BY: DENNIS PORTNOY, M.F.T.
For Catholic health care leaders, balancing mission with regulatory and fiscal realities means facing up to a future that demands delivering higher quality health care to more people at lower cost. In the struggle to provide quality, compassionate care in a climate that offers fewer resources and, at the same time, adapt to new business models, leaders can underestimate the strain on their front-line caregivers. But losing sight of burnout and compassion fatigue — which is a type of burnout — puts both the health care workers and their patients at risk.
It takes a multi-pronged approach to minimize the negative impact. The organization and its policies play a key role by creating conditions that not only reduce the risk of burnout and compassion fatigue, but also promote healthy, more effective workers.
Workers involved in direct patient care are exposed to suffering and negativity on a daily basis. They face increasing demands in the workplace, while at home they juggle family life, personal interests and often care for their own children and their aging parents as well.
Psychologists Ayala Pines, Ph.D., and Elliot Aronson, Ph.D., describe burnout as a state of physical, emotional and mental exhaustion caused by long-term involvement in emotionally demanding situations. It is accompanied by disillusionment and negative feelings.1 Psychologist and author Judith Herman writes that repeated exposure to people's suffering can diminish the helper's trust in humanity and often leads to a heightened sense of vulnerability.2
Researchers have described how burnout among nurses affects the quality of treatment for patients, lowers morale and increases absenteeism, with an accompanying financial impact on the hospital. Nurse turnover due to stress takes a financial toll, as well.3, 4
Hospital leaders need to understand how downsizing, re-engineering and staff turnover causes burnout in health care managers, as Anne M. Nordhaus-Bike has shown.5 In terms of dollars and cents, researchers Deborah Jones, Takeshi Tanigawa and Stephen Weiss place associated costs at $300 billion annually. This figure includes estimates of the dollar effects of reductions in operating effectiveness, medical expenses and attrition resulting from stress.6
Professional caregivers and their employers also need to learn to recognize signs of burnout and compassion fatigue, because people in helping roles are at great risk.
In the early stages, burnout symptoms include frequent colds, reduced sense of accomplishment, headaches, fatigue, lowered resiliency and moodiness and increased interpersonal conflicts. If not treated, burnout gradually moves into an advanced stage displaying symptoms of somatic complaints, social withdrawal, depersonalization, cynicism, exhaustion, irritability, low energy, feeling underappreciated and overworked. In time, a helper becomes numb, disillusioned, hardened and overwhelmed. Often, caregivers don't realize the negative effects until they experience a health crisis or other significant trauma.
Compassion fatigue is a type of burnout. It emerges suddenly and with little warning, and it is usually more pervasive than burnout. In addition to regular burnout symptoms, a person experiencing compassion fatigue can feel a loss of meaning and hope and can have reactions associated with Post Traumatic Stress Disorder (PTSD) such as strong feelings of anxiety, difficulty concentrating, being jumpy or easily startled, irritability, difficulty sleeping, excessive emotional numbing, intrusive images of another's traumatic material. Past traumas can also be activated. Long-term effects include reduced empathy, diminished sense of personal safety, reduced sense of control, hopelessness, increased involvement in escape activities and chronic overeating, drug or alcohol use.
Much of the research on compassion fatigue has focused on counselors and first responders who work with trauma victims. Laurie Anne Pearlman and Lisa McCann, who have done research on the long-term effects of compassion fatigue, report helpers develop a diminished sense of personal safety and disrupted schemas around trust, vulnerability, meaning and control.7
There is overlap between burnout and compassion fatigue, and an individual can suffer from both. They share some symptoms, and both take a toll on health and on relationships. Both affect the workplace in low morale, absenteeism, decreased motivation and apathy, though people suffering from compassion fatigue often love their jobs.
Compassion fatigue is caused by empathy. It is the natural consequence of stress resulting from caring for and helping traumatized or suffering people. It involves a preoccupation with an individual or his or her trauma, and it doesn't require being present at the stressful event. Simply being exposed to another person's painful narrative can be enough. Author and researcher Beth Hudnall Stamm defines compassion fatigue as the convergence of primary stress, secondary traumatic stress and cumulative stress in the lives of helping professionals and other care providers.8
For those in the helping professions, early recognition and improved self-care both in and out of the workplace are key to creating wellness. Many caregivers focus on others at the expense of their own well-being. It is crucial for them to replenish themselves and commit to having a life outside of work that includes daily nurturing activities. People often understand this concept intellectually, but the knowledge doesn't necessarily lead to taking better care of themselves.
It is important for individuals and their employers to recognize and challenge the psychological obstacles that get in the way of self-care, such as the belief that focusing on personal needs is selfish or indulgent. Enlightened self-interest is quite different from narcissistic preoccupation. Self-care actually increases a caregiver's capacity to care for others. Self-care, however, is not just about making healthy lifestyle choices — it is about being present with one's feelings, sensations and intuitive guidance in order to detect what is best in any given moment.
A 2010 study done on nurses and compassion fatigue revealed that compassion fatigue was significantly higher in nurses who worked 8-hour shifts compared with nurses who worked 12-hour shifts.9 Compassion satisfaction was significantly higher in intensive-care-unit nurses than in emergency department nurses. Nurses with the least experience reported significantly higher rates of compassion satisfaction compared to the more experienced nurses.
Compassion satisfaction was strongly negatively correlated with numerous items on the compassion fatigue and burnout subscales. Nurses who had higher compassion satisfaction scores were more interpersonally "fulfilled," as defined by scores on "being happy," "being me," and "being connected to others." These nurses did not feel as trapped and did not experience difficulty separating personal life and work. They were less likely to feel exhausted, bogged down or "on the edge."
Compassion fatigue was often triggered by patient care situations in which nurses:
- Believed that their actions would "not make a difference" or "never seemed to be enough"
- Experienced problems with the system (high patient census, heavy patient assignments, high acuity, overtime and extra workdays)
- Had personal issues, such as inexperience or inadequate energy
- Identified with the patients
- Overlooked serious patient symptoms
To offset and reduce the risk of burnout and compassion fatigue in staff members, organizations and managers can:
- Create an open environment where employees have a venue for mutual support. Encourage employees in meetings and with supervisors to talk about how they are affected by their work
- Offer training that educates employees about burnout and compassion fatigue and how to recognize the symptoms
- Share the caseload among team members, particularly the most difficult cases
- Make time for social interaction among teams. Social events and a yearly retreat away from the workplace can build cohesion and trust
- Encourage healthy self-care habits such as good nutrition, sleep, taking work breaks
- Reward effort and offer flexible work hours
- Offer training that focuses on self-care and life balance as a way to build resilience to stress
Incorporating elements from existing programs such as the approach developed by therapist J. Eric Gentry, Ph.D., can also help.10 Gentry's approach has several components. The first involves what he calls intentionality, in which he focuses on helpers becoming more self-directed and developing an internal locus of control. This includes articulating a personal and professional mission statement focusing on goals and what's important to them.
The next component is recognizing and accepting symptoms and committing to addressing personal issues. This includes identifying triggers and which client issues activate the symptoms. His program emphasizes learning skills to deal with responses to stress — self-soothing and grounding, self-care, boundary setting, eye movement desensitization and cognitive restructuring.
There are programs that focus on stress management for nursing staff that incorporate mindfulness training, relaxation techniques and self-care practices. Anderson Torres, Ph.D., director of health initiatives, at Bon Secours New York Health System/Schervier, has implemented a program using guided imagery, cognitive desensitization and breathing exercises to help nurses cope with stress.
These sessions, a part of Bon Secours' corporate wellness program, are scheduled when departments identify a need. Torres notes that frequent focus on stress management in a supportive environment — in daily staff "huddles," for instance — helps to normalize feelings related to stress. As I note below, these stress-related feelings can be accompanied by feelings of anxiety and isolation and even guilt, further compounding the problem and making it harder for staff members to seek help.
While anecdotal evidence suggests such programs are helpful, more research on effectiveness of such methods is needed. More research also is needed to demonstrate the effectiveness of various techniques and programs in addressing problems related to compassion fatigue.
My own approach emphasizes underlying factors that block helpers from implementing self-care strategies, attitudes that increase susceptibility to burnout and compassion fatigue and identifying beliefs that lead to over-identifying with the role of helper.
For example, when helpers' self-concept and sense of worth is based primarily on their strengths, accomplishments, dependability, competence and self-sufficiency, they often take on too much and have an excessive need for control. They have difficulty delegating, recognizing their need for support and are much better at giving than they are at receiving. Since they are disconnected from their emotional needs, they are unable to focus on self-care.
Their inability to embrace their vulnerability, to let go and get support makes them susceptible to burnout and compassion fatigue. It's hard for them to acknowledge their limitations and mistakes, and they equate limitation with failure and being weak. They are rescuers and thrive on fixing problems.
They are often very productive, but in the long run, they crash and burn.
Another example is helpers whose worth is defined by the good they do for others. They put everyone else's needs before their own needs and absorb the suffering of others.
Caregivers need to be able to deliver service excellence without compromising their well-being. It is important for them and for their employers to recognize early warning signs of burnout and compassion fatigue. It is also essential that workers in all levels of health professions engage in self-care practices, learn to modulate their responses to the stresses around them, be aware of destructive attitudes and reach out for help.
DENNIS PORTNOY is a licensed psychotherapist who has been in private practice for over 25 years. Located in San Francisco, he also specializes in training helping professionals in preventing and counteracting burnout and compassion fatigue.
NOTES
- Ayala Malakh-Pines and Elliot Aronson, Career Burnout: Causes and Cures (New York: Free Press, 1989).
- Judith Herman, Trauma and Recovery: The Aftermath of Violence — From Domestic Abuse to Political Terror (New York: Basic Books, 1997).
- Cheryl Bland Jones, Michael Gates, "The Costs and Benefits of Nurse Turnover: A Business Case for Nurse Retention," OJIN: The Online Journal of Issues in Nursing 12 no. 3 (Sept. 30, 2007): Manuscript 4.
- D. Ragsdale, E.L. Burns and S. Houston, "Absentee Patterns among OR Staff," AORN Journal 53, no. 5 (1991):1215-21.
- Anne Nordhaus-Bike, "The Battle Against Burnout," Hospital and Health Networks 69, no. 10 (1995): 36-40.
- Deborah Jones, Takeshi Tanigawa and Stephen Weiss, "Stress Management and Workplace Disability in the U.S., Europe and Japan," Journal of Occupational Health 45, no. 1 (2003):1-7.
- Lisa McCann amd Laurie Anne Pearlman, "Vicarious Traumatization: A Framework for Understanding the Psychological Effects of Working with Victims," Journal of Traumatic Stress 3, no. 1 (1990): 131
- Beth Hudnall Stamm, Secondary Traumatic Stress: Self-Care Issues for Clinicians, Researchers, and Educators (Sidran Press, 1999).
- Elizabeth A. Yoder, "Caring Too Much: Compassion Fatigue in Nursing," Applied Nursing Research 23, no. 4 (2010): 191-197.
- Information about J. Erik Gentry's programs is available through his website, www.compassionunlimited.com.
ADDITIONAL RESOURCES
WEBSITES
www.proqol.org
Professional quality of life information, including compassion fatigue/burnout
Professional Quality of Life Scale self-test
www.myselfcare.org
Self-care quiz, articles
www.compassionfatigue.org
Information for caregivers
www.giftfromwithin.org
Information and articles for post-traumatic stress syndrome survivors and their caregivers
BOOKS
How Can I Help? Stories and Reflections on Service, by Ram Dass and Paul Gorman (Knopf, 1985) 256 pages, $12
The Truth about Burnout: How Organizations Cause Personal Stress and What to Do About It, Christina Maslach and Michael P. Leiter (Jossey-Bass, 1997) 200 pages, $25
COMPASSION FATIGUE BURNOUT SYMPTOMS
Cognitive
Lowered concentration, apathy, rigidity, disorientation, minimization, preoccupation with trauma
Emotional
Powerlessness, anxiety, guilt, anger, numbness, fear, helplessness, sadness, depression, depleted, shock, blunted or enhanced affect.
Experiencing troubling dreams similar to a patient's dream. Suddenly and involuntarily recalling a frightening experience while working with a patient or family
Behavioral
Irritable, withdrawn, moody, poor sleep, nightmares, appetite change, hyper-vigilance, isolating
Spiritual
Questioning life's meaning, pervasive hopelessness, loss of purpose, questioning of religious beliefs, loss of faith/skepticism
Somatic
Sweating, rapid heartbeat, breathing difficulty, aches and pains, dizziness, impaired immune system, headaches, difficulty falling or staying asleep