by the appearance of several side effects secondary to stress, that in turn lead to furthering the burn out. 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 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 feel and understand 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 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 should allows a better therapeutic outcome.
Emphatic response – This refers to the results and effects of having compassion and empathy. Can the provider have empathy to produce 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 then good for the provider. Being empathetic is a positive trait but the 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 interest in the well being of a patient, he/she open up the doors of communication. There has to be an openness in there where energy is free, unstable and raw. In order to understand others we have to go in there 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 that the suffering of others 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 in their shoulder type attitude.
Halting compassion fatigue – Is the ability to identify compassion fatigue and its triggers and then having the resolve and the power to stop it or get off the run away 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; others times is to simply have an automatic system that shut off 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 the part I have the most interest in and I know to be possible to achieve. Is 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, being personable without involving the ego. Someone who cares but do not take personal responsibility for everything. At the end of the day, all that transpasses, stays behind.
Joy and compassion – is the ultimate positive outcome between patient and care giver. Joy and compassion is achieved when you did a good job being empathetic and helped your patient and the 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 to someone’s suffering. This experience is a transformative for both patients and caretakers.
The ability to transform heavy and dense emotions into light ones. How can this be done? It will depend on the level of commitment to help others and the ability to be present and aware of difficult situations and the ability not to get our 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, you still vulnerable. There is a cumulative effect in dealing with emotions.
I consider myself to be tolerant to patient’s emotions. I can get involved as I need but I’m usually able to keep things separate. One day however I was down and I was tired. Mostly tired of seeing the same never ending drama.
One day 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. It felt that they 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 a difficult and traumatic events; that at certain point trigger a negative emotional response in the provider. This variety of stresses in the work place 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 the advance of technology we can extend the life of dying patients. But the outcome is the same; the patient end up perishing one way of 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. This also happens with countless procedures patients must endure when the outcome is known – the patient dies.
Unnecessary invasiveness – Is whey 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 with patients. Patients bring their personal and physical chaos to the RN and want it to be fixed immediately. As patients realize it will not play out so easily they threatened RN with law suits or calling the state.
Individual’s history – This is when your personal history of abuse and childhood trauma is triggered by the emotional stresses you see at work. For example a person who’s been sexually abused in the past might be particularly vulnerable if being stalked by patients. Anxieties from the past play a central role in stress development.
3 Ways to cope with compassion fatigue and burn out
#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 bother inquiring. 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 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 can fire them too. If you feel you’re being emotionally abused by your employer (and that is a harder problem to solve) you may also try to address this problem. The majority of people never try anything; they just complain to others in the break room.
The get off the runaway train concept also works if you can’t get out. You can pace yourself. You can take a day off; you can take breaks; you can knowledge 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 without leaving.
#2 Train yourself to handle emotional stress
Prepare mentally – People prepare to be a nurse for years; but there is often little preparation to handle psychologically stress. It is a simple skill but involves a lot of practice and determination.
One reason we have so much emotional stress, is because stress is a reflection of something we have inside. Because we are all human and can’t separate the suffering of others from our own. The proof of that is that we are much more affected when we ourselves, feel depressed or vulnerable.
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. 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, create friction and stress. The simple act of thinking of pain create pain. But what if we embrace it and get so close we can’t even see where we are. 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 and expecting improvements, but in many cases there is very little that can be done for these patients. To watch this unfold is can be very painful.
Whoever if there is full acceptance, the outcome may be somewhat better. I noticed the same principle 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 then a painful battle. We can apply these same principles of acceptance to our duty of being exposed to human trauma and unfortunate patient’s outcomes.
Prepare physically -Being physically prepared makes a big difference to you 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 the same frequency to avoid burn out. Remember, our 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 we can do. Tonglen means giving and receiving; and is the practice of being present to our suffering and the suffering of others. We must first get in touch with our own fears.
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. Following 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 breath out well purified white light energy. This is a 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 may types of meditation. However, with awareness meditation you focus on the breath. The idea is that you continually focus on something to remain in this present moment. The breath is good because it is as real as it gets. You know you are breathing, and there are several ways in which 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 a meditation focus because it link us to our present moment. Learn more about meditation.
#3 Discovering the joy of compassion
You have to find that spark in yourself. There is a joy in taking care of others. You might know it already but just need a refresher. It might be one of the reasons you went into nursing. But we forget due to so many technical aspects of the profession.
I don’t know what can bring you 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 you, you’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 the problems. We have to assume that all problems are our problems. Once you own the problems, their yours and now you can do whatever is necessary to take care of them. Don’t blame your boss.
Your boss might be more in trouble then 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 the system. We just have to sit with it.
Patient focused care
But there is a hidden gem in nursing, and you just have to uncover again. Nursing is all about other people and not you. And here is the solution to your problem. In nursing you have a great opportunity to get out of your head. The byproduct of focusing in the patient’s problem is 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)
- 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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