“The expectation that we can be immersed in suffering and loss daily and not be touched by nursing burnout is as unrealistic as expecting to be able to walk through water without getting wet and having nursing burnout” Remen
Nurses are routinely exposed to complex and traumatic situations. They are usually short-staffed, have increasingly sicker patients, face aggression, bullying, and angry bosses, and often lack support and appreciation. If you think this is an exaggeration, ask any nurse and see what they say.
Being a nurse demands toughness, intelligence, and flexibility to handle daily unpredictable and dangerous situations. Even though nurses are used to high stress, long-term exposure to these conditions can eventually cause burnout.
Burnout is a word we throw around casually but hides a harter to see complexity. Burnout can be just a common exhaustion due to work. But it could be hiding a more serious condition called emotional trauma, which is a more severe and debilitating invisible chronic condition known as PTSD.
We can divide nursing burnout into three categories
Burn out
Compassion fatigue
Vicarious traumatization
Burn out
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 emotion-free burnout; a person can be tired and overworked, but no emotions are involved. But emotions are sometimes beneath the surface without you or anyone else knowing.
Burnout can be defined as "a syndrome of emotional exhaustion," depersonalization, and reduced accomplishments that can occur among individuals who do people's work. [6]
Burnout affects some individuals differently according to their personalities. Stress levels are higher for some due to their predispositions. Researchers have developed five personality types to illustrate this point, called the big five [21].
Compassion fatigue
Compassion fatigue can also be called secondary traumatic stress, characterized by a “natural behavior and emotions resulting from knowing about a traumatizing event experienced by a significant other."
The stress results from helping or wanting to help a traumatized or suffering person [2]. Compassion fatigue affects nurses, doctors, psychiatrists, mental health workers, and EMTs. It can last a few days or be a chronic problem. Most studies agree that it is a phenomenon born out of the therapeutic relationship between the patient and health care provider. The suffering and trauma experienced by the patient trigger a multi-level response in the provider.
Those who possess a greater capacity for caring and feeling and the ability to have empathy tend to be more at risk of suffering from compassion fatigue.
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.
A model based on six elements was suggested to help us better understand compassion fatigue's complexities [9, 10]. These six elements relate to personal attitudes, individual responses and skills, and personality traits, helping 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 can put themselves in the other person's shoes. This is called empathy, a skill that allows us to get in touch with the trouble of others as if they were our own. Empathy is the ultimate form of assessment because by understanding how others feel, you can determine their true needs. People choose health care as a profession because they care about others in some way or another. Your ability to connect to your patients is important, and it should allow for better therapeutic outcomes.
Emphatic response - 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 to our sense of duty to others.
The ability to have empathy doesn't necessarily mean that we are using it wisely. Nor does it mean that having an emphatic healthcare worker will translate into better patient care. Being exposed to raw emotion from patients is a volatile 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 on patients and providers, bringing us to our next element.
Residual compassion stress - When a provider is genuinely interested in a patient's well-being, he/she opens the doors of communication. There has to be openness where energy is free, unstable, and raw. To understand others, we have to hang out outside our comfort zone. Few individuals possess the skills to handle this situation well without accumulating residues.
Residual stress aggravated by certain personality types is called "the savior type syndrome." These individuals feel personally responsible and think that the suffering of others has to be resolved. They get involved on a highly personal level and are most at risk of developing stress due to a "carrying the world on their shoulders" attitude.
Halting compassion fatigue - is identifying its triggers and resolving 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 have an automatic system that shuts off the tendency to be sucked into the emotional vortex. Visualizations or affirmations include: "When I put the scrub, I'm a different person, and I'm not affected by anything."
Resilience and hope - This 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's pain and suffering into a positive energy. This stage requires deep understanding and awareness. It requires a person to be fully present, engaged, and personable without involving one's ego. Someone who cares but does not take personal responsibility for everything. All that transpasses stays behind at work and doesn't create residues.
Joy and compassion - This is the ultimate positive outcome for patients and caregivers. Joy and compassion are achieved when you do an ultimately good job of being empathetic; the result is joy. That is, you 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, your ability to be present and aware in difficult situations, and your ability not to get the ego involved.
Vicarious traumatization
It can be seen as all other emotional traumas caused by an array of demanding situations created by patients and their problems, workplace, and job requirements. Vicarious traumatization is usually associated with long-term exposure to challenging and traumatic events that, at a certain point, trigger a negative emotional response in the provider.
This variety of stresses in the workplace often resonate with an 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 factors 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. However, the outcome is the same: the patient ends up perishing in one way or another. Vicarious traumatization happens when a nurse witnesses 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 is certain - the patient will die.
Unnecessary invasiveness - This 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. , unnecessary colonoscopies, lab exams, and unnecessary medications.
Abuse from patients - Today, nurses suffer from a stream of abuse from patients. Assault, verbal abuse, stalking, and a general lack of respect and appreciation. Behavior is one of the most challenging aspects of stress related to patient care. Patients bring personal and physical chaos to the RN and want it fixed immediately. As patients realized this scenario would not play out so quickly, they threatened RN with lawsuits or called the state to voice their grievances.
Individual 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 being traumatized if being stalked by a patient. Anxieties from the past play a central role in stress development.
Five personality traits helping healthcare workers cope with patient care-related stresses
Neuroticism
Extroversion
Openness to experience
Agreeableness
Conscientiousness
These personality types are further affected by two variables
Work-related attitudes
Nurses who foster false expectations or unrealistic health outcomes for their patients can be more vulnerable to emotional stress than others. For example, they can become emotionally affected if the patient doesn't get well as the RN expected. Another example is the nurses' vision, values and beliefs which include philosophy of care. These concepts may also not play out as planned, leading to frustration and burnout.
Work-related characteristics
This relates to the individual's inability to control an 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. Other overwhelming job-related stresses are inherent to nursing and beyond 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
Numbers 1 - 2 fall 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 getting sicker and more acute, or nursing being a hard job, plain and simple. Such conditions are usually easier types of stress to cope with. In a sense, they are inevitable and will always exist along with the profession; therefore, they are accepted as part of the job. However,
3 - 4 are man-made and tend to be more harmful and capable of causing emotional damage to nurses. For example, due to workplace restructuring, 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 management's insensitivity, which sees nurses as simple workers with no regard for their hard work and emotional stress loads.
The lack of support and empathy from employers bring a far more damaging stress than natural causes 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. These conditions can be evidenced by the emergence of several side effects secondary to stress, which, in turn, lead to further burnout. These are:
Lack of sleep
Poor diet
Interference with personal life
Poor pay
Lack of appreciation
Poor management
Three 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 it altogether. Yes, whenever possible, remove yourself from stressful situations. This may not always be possible, but most people don't think of alternatives. Use the get off the runaway train approach. If a train is coming your way, you don't think—you get out of the way.
The same principle applies to everything in life, including stress in nursing. Don't expose yourself to danger unless there is no other option. For example, If you're assigned an aggressive patient and he is causing you emotional stress, switch this patient to another nurse. This is commonly done.
Patients can fire you, but you have the right to refuse care in some instances. Remember that you also have the right to refuse care if you find yourself being abused by a patient or by your employer, for that matter.
Most people never try this strategy; they complain to others in the break room or push through and hope the problem will disappear. The get off the runaway train can be done even if you can't get out of the way. You can pace yourself. You can take a day off, take breaks, call in sick, acknowledge that a situation hurts you, and admit it to yourself will make a difference.
#2 Train yourself to handle emotional stress
It takes years to prepare to become a nurse, but there is often little preparation to handle psychological stress. Training involves practice and determination. Usually, emotional stress reflects something we already bring with us.
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, keep an emotional distance, but other times, it 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.
We usually create the discomfort and fear we experience 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 can see that we are 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 regarding adverse outcomes. Patients have dire situations, deteriorating health, and an unfavorable prognosis. They come to us expecting improvements, but little can be done for these patients in many cases.
To watch this hopeless situation unfold 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 life 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.
Being physically fit—Being physically prepared significantly affects your ability to handle stress. If your body is weak, everything becomes a burden. Studies have shown that intense physical activity stimulates the brain in many ways. I recommend exercising vigorously and with frequency to avoid burnout. Remember, your mind and body are the same: a strong body, a strong mind.
Practice Tonglen [17] - Tonglen is one of the richest and bravest practices you can apply in healthcare. Tonglen means giving and receiving, and it 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 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 others' overwhelming suffering.
What comes next is our willingness to transform fear and alienation into compassion through mercy and the cultivation of openness. The practice of Tonglen is quite simple. The practice consists of sitting beside a suffering person and practicing breathing. You breathe in all the heavy and tarry black sooty pain first. On exaltation, you 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 hear your breathing. Ultimately, your breath is your life. So, using the breath as the focus of your meditation is a great idea because it links us to our present moment. Learn more about meditation.
#3 Discovering the joy of compassion
Find that spark in yourself. There is joy in taking care of others. You might know this already, but you need a refresher. But we tend to forget about joy because we get burned out. When you put others first, you feel good; focusing on yourself makes you feel miserable.
The only person getting irritated is yourself. There is no irritation outside yourself. There is just work to be done. We want to see what's in for us. You have to take charge of your problems. You have to assume that all problems are our problems. Once you do that, you will be in charge.
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 her boss yells at her even louder than she yells at you. The system is broken, and you are not going to fix it. You have to sit with it.
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References
Photo by Ron Lach
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