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Sierra is glad her days off have finally come. She loves being a nurse, but after working two years on the oncology unit, the pressures of changing shifts, frequent understaffing and late stays to finish paperwork are taking their toll. Sierra frequently feels tired, and the attitudes of coworkers irritate her. But she knows she will be refreshed and ready to face work again after her vacation at the beach.
Eric, out of school five years, is feeling comfortable with his role as a staff nurse on a busy step-down unit, as well as with the charge position he took on weekend shifts. However, the days off that used to bring Eric back to work ready to give his best don't refresh him anymore. He enjoys work, but seeing people with severe cardiac disease bothers him. He is angry at his patients for what he perceives to be their increasingly demanding natures or unwillingness to make lifestyle changes. Although his friends are supportive and listen to his frustrations, talking with them isn't as helpful as it used to be.
Rita just can't shake the fatigue, sadness and emptiness that consumes her waking hours. When she first started working on the emergency room trauma team, it was exciting responding to emergencies. Now, as the patients come in, it almost feels as though she's being injured. Sometimes she wakes up after dreaming that she hears cries of pain or sees patients' and family members' agonized faces in her sleep. Rita knows she is one of the best nurses on the unit, but feels that if she would learn more, try a little harder and think faster she could decrease the patients' suffering. She wishes she could be like some of her coworkers who seem to numb their feelings and remain focused on the technical aspects of what needs to be done.
Do you relate to these nurses' experiences? What actions would you recommend to Sierra, Eric or Rita? Does God offer help for these problems? If these scenarios describe you, what can be done to help you feel better?
In these vignettes, two of the nurses suffer from compassion fatigue, whereas one is experiencing burnout. What is compassion fatigue and how is it different from burnout?
The work of nursing involves experiencing stress from numerous sources: workload, coworkers, organizational stress and emotional pain on behalf of our suffering patients. Nurses interact with various personality types, deal with assistive personnel and often work long shifts, all while striving to give excellent care in a "do more with less" environment. Is it any wonder nurses experience the negative effects of stress?
Nurses have talked about being "burned out" for years, but in the past decade, the term "compassion fatigue" has arisen. The term was coined in 1992 to describe the level of burnout experienced by nurses and physicians worn down by caring for patients in posttraumatic stress disorder clinics and emergency rooms.1 The terms "burnout" and "compassion fatigue" are being used in a variety of ways and with some disagreement. Some say compassion fatigue is a form of burnout, whereas others insist that the term has replaced burnout and means the same thing. Others suggest that compassion fatigue refers to a type of secondary posttraumatic stress disorder, and that it is entirely different from burnout. As a different disorder, compassion fatigue is considered to be a more complex problem that stems from working in a difficult work environment with patients who have debilitating or serious illness or trauma.
Compassion is an emotion whereby we enter into the world of the client, become aware of his suffering and, upon feeling his pain, take action to ease it. Compassion is defined as a "feeling of deep sympathy and sorrow for another who is stricken by suffering or misfortune, accompanied by a strong desire to alleviate the pain or remove its cause."2 Although the ability to be compassionate and have empathy is a desirable quality that contributes to establishing trust and therapeutic effectiveness with patients, it is exactly this sensitivity that makes nurses vulnerable. Over time, compassion can exact an emotional toll.
Compassion fatigue describes the emotional, physical, social and spiritual exhaustion that overtakes a person and causes a pervasive decline in his or her desire, ability and energy to feel and care for others. Such fatigue causes the sufferer to lose the ability to experience satisfaction or joy professionally or personally. Compassion fatigue is not pathological in the sense of mental illness, but is considered a natural behavioral and emotional response that results from helping or desiring to help another person suffering trauma or pain.3
[white square] Is a complex problemresulting from helping others who are suffering.
[white square] Results in psychological, physical, social and spiritual symptoms; decreased productivity and increased errors.
[white square] May be resolvedby self-help strategies, but higher levels require professional intervention.
[white square] The Bible offers principlesto help us recover from compassion fatigue.
An analysis of the definitions and descriptions of burnout and compassion fatigue suggests three responses to work stress that I label burnout, compassion fatigue level 1 and compassion fatigue level 2.
Burnout has been associated with the routine hassles of nursing work such as dealing with time pressures, managing complex patient loads or coordinating care with other departments and team members. This condition reminds us of a candle that goes out because the wax has been used up. We say the candle is "burned out." Similarly, we refer to the grass in our lawn as being burned out in late summer due to the stress of high heat and decreased rainfall. Situations in which nurses experience powerlessness, frustration and difficulty in meeting personal and professional expectations can lead to burnout. Burnout can be experienced by anyone, but in nursing it is seen as a predictable phenomenon that results from the intensity and conditions of our work. Nurses who are burned out usually become less empathetic to their patients and display negative behaviors toward coworkers. As a less complicated response to the demands of nursing, making changes in the work environment, taking a vacation or changing jobs can help the nurse with burnout to recover.
Compassion fatigue level 1 (CF-1) occurs when we closely identify with the patient and personally absorb the patient's trauma or pain. Compassion fatigue is a response to the people who are suffering rather than to the work situation. It does not result from being busy, but from giving high levels of energy and compassion over a prolonged period to those who are suffering, often without experiencing the positive outcomes of seeing patients get better. Nursing care situations that contribute to CF-1 include a high turnover of patients who are acutely ill, rotating shifts and changing job assignments. Those working in crisis-oriented venues such as emergency or trauma centers seem most vulnerable. As a result of CF-1, nurses become emotionally drained, experience stress-related illnesses and eventually leave the profession if the condition is not addressed. Whereas nurses with burnout adapt to their exhaustion by becoming less empathetic and more withdrawn, compassion-fatigued nurses continue to give themselves fully to their patients, finding it difficult to maintain a healthy balance of empathy and objectivity.4
The nurse with compassion fatigue level 2 (CF-2) has the same responses as the nurse with CF-1, but in addition may reexperience traumatic events through the descriptions of the patient, in experiences similar to "flashbacks." Because of this reexperiencing of trauma, the individual experiencing CF-2 attempts to shield him- or herself through avoidance or addictive behaviors. Because of its similarities to posttraumatic stress disorder, CF-2 has been called secondary posttraumatic stress disorder, secondary stress disorder and secondary victimization. Whereas some nurses with CF-2 may withdraw emotionally from patients, coworkers and even their families, others continue to give emotionally despite feeling that they are losing their sense of self. Depression and constant autonomic arousal are common outcomes.5
Anyone who works in a difficult work environment is at risk for burnout, whereas healthcare professionals who regularly observe or listen to experiences of fear, pain and suffering are at risk for the development of compassion fatigue. It is no surprise that compassion fatigue is a job hazard for rescue workers providing aid after natural or man-made disasters. Compassion fatigue can be experienced by people giving daily care to an acutely ill or dying family member, especially because the caregiver is highly vulnerable to the patient's pain while experiencing his or her own feelings of loss and helplessness.6 Sierra's situation typifies burnout, whereas Eric exemplifies CF-1 and Rita illustrates the depths of CF-2.
Note that the presence of burnout places nurses at greater risk for the development of compassion fatigue. Stress theory asserts that the longer a stress occurs or the greater the number of stressors at any one time, the more severe the impact of stress on an individual. In the same way, the occurrence of multiple and enduring stressors increases the risk for compassion fatigue. Furthermore, multiple life stressors outside of work compound work-related stressors, impacting the development of burnout or compassion fatigue.7
Specific indicators of compassion fatigue vary, but include physical, psychological, social and spiritual symptoms (Table 1). Checklists and surveys have been developed to assess compassion fatigue and burnout, such as the Compassion Satisfaction-Fatigue Test, the Secondary Traumatic Stress Scale and the Maslach Burnout Inventory. These surveys are helpful for diagnosing and treating compassion fatigue because they document the presence of symptoms. However, no reliable, valid test exists for accurate measurement of compassion fatigue. Existing instruments are limited because they target a specific subset of healthcare workers (i.e., mental health, social work) or have serious psychometric limitations.8 Clearly, more research is needed to understand and measure this concept.
When compassion fatigue occurs, it not only inflicts great emotional pain on the sufferer, but also leads to a decline in job performance and efficiency and a rise in mistakes. As nurses with compassion fatigue continue to work in their toxic state, they can disrupt the morale of the unit. Personal relationships are affected at work and at home. Depending on the severity and duration of the situation, emotional and physical health may decline.
A significant organizational outcome of compassion fatigue is that sick days are used more frequently in relation to anxiety, depression and stress-induced physical illness. Additionally, nurses with compassion fatigue change jobs within healthcare, leave nursing for another type of work or leave the workforce completely. When the costs of lowered productivity and increased sick leave combined with educating, orienting, or replacing nurses are considered, compassion fatigue becomes an important workplace concern. Finding relief can help nurses give appropriate and effective nursing care, remain in their jobs longer and contribute to a more positive work environment.9
When does work stress become significant, and at what point should we do something about it? If you can trace your stress to work conditions, time pressures, personalities and the fatigue of expending physical energy, you probably are dealing with burnout. Taking a few days off or seeking resolution in the work situation should help you feel better. However, if you find that you are not recovering quickly after dealing with trauma, that stress experienced by patients affects you and that you feel an increasing sense of hopelessness, vulnerability or being overwhelmed, you may be experiencing compassion fatigue.
Because compassion fatigue affects the whole person, treatment includes strategies that speak to each dimension (Table 2). These strategies treat compassion fatigue and help to prevent or lessen the severity should it develop. The prevention and treatment for all levels of compassion fatigue are similar, whereas recovery time varies according to the person and the severity. Lower levels of the condition may be resolved with self-help strategies and support from family and friends. However, because depression and secondary traumatic stress disorder are potentially serious problems identified in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed (DSM-IV),10 those experiencing more severe levels of compassion fatigue should obtain professional help.11
As with other problems, prevention is better than intervention. However, the nature of the work nurses perform may make prevention of compassion fatigue impossible. Daily practice of good physical and emotional health maintenance can lessen the impact of compassion fatigue. Place yourself in situations that allow you to see the positive aspects of life, such as volunteering in the church nursery (if you enjoy babies) and maintaining a place in which you are receiving rather than giving. Joining a small group or participating in Sunday school or a special interest group led by someone else is a way to find places that put you on the receiving end of care.
General guidelines for compassion fatigue recovery involve basic strategies of a healthy lifestyle. But although nurses know what should be done, making the decision to change or establish new habits can be challenging. The desire to change needs to be stronger than the discomfort of making the adjustments. The key to recovering from compassion fatigue is to focus on self in a healthy way so that you are appropriately sensitive to others' needs.
Like an advanced practice nurse or physician who writes a prescription to treat illness, God prescribes treatments for compassion fatigue. Because God created us (Gen 1:27), he knows what will bring healing. In fact, it is precisely by growing spiritually in relationship with God that true healing and resilience are activated. God reveals his prescriptions through the Bible. Following these prescriptions helps us to prevent compassion fatigue, lesson its severity or find healing.
To help make the connection between our problems and God's solutions, scripture frequently uses metaphors. For example, God used water as visual aid to help the Israelites understand deeper spiritual truths. When the people were following God and keeping his covenant, God promised blessing in the form of flowing water and abundant produce from fields and gardens (Is 58:11). Those who delight in and seek God are described as trees planted by streams of water. Their leaves never wither. They bear fruit in season, and they prosper (Ps 1:1-3). Jesus referred to himself as "living water" (Jn 4:10-11, 7:38) because it is through him that God's blessing are received.
On the opposite end of the spectrum, when the Israelites turned away from God, he allowed a lack of rain, resulting in drought and famine (1 Kings 18). God used the literal burnout of the land to illustrate the spiritual dryness and death that comes from not choosing to follow his ways and live under his blessing.
The biblical principles that follow are based on metaphors from scripture and two additional symbols, those of a prescription and a teacup. The teacup represents the nurse's life as created by God. Like an exquisite collector-quality teacup, our lives have a beautiful form and purpose. Isaiah 64:8 proclaims, "Yet, O Lord, you are our Father; we are the clay, and you are our potter; we are all the work of your hand."
The biblical principle of removing is found in Exodus 12. There, God instructs the Israelites to remove all the yeast from their houses in preparation for their new beginning as a free people in covenant relationship with God. Why? Yeast represents sin in scripture, such as hypocrisy (Mk 8:15; Lk 12:1) malice and wickedness (1 Cor 5:8). When Jesus healed, he often removed evil spirits, then instructed people to walk in a new way of life (Mk 5:12-19). Jesus instructed his twelve disciples to follow a similar pattern (Mt. 10:1).
These scriptures suggest removing what's inside that is contributing to the problems. We don't want to drink out of a teacup filled with yesterday's tea. Likewise, we need to empty the old stuff inside because God cannot fill us if we are full of other things.
What must we do to empty our cup?
* 1. Clarify the situation. Pray, asking God to show you the source of your struggle and what's bothering you (Ps 139:23-24). Determine negative factors such as resentments, bad attitudes, anger, personality conflicts, jealousy, fear or ways of thinking life should have worked regarding children, spouse, home or career, or for our patients.
* 2. Express frustration appropriately. We can pour out frustration and despair to God, just as we hear King David doing in the Psalms, for example, Psalms 28, 32 and 38. In these passages, David speaks plainly to God about his frustrations and how he felt abandoned, using the principle of lament or crying out. We note David complaining woefully, but then we see a change as he acknowledges that God has heard his cries. Often he closes with an entirely different attitude-one of victory and strength.Note that complaining does not remove or change our circumstances, but rather expends energy. Sharing concerns with professional counselors who can provide objective feedback or seeking appropriate means for communicating systemic problems is an appropriate strategy for expressing frustrations. Praying with coworkers for patients who are suffering or praying to experience satisfaction in caregiving are also appropriate.
* 3. Forgive others. It is crucial to forgive others for real or perceived offenses (Mt 6:12-15). Jesus commands us to forgive as often as it is needed (Mt 18:21-35). Pray and ask God to help you forgive, purposing in your mind and heart to forgive and telling yourself you are forgiven. Begin praying for those who have hurt you (Mt 5:44-48), remembering that if judgment is needed, God will take care of it (Rom 12:19). Asking God for his compassion, for the faith needed to forgive and for the strength to keep going opens our hearts to his transforming power.Helpful techniques in forgiving others are to imagine how the situation might look from their perspective. What might they have been trying to do, albeit with misguided motives? Did they act out of ignorance or emotional neediness? Ask God to help you view others from his perspective rather than your own. Remember, others are created in the image of God just as you are. Ask yourself what right you have to hold on to condemnation if God is willing to forgive them?
* 4. Deal with pride and self-focus. Pride manifests itself in varying ways such as self-pity, a critical spirit, fear, comparison or envy. Unfortunately, many times we are not aware that pride is at the root of our negative feelings (Obad 1:3), so we blame others, when actually it is our response that is unhealthy. Prideful attitudes result from not trusting God to care for us. We therefore feel the need to establish our honor and worth. If you recognize this in yourself, confess this attitude and then focus on God-who he is, his character and his relationship with you. Seek his mind, his pleasure and his desires. Lose your life to God in order to save it (Ps 37:3-6; Jn 12:24-26).
The pain for others that is at the core of compassion fatigue also needs to be emptied out of our cup. We are offered the opportunity to cast all of our anxiety on Christ because he cares for us (1 Pet 5:7). God tells us not to worry about anything, but to tell him our needs about everything. Then the peace of God, which surpasses all understanding, will guard our hearts and minds in Christ Jesus (Phil 4:6-7). Begin to pray about your pain and ask God to help you. He sees all the pain and suffering in the world, understands our pain completely and promises to help us as we turn to him (Heb 4:15-16).
Not only do we want to remove the harmful stuff from our teacups. We also want be clean-fresh and transformed (Mt 23:25-28; Heb 9:13-15; 2 Tim 2:20-22). We can resolve to change our responses and behaviors, but ultimately, supernatural restoration, forgiveness and transformation are needed for us to be truly free (Rom 12:2; 2 Cor 3:18). Cleansing involves receiving forgiveness from God, self and others.
Receiving forgiveness from God means we identify our faults and then confess our shortcomings to him. Instead of self-condemnation, confession is agreeing with God that these responses are wrong. We claim God's forgiveness because he said he would forgive (1 Jn 1:9) and remember our sins no more (Heb 10:15-23). Forgiving self can be especially pertinent to the nurse who is overwhelmed by compassion fatigue. We are freed to forgive ourselves because scripture tells us there is no condemnation for those who are in Christ Jesus (Rom 8:1). Sometimes we need to ask forgiveness from others, offering heartfelt apology and making things right to restore the relationship. Even if forgiveness is not extended, you have done what is right (Mt 5:23-24).
Those of us in helping professions often have so many demands on our time that we neglect our physical and emotional needs. As Christians, we are called to offer our bodies as living sacrifices, holy and pleasing to God, as an act of worship (Rom 12:1-2; 1 Cor 3:16). Three aspects of renewal are physical exercise, good nutrition and healthy patterns of rest and work. As nurses, we know about exercise and nutrition, but do we know that rest is part of God's plan? (Gen 2:1-4; Ex 20:8-11). Rest includes not only adequate sleep, but also taking time to abstain from work, doing relaxing or enjoyable activities and engaging in regular times of devotion to God (personal quiet time, worship, retreats). To achieve adequate rest, we must set boundaries on our commitments. Jesus also tells us to come to him for rest, learning from him, and asking him to help us with our work (Mt 11:28-30).
Scripture repeatedly addresses our being filled by God, for example, with joy (Ps 4:7, 16:11), satisfaction and good things (Ps 107:8-10) and righteousness (Mt 5:5-6). We are to be filled with the Holy Spirit (Eph 3:19), actively developing a relationship with God through time with him-personally and corporately-in Bible study, prayer, meditation and worship. This type of spiritual renewal results in the continual refilling of our emotional and spiritual reserves. Seek to maintain relationships with others who have common faith through church and groups such as Nurses Christian Fellowship.
To defeat the effects of stress, replace destructive and stressful choices with habits that are satisfying and renewing. Creative pursuits are a good filling activity, dissipating stress hormones and helping us to express emotions we might not be able to articulate. Producing something useful or beautiful enhances self-esteem and can cause secretion of positive hormones such as serotonin and endorphins. Using God-given gifts facilitates satisfaction and a sense of well-being.
Serving others would seem to be a further drain, but believing that God's love flows through us as we serve can be a life-giving step of recovery. The difference is in becoming a conduit of God's love and compassion, not just emptying our personal reserves.
When Elijah was compassion fatigued and running for his life (1 Kings 19), God validated his value and purpose by sending him out again to appoint new leaders. The Apostle Paul told the Galatian church that their freedom was not for self-indulgence, but rather for serving one another in love (Gal 5:13). Serving others in ways God asks of us is not a burden or obligation. This type of serving replenishes inner reserves because it is a part of fulfilling God's purpose, bringing joy rather than depletion (Eph 2:10).
An essential aspect of serving is humility, honoring one another and not considering self more highly than is appropriate (Phil 2). Jesus Christ is the prime example of humility because although he was God, he became human to provide the way for us to connect with God.
Expected outcomes of resolving compassion fatigue are personal fulfillment, peace, purpose, renewed physical energy and decreased negative impacts on family and social life. Professionally, compassion-restored nurses return to giving effective and appropriate nursing care, contributing to a positive work environment and finding increased job satisfaction. If you or a colleague is suffering compassion fatigue, don't hesitate to seek help. Restoring your compassion is worth the difficult journey toward recovery.
Continuing the illustration of examining our teacups, after following these biblical prescriptions, we see that when negative attitudes are removed and our hearts are cleansed through God's grace, then filled with the Holy Spirit, we are renewed. The renewal we experience overflows into the lives of our patients and coworkers. Scripture teaches a principle of overflowing out of the heart that can be from evil or good (Lk 6:45). When we have a relationship with God, by the power of the Holy Spirit, there can be an overflowing of hope (Rom 15:13), comfort (2 Cor 1:4) and thanksgiving (2 Cor 4:15)-all for God's glory!!
* America's Continuing Education Network. Compassion Fatigue: The Stress of Caring too Much - http://www.ace-network.com/cfspotlight.htm#WhatIs%20CF.
* Compassion Satisfaction and Fatigue Test - http://www.isu.edu/~bhstamm/tests/satfat.htm.
* Academy of Traumatology. Traumatology Journal - http://www.traumatologyacademy.org/index.htm.
1 Brenda M. Sabo, "Compassion Fatigue and Nursing Work: Can We Accurately Capture the Consequences of Caring Work?" International Journal of Nursing Practice 12, no. June (3 2006): 136-142. [Context Link]
2 Webster's Encyclopedic Unabridged Dictionary of the English Language (NY: Gramercy Books, 1989), 229. [Context Link]
3 Charles R. Figley, Compassion Fatigue: Secondary Traumatic Stress Disorders in Those Who Treat the Traumatized (New York: Routledge, 1995) and Charles R. Figley, "Catastrophes: An Overview of Family Reactions," in Stress and the Family: Coping with Catastrophe, eds Charles R. Figley and Hamilton I McCubbin, 3-20 (New York: Brunner/Mazel, 1983). [Context Link]
4 Ibid. [Context Link]
5 Ibid. [Context Link]
6 Charles R. Figley, Treating Compassion Fatigue (New York: Brunner-Routledge, 2002). [Context Link]
7 Ibid. [Context Link]
8 Sabo. [Context Link]
9 John-Henry Pfifferling and Kay Gilley, "Overcoming Compassion Fatigue." Family Practice Management 7, no. 4 (April 2000): 39-46. Accessed May 14, 2006 at http://www.aafp.org/fpm/20000400/39over.html. [Context Link]
10 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (Washington DC: APA, 1994). [Context Link]
11 Pfifferling and Gilley. [Context Link]
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