“Like all workers, nurses have been affected by the economic recession,” said Stephanie Kotos, a nurse who works in behavioral health services at Northside Hospital in Atlanta. “We have seen staffing issues and workplace changes. Nurses have been asked to do more with less. That’s not uncommon in today’s workplaces, but with nurses you have lives hanging in the balance.”
Mistakes and accidents are more likely to occur when nurses are overworked and exhausted, said Kotos, RN. Productivity goes down and patient outcomes can suffer.
The general workplace calls this condition burnout. Nurses call it compassion fatigue, a combination of physical, emotional and spiritual depletion associated with caring for patients in significant emotional pain and physical distress.
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“We’ve all known nurses who are apathetic, withdrawn, exhausted, irritable and short-tempered,” Kotos said. “There have been times I could be the poster child for compassion fatigue myself.”
Assessing and managing indigent patients who come to Northside for mental health services can be stressful.
“I hear horrible stories every day,” she said. “We are trained to let it roll off us, but there is some buildup over time. You have to learn to let those emotions out in positive ways.”
Importance of self-care
But nurses may not always know what those positive behaviors look like.
“Self-care isn’t taught in nursing school,” said Cheryl T. Handy, associate nurse executive at Atlanta VA Medical Center. “We’re taught to care for others, to solve problems and take responsibility. As a result, many nurses lack the ability to say no.”
Capable nurses may work too many hours or take on more responsibilities than is good for them or their patients.
Handy, MN, RN, NE-BC, helped institute positive changes for nurses by serving on the self-governance committee in 2007, when Atlanta VA Medical Center began its effort to attain American Nurses Credentialing Center magnet hospital status.
“We adopted (nurse theorist and nursing professor) Jean Watson’s Caring Science theories and her 10 Caritas processes as the basis for our nursing practice,” said Handy, who studied for six months to become a Caritas coach.
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“The first Caritas process talks about the cultivation of a personal/professional practice of loving kindness, compassion, and equanimity (inner balance) to self and others,” she said. “We committed to foster caring, compassionate work environments, realizing that it would be better for staff and good for patients. We’ve seen an increase in patient satisfaction surveys.”
Handy had seen each hospital unit create a centering space, where nurses and others are surrounded by positive affirmations and images, inspirational books, candles and plants.
“We had to get creative, because we didn’t have a budget or additional space, but nurses now have a place to pray, meditate or release negative thoughts before shifts or after stress experiences,” she said. “Taking time to pause and be still helps them to be intentional and authentic in their encounters with patients, to be more cognizant of the energy they are radiating, and to recognize their true purpose of providing good care to America’s heroes.”
Speakers, lunch-and-learn sessions, and pampering days that include massages and relaxation therapy help empower nurses to take care of themselves and each other. Leadership and team meetings at Atlanta VA Medical Center now begin with centering exercises and include acknowledgement of professional and personal accomplishments. Before undergoing oncology treatments, patients always receive a hug. These small things matter, Handy said.
“Love is the greatest healing force in the universe and nurses can create that healing environment before they even deliver the medicine,” she said. “But first, we must empower them to take care of themselves.”
Helping the nurses she manages to stay healthy and balanced is important to Kathy Adams, founder and director of clinical services at Accord Services, a private-duty nursing company that serves patients with catastrophic and complex injuries.
“After working at Shepherd Spinal Center for eight years, I saw that this service was desperately needed, but working with these patients and their families can be psychologically stressful for our nurses,” said Adams, RN. “In the hospital, you have a support system, but in home health, you’re on your own.”
Adams offers extensive training, flexible scheduling and team meetings during which clinicians can share their experiences is dealing with cases and other challenges.
“Nurses have to know what they are getting into and understand their role,” Adams said. “If they don’t set boundaries, they can become too involved in their clients’ problems and lose sight of the clinical goals. They can burn out and make mistakes.
“A nurse has to know it’s safe to ask for help. We tell them they can call when they need to talk or to request time off or a different assignment.”
Linda Stead, RN, BSN, vice president of nursing, chief nursing officer and patient safety officer at Piedmont Mountainside Hospital in Jasper , said that compassion fatigue has been a constant in nursing. “Years ago, nurses had more patients and other responsibilities. Now they have fewer patients, but they have higher acuity levels and there’s more documentation and protocols. Changes are occurring at a quicker pace and everyone is expected keep up.”
Compassion fatigue can spring from nurses identifying too strongly with patients, negative patient outcomes, staffing changes and home pressures such as financial or family issues.
“It’s a good idea to begin with the idea that nurses are people, and people have limitations,” Stead said. “Debriefing is not always possible in the ER, but when nurses can take five minutes to talk about something, they can put it behind them and move on.”
Health care facilities can help nurses by teaching them to be aware of the signs of compassion fatigue. Leadership can advocate good teamwork and conduct surveys or town hall meetings that allow nurses to voice concerns. Appreciation and recognition events can help improve workplace morale.
Stead encourages nurses to carry a simple advice tool called "Caring for Yourself in the Face of Difficult Work," which can be found at www.proqol.org.
“Nurses take care of everyone in the whole world, and they deserve to take care of themselves,” she said. “They need to get enough sleep, eat right and pursue outlets like church, hobbies or exercise that rests them mentally. They need to do something for fun. That balance will help them come back to work more engaged.”