When Compassionate Care Takes A Turn Toward Fatigue

By Jennifer Flynn, Risk Manager, Nurses Service Organization & Mary M. Gullatte, PhD, RN, ANP-BC, AOCN, FAAN, Corporate Director of Nursing Innovation and Research for Emory Healthcare

Fatigue, emotional distress, or apathy resulting from the constant demands of caring for others: today’s nurses are facing new levels of compassion fatigue. Empathetic, passionate, and caring nurses can fall victim to the continual stress of meeting the needs of not only their patients but their families as well. This can pose serious safety concerns on two sides of the spectrum. It can lead to errors and issues in patient care, and overall nurse burnout can drive more skilled nurses out of the profession.

According to the American Association of Colleges of Nursing, 13 percent of newly licensed RNs were working in a different career within one year of their licensing, and 37 percent indicated they were ready to change jobs. Lack of staffing, trouble with management or salary issues aren’t the only things pushing nurses from the bedside. Significant, ongoing emotional stress is a key contributor that can often go ignored.

Defining the Issue

Multiple terms have been used to describe compassion fatigue, but in its simplest terms, compassion fatigue implies a state of psychic exhaustion where caregivers face severe sense of malaise that results from caring for patients who are in distress over time. Traumatology expert and senior faculty at the Figley Institute, Dr. Charles Figley calls this phenomenon the “cost of caring” for others in emotional pain.

While all healthcare providers are subject to compassion fatigue, nurses are particularly vulnerable because they are inserted in the lives of others in an intimate way during a critical time in that individual’s life. They become partners instead of observers in a patient’s journey and are pulled into existential concerns of life, death, sadness, and loss. In this regard, compassion fatigue could be considered an occupational hazard. Statistics Canada’s first-ever National Survey of the Work and Health of Nurses (2005) found that “close to one-fifth of nurses reported that their mental health had made their workload difficult to handle during the previous month.” In the year before the survey, more than 50 percent of nurses said they had taken time off work because of a physical illness, and 10 percent had been away for mental health reasons.

Dennis Portnoy, a licensed psychotherapist who specializes in topics such as professional burnout and compassion fatigue, created a self-assessment tool that caregiving professionals can use to recognize attitudes and habits that perpetuate compassion fatigue. According to Portnoy, nurses who are experiencing compassion fatigue tend to identify very strongly with statements such as:

• “People rely on me for support.”
• “When I make a mistake, I have difficulty forgiving myself.”
• “My achievements define my self-worth.”
• “I take work home frequently.”
• “I am willing to sacrifice my needs in order to please others.”

Not to be confused with “burn out”, where a nurse may gradually withdraw and step away from his or her work, a nurse with compassion fatigue may try even harder and give even more of themselves to patients in their care. Both scenarios can leave nurses feeling like they are running on empty, putting themselves, their co-workers, the public, and their patients at risk.

The Consequences of Compassion Fatigue

Nurses have a responsibility to themselves and their patients to ensure they’re adequately supported to provide the highest quality and compassionate care possible. Facing multiple workplace stressors, coupled with the demands to respond to complicated patient needs as well as their home life, can negatively impact a nurse’s ability to cope with stress to the detriment of overall patient and nurse safety.

The consequences of such involved, caring work can lead to:

• Inability to react sympathetically to a crisis or disaster because of overexposure to previous crises and disasters.
• Extreme states of tension and preoccupation with the suffering of those being helped to the degree that it can be traumatizing for the helper.
• Cynicism, emotional exhaustion or self-centeredness in a healthcare professional who has been otherwise dedicated to his or her work and clients.

This emotional exhaustion also can cause breakdowns in communication and build stress that leads to errors by the nurse, which pose safety risk and liability. According to the CNA AND NSO Nurse 2015 Claim Report, allegations against nurses involving assessment and monitoring represent 15.7 percent and 13.8 percent of total claims, respectively.  Compared to the previous data set, both allegations categories increased by 3.1 percent and 7.0 percent, respectively. Most of the assessment-related closed claims involved a failure to assess the need for medical intervention where the nurse failed to contact the treating practitioner for additional medical treatment. Over half the monitoring-related claims involved failure to monitor/report changes in the patient’s condition to the practitioner.

Compassion fatigue expert Francoise Mathieu writes that many factors outside of a nurse’s core care-giving work also contribute to the continuum of compassion fatigue. Current life circumstance, coping style and stressors at home from childcare or aging parent care all play a role. Some studies show that “helpers,” such as nurses, are more vulnerable to life changes such as divorce and difficulties such as addictions than people who do less stressful work. Workplace stressors such as managing paperwork, new technology or organizational realignment can also play a role.

Although nurses are accountable for their individual practice, employers also have a responsibility to help identify and address sources of compassion fatigue in the workplace. Designing schedules and organizing work can be key strategies to help prevent the consequences of nurse fatigue, but early identification of compassion fatigue demands understanding and ongoing assessment. The Professional Quality of Life Scale (ProQOL) can help measure these symptoms and be used regularly to track changes over time, particularly when a nurse is trying prevention or intervention strategies.

Long-Term Solutions

Compassion fatigue and its negative impact on nurses, patient satisfaction and safety is slowly becoming a better understood phenomenon in the nursing field. Acknowledging the severe emotional impact of a nurse’s obligation to routinely meet a patient’s immediate and comprehensive needs, nurses are in need of more specialized support resources to counter the impact.  These can and should involve programming designed to educate nurses about the issue, resources to manage work/life balance and efforts to design supportive and positive work settings.

Promoting self-care and other healthy rituals is important for preventing or recovering from compassion fatigue. Encourage nurses to participate in activities that can promote physical, emotional and spiritual well-being. Nurses should also be encouraged to seek out support in the form of Employee Assistance Programs (EAPs), caregiver or nursing support groups, or other forms of counseling and emotional support. Remember that self-care always includes adequate nutrition, hydration, sleep and exercise.

The responsibility to solve for these risks relies with the healthcare industry as a whole, as well as management and nurses in the field to foster the environment and demand the resources necessary to overcome the issue.

About the Authors

Jennifer Flynn, CPHRM, is Risk Manager for Nurses Service Organization in the Healthcare division of Affinity Insurance Services, Inc. specializing in risk management. With more than 16 years’ experience in the healthcare insurance business, Jennifer is dedicated to educating healthcare professionals on professional liability risks and offering strategies to mitigate those risks. For more information, please visit www.nso.com. 

Mary M. Gullatte, PhD, RN, ANP-BC, AOCN, FAAN, is the Corporate Director of Nursing Innovation and Research for Emory Healthcare and the former Vice President of Patient Services and Chief Nursing Officer at Emory University Hospital Midtown. She holds an adjunct faculty position at the Nell Hodgson Woodruff School of Nursing at Emory University. Dr. Gullatte holds professional memberships in Oncology Nursing Society, American Nurses Association, and Sigma Theta Tau. She is a current member of the advisory board for Nurses Service Organization and serves on the Nursing Advisor Board to the Joint Commission.

This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to service@nso.com or call 1-800-247-1500. www.nso.com.

This article is provided for general informational purposes only and is not intended to provide individualized business, risk management or legal advice.  It is not intended to be a substitute for any professional standards, guidelines or workplace policies related to the subject matter.