Book Review-Compassion Fatigue and Burnout in Nursing

I’m not a nurse, but I’m married to one. My daughter is also a nurse. If nursing could rub off onto someone, I’d be covered in it. That’s one of the reasons why I was so curious about what Compassion Fatigue and Burnout in Nursing had to offer to help me understand.

When Terri (my wife) was working in a pediatric intensive care unit, there were days I knew she would come home to go directly to our room, and I knew I needed to just hold her and let her weep. The things she saw were horrific. How she was able to face it day after day was beyond me. While I can’t say I understand compassion fatigue directly, I can understand some of the burden that is borne by healthcare workers trying to ease the world’s suffering.

I also understand burnout and largely see it as an overarching container that includes compassion fatigue as well as other specific types of burnout. While this view isn’t uniformly held, it’s one that many people agree with.

Compassion Fatigue

Compassion fatigue is the experience that workers sometimes get while caring for others who have experienced trauma. It happens in nursing and other workers who have care at the center of their lives. It’s sometimes called “secondary trauma,” because it’s the trauma suffered by people caring for those who experienced the trauma directly. However, care must be exercised to not minimize the trauma or dismiss it because it’s not primary.

Our egos are amazing things. They allow us to ignore the very real and present fact that we’re all vulnerable. We’re not nearly as powerful as we’d like to believe. Our psyches couldn’t cope with the idea that, at any moment, an asteroid could come raining down and destroy our lives as we know it. (See Change or Die for more along this line.) When you witness the harm that happens to others – particularly when that harm comes at the hand of other human beings – it forces you to confront your own vulnerability and recognize that there are many intentionally and unintentionally cruel people on the planet. The only way to blunt out these feelings is to stop caring about others. You can still care for their physical needs but disconnect emotionally to protect yourself. This is the heart of compassion fatigue.

Put Out the Fire

Burnout

Burnout, on the other hand, is a result of the gap between our expectations and our results. When we expect that we can do much and then see results that are not much, we’ll eventually experience this as burnout. Another way to think about burnout is as the exhaustion of our personal agency. (See Extinguish Burnout for more about these and other aspects of burnout)

For most caring professionals, the expectation is that they can prevent, alleviate, or heal the trauma that others experience. When the patients keep coming, it takes great strength to maintain the belief that you’re making a difference. When the traumatized doesn’t seem to be getting immediately better, the caregiver is faced not only with their own vulnerability but also the understanding that their expectation of their capacity to help others was likely very over blown.

Compassion fatigue is viewed as an acute event associated with the care of others, and burnout is more frequently viewed as a chronic condition that doesn’t have a precipitating event. However, burnout is often triggered by an event that causes someone to question the gap between their expectations and their results. In this context, it makes sense that compassion fatigue is a form of, and triggering factor for, a broader condition of burnout.

The Unseen Impact

Combatting burnout often means recognizing the impact we have that might otherwise be ignored or overlooked. The patients who get better don’t come back, so the only observations are that patients don’t get better. We begin to believe that what we see is all there is. (See Thinking, Fast and Slow for more on this.) The most prevalent image in our minds is the image of the person who didn’t recover and is back again.

Combatting compassion fatigue is a bit different. Our natural tendency will be for our ego’s defenses to attempt to “right the ship” and make us feel as if we’re more powerful than we are. However, this takes time, and when you’re bombarded by pain and suffering, it may not be possible for our egos and our faith in humanity to get a foothold. For that, we need to create space by focusing on the beauty, joy, and compassion in the world.

It’s easier said than done. But the more we can find comfort in the fact that most people are decent human beings, and few people face the kinds of trauma that caregivers witness every day, a sense of balance and normalcy can be regained.

Care and Compassionate Care

It’s entirely possible to do one’s role as a nurse and not care. The technicalities of the role can be learned and executed, like a robot making their millionth widget. However, that’s not the role of nurses – or any caregiver. The technical aspects of care are necessary but not sufficient to be a good nurse. Good nurses have a genuine concern for those in their care. They don’t become overly involved with the patient’s (and the family’s) needs, but they do adapt their way of working to maximize the things that are important to the patient and the family.

Without losing their own identity, they place themselves in the position of the patient and respond from a place of compassion – the same place that drew them to the career in the first place. Compassion is empathy – understanding another’s situation – and the desire to alleviate suffering. (See more about compassion in Sympathy, Empathy, Compassion, and Altruism.) When a caregiver suffers from compassion fatigue, they no longer have the strength to connect with someone – to understand them – and protect themselves from becoming overwhelmed with their circumstance.

As a result, the best care that nurses offer, the kind of care they all became nurses to give, cannot be done while experiencing compassion fatigue. Organizations are well served to identify and support nurses in resolving their compassion fatigue for better nurse retention and patient outcomes.

Moral Distress

If you want to find something that will steal the motivation and personal agency for someone, put them into a situation of moral distress. Moral distress is knowing the right thing but feeling as if you can’t do it. There are times when this moral distress is real, times when it is perceived, and, unfortunately, times when there should be moral distress but is not.

Shortly after the second World War, the world was asking how it was possible that so many German soldiers were able to assist with the mass extermination of Jews. Milgram devised an experiment where a test subject thought they were shocking another test subject –even when the shocks were presumed lethal. Milgram showed that many people could be coerced into these acts. (See Moral Disengagement and The Lucifer Effect for more on this set of experiments.)

For those cases where a nurse feels moral distress because of a difference in point of view, perspective, or diagnosis, the pain they feel is real. The organization (and the nurse) are missing an opportunity to understand the problem more fully so that the moral distress can be alleviated. In medicine, there’s rarely one right answer. The truth is that most patients are complex, and there are a variety of risk factors that the team navigates to try to return the patient to health. When the whole team – including the nurse – can openly discuss the challenges and agree upon a plan, the moral distress of some situations can be addressed.

There are, however, some cases of moral distress that are real. A surgeon won’t scrub up when walking into the operating room or picks up an instrument after it’s been dropped to the floor and continues to use it. Providers ignore nurses’ pleas for more pain medications or a different course of treatment for patients who are suffering. In some cases, nurses don’t feel as if they’ve got the opportunity to safely communicate their concerns, and that is their moral distress. (See The Fearless Organization for more about creating a culture of safety.) In other cases, even after a nurse voices the concern, they’re ignored or minimized. These are organizational challenges that eventually need addressed, or they’ll rip the organization apart.

Emotional Violence

Compassion Fatigue and Burnout in Nursing contains more than a few semi-related nuggets of information, including the revelation that emotional violence is still violence. While this may seem obvious, our world treats our words differently than our actions. “Sticks and stones may break my bones, but words will never hurt me” just isn’t true. Most of our hurts in the modern world come from words and the emotions they stir inside of us. While there’s a law against striking someone else, there’s nothing protecting us from a tongue lashing.

Emotional violence, or the words we say to each other and the non-verbal ways we communicate our disapproval with another person, are a form of violence that is all too often ignored. They’re the kinds of senseless attacks that we see around us and do nothing about. Left unchecked, they’re also one of the ways that we encourage Compassion Fatigue and Burnout in Nursing.

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