Code of Ethics

Historical Review in Understanding Burnout, Professional Compassion Fatigue, and Secondary Traumatic Stress Disorder From a Hospice and Palliative Nursing Perspective

Christina S. Melvin, MS, PHCNS, BC, CHPN

Disclosures

Journal of Hospice and Palliative Nursing. 2015; 17(1):66-72. 

 

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Abstract and Introduction

Abstract

This article compares and contrasts the terms burnout, professional compassion fatigue, and secondary traumatic stress disorder as they relate to hospice and palliative care nurses. Burnout describes distress experienced by employees related to job expectations and working conditions. In the 1990s, the term professional compassion fatigue emerged to describe the weariness experienced by health care providers repeatedly exposed to seriously ill, traumatized, suffering, and dying patients. More recently, the term secondary traumatic stress disorder has been used to describe the reactions of health care providers who experience a traumatic event vicariously by caring for seriously ill and dying patients. Recommendations include early detection of burnout, professional compassion fatigue, and secondary traumatic stress disorder. Strategies to preserve the nurse's ability to cope include developing supports, personal awareness, and refinement of resiliency skills, self-care strategies, assertiveness skills, debriefing sessions, spirituality, and the ability of the nurse to say no. The symptoms, recommendations, and intervention strategies for nurses are described.

Introduction

This article will examine the physical and emotional costs of hospice/palliative care nurses caring for seriously ill, traumatized, suffering, and dying patients. Nurses spend more time in direct contact with patients and families than any other health care discipline, which predisposes them to physical and emotional distress. One of the underpinnings of end-of-life care is the provision of exquisite symptom management; the nurse is in a strong position to provide this expertise.[1] Pioneers in hospice and palliative care Dr Florence Wald, Dame Cecily Saunders, and Dr Elizabeth Kubler-Ross emphasized that persons in need of care at end of life "merit the most competent, expert, evidenced-based care provided in a way that embodies compassion, respect for dignity, and an appreciation for the whole person and family."[1]

Hospice and palliative care professionals continually witness the suffering and deaths of their patients; these nurses are at risk of developing physical and emotional distress. Nurses play a critical role in caring for patients who are suffering; the relief of suffering is at the center of nurses' work as a profession committed to dealing with the human response to illness, injury and suffering. Although this care is at the core of what nurses do, it is this very work that predisposes nurses to distress.

This article is a review of the literature, with an explanation of these terms that will outline the progression in the understanding of the physical and emotional distress that nurses may experience while caring for patients who are suffering, traumatized, seriously ill, and/or dying. The terms that will be discussed include burnout, professional compassion fatigue (PCF), and secondary traumatic stress disorder (STSD). Furthermore, case studies are included as exemplars illustrating these terms. As our understanding of these phenomena grows, so can the recognition and treatment. Although there are differences in definitions and symptoms in these terms, symptoms are recognizable and strategies must be implemented to assist distressed hospice/palliative care nurses. It is therefore essential that nurses understand what these phenomena are, can identify the symptoms if these appear, and are able to intervene should these be noted in their peers and/or themselves.

Background

Historically, hospice and palliative care nursing has been recognized as encompassing the true essence of nursing. Dame Cecily Saunders, founder of the modern-day hospice movement, identified in 1967 that the needs of dying people are unique.[1] It has been through her work and that of Dr Elizabeth Kubler-Ross that the specific needs of dying people were addressed (physical, psychological, social, and spiritual). Dr Florence Wald, a nursing pioneer, led an interdisciplinary team to create the first hospice in the United States in the mid-1970s.[1]

The National Consensus Project for Quality Palliative Care defined palliative care as the following:

Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.[2]

This definition broadens the scope of palliative care to care that encompasses those needs before end-of-life care and suggests that palliative care be integrated with life-prolonging therapy that subsequently is enhanced as death nears.[1] The goal is to change the standard of practice of palliative care to avoid "too little, too late."[1] Hospice care is described as a program through which palliative care is intensified as a patient moves closer to death. Ideally, a patient living with chronic, debilitating, or progressive disease receives palliative care throughout the course of that disease, and as death approaches, services are seamlessly increased to meet the patient's individual needs.[1]

This article will address the specific stressors that predispose hospice and palliative care nurses to PCF and/or STSD and differentiate these terms from burnout.

Literature Review

This literature review encompasses both historical and current definitions of the terms burnout, PCF, and STSD. The differences and similarities are evident; however, symptoms overlap within the PCF and STSD phenomena. Stamm[3,4] described similar symptoms that appear in burnout, PCF, and STSD in the definition of Professional Quality of Life, which encompasses both Compassion Satisfaction and Compassion Fatigue. Professional quality of life is defined as "the quality one feels in relation to their work as a helper."[3,4] The descriptive terms PCF and STSD represent intersecting lines of evidence.[3,4] The concept of professional quality of life examines job satisfaction at both ends of the spectrum and may become a more comprehensive descriptor of these unique terms.

Burnout

Freudenberger [5] originally brought the term burnout to professional and public awareness in 1973. He began to recognize significant negative changes in mood, attitude, motivation, and personality among volunteers working in a free clinic. Figley[6] described burnout as the physical, emotional, and mental exhaustion caused by long-term involvement with emotionally demanding situations.

Slatten et al[7] defined burnout as "an organizational hazard for employees and managers working in difficult organizational environments." A disconnect arises when the employee is unable to meet role expectations that the employer cannot support due to organizational structure.

In subsequent research, Maslach and Leiter[8] described burnout as for individual's relationship with his/her job; the definition has been further conceptualized as a continuum between the negative experience of burnout and the positive one of engagement. There are 3 interrelated dimensions to this continuum, including exhaustion-energy, cynicism-involvement, and inefficacy-efficacy. Exhaustion is not just something that is experienced, but rather it prompts actions whereby the employees distance themselves emotionally and cognitively from their work, presumably as a coping mechanism. Cynicism (or depersonalization) is an attempt to put distance between oneself and various aspects of the job.[8] Within the work environment, burnout is at 1 end of a continuum as people establish work relationships, whereas at the other end of the continuum, people experience energy, are involved with their work, and experience feelings of effectiveness.[8] The 2 primary drivers of burnout include excessive workload and conflicts of personal values with organizational values.[9] Thus, burnout is caused by unmet role expectations within an organization and is more related to organizational expectations. Symptoms of burnout develop as a result of demanding situations in the work place in contrast to symptoms related to the exposure to trauma and/or suffering of others (PCF/STSD).

Case Study. (The following case study was developed by the author as an exemplar). This nurse is suffering from burnout as she deals with the ongoing demands from her workplace, caring for 2 young severely burned patients and caring for her own young children.

I have worked on this burn unit for 3 years. After a long shift with 2 severely burned 30-year-old patients, I was asked to work a double shift. I am totally exhausted and have to go home to my children. I feel guilty when I refuse. I need to leave this unit and find another job as I cannot cope with these repeated demands and being short staffed. Patient safety is a risk.

Professional Compassion Fatigue

The term compassion fatigue first began to appear in the literature in the early 1990s. As often done in the literature, the terms compassion fatigue and PCF will be used interchangeably in this article. Professional compassion fatigue was used to describe nurses who were worn out by daily hospital emergencies and is insidious in nature with long-term consequences that are often difficult to reverse.[6] Professional compassion fatigue is a result of repeated exposure to the suffering and trauma of others, whereas burnout tends to be related to the work environment itself.[8,10,11] LaRowe[12] describes compassion fatigue as "a heavy heart, a debilitating weariness brought on by repetitive, empathic responses to pain and suffering of others,"whereby nurses may absorb and internalize the emotions of patients and, at times, coworkers. Repeated exposure will likely contribute to nurses experiencing negative long-term health effects.

Figley,[13] in his seminal work, described compassion fatigue as a formal caregiver's reduced capacity or interest in being empathetic or bearing witness to the suffering of patients and is the emotional state that results from knowing about the traumatizing events that another human being experienced. Figley [6] reasoned that nurses are at particular risk for PCF because compassion and empathy are core values of nurses. Using these values in their everyday practice predisposes nurses to being "wounded by their work" as they routinely deal with the suffering, trauma, serious illness, and/or death of their patients.[14] A nurse's history of psychological trauma also increased the likelihood of developing compassion fatigue.[6] Professional compassion fatigue is often described as the emotional burden of being exposed to traumatic events of patients and may manifest itself by the loss of a sense of self, meaning and purpose, compassion, or ability to be empathic.[15] Furthermore, Sabo[16] stated that the health care provider's declining ability to provide empathy in a therapeutic relationship is considered a key symptom of PCF.

Conant [17] stated that although PCF is not "listed as an illness in many diagnostic manuals…it can be seriously debilitating." Professional compassion fatigue is an "evolving syndrome encompassing multiple behaviors and symptoms that extend from frazzled tiredness and anxiety to psychological and physical illness."[18] Symptoms include anxiety, intrusive thoughts, apathy, depression, lessened enthusiasm, desensitization, diminished ability, irritability, emotionally feeling overwhelmed,[19] hypervigilance, emotional disturbances, and disordered thinking.[7] Coetzee and Klopper[19] further described PCF as all-encompassing, including energy fatigue, energy expenditure outstripping the restorative process and the loss of power of recovery of the health care provider. It is evident that PCF has the potential to have devastating effects on nurses, which frequently results in nurses leaving the field.

Hooper et al[20] describe additional effects experienced by health care workers. These effects include increased absenteeism and staff turnover, decreased quality of patient care, decreased patient safety, and difficulty recruiting and retaining staff. The following exemplar highlights some of these findings.

Case Study. (This exemplar demonstrated a nurse who refused intervention from her nurse manager after the death of a child with whom this nurse had developed a strong relationship. Some of the symptoms the nurse was demonstrating included anxiety, intrusive thoughts, and decreased patient safety).

A nurse in a study conducted by Feldstein and Gemma, who worked for a large university medical center, began caring for Laurie Ann, who was age 8 years, upon graduating from nursing school. The nurse noted: "I grew up caring for Laurie Ann!"[21] After 2 years of caring for this child, the nurse learned one morning that Laurie Ann had died. The nurse manager, noting the nurse's distress, attempted to console her, but the nurse could not allow herself to indulge her feelings of sadness as she had other patients to care for, including a new child with the same diagnosis. In the following weeks, this nurse described herself as "being preoccupied with thoughts of Laurie Ann's death."[21] During this same period, the nurse made a medication error and was late for work several times.

Secondary Traumatic Stress Disorder

In 1995, Figley began using the term PCF interchangeably with STSD in describing the repeated exposure of empathetic caregivers who indirectly experienced the trauma of their patients.[10] Secondary traumatic stress disorder is defined as "the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person" that affects caregivers.[6]

Regularly, people in the helping professions are secondary witnesses to trauma, such as soldiers who have experienced war, people who have experienced violence (physical, emotional, sexual), or people who have experienced traumatic accidents.[23] As nurses witness trauma and suffering through the eyes of their patients, they cannot help but be affected emotionally. Although it is a privilege to care for those in need, "there is a cost to caring."[24] Showalter [23] stated that as healers, "we collect bits and pieces of their (patient's) trauma by exposure to their lives." Many helping professionals carry home these images in their minds and intense feelings in their bodies at the end of their work day. "Those who are strongly empathetic may be most at risk."[23] This repeated exposure is highly personal to the nurse and has the potential for negative consequences in a nurse's everyday life. Unlike posttraumatic stress disorder, the caregiver does not experience the traumatic event personally but rather experiences the event vicariously by caring for the traumatized person.[16]

Quinal et al[22] surveyed 43 oncology nurses regarding secondary stress using the Secondary Traumatic Stress Scale. A score of 38 or higher indicated the presence of secondary traumatic stress. Sixteen oncology nurses (38%) experienced secondary traumatic stress. The 5 most frequently reported symptoms were difficulty sleeping, intrusive thoughts about patients, irritability, fore-shortened future, and diminished activity levels. Two other studies using different assessment processes reported rates of PCF/STSD as 25% in forensic nurses and 78% in hospice nurses.[25,26] Additional symptoms of STSD have been noted to include disturbing dreams about patients, avoidance of patients, emotional numbing, avoidance of people and places, and detachment from others.[27]

Case Study. (The following case study was developed by the author as an exemplar).

It is not uncommon as death approaches for veterans to re-experience the traumas from their days in the battlefield. A nurse working on a palliative care unit in a US Veteran's Hospital for more than 10 years stated: "I have seen many veterans die. What distresses me most is that while I witness the actual dying process, so do I experience their trauma on the battlefield through their eyes. I go home and I cannot get the images out of my head as they describe the maimed bodies of their comrades, dead women, and children and total devastation. I sit with the veterans as they relive these experiences and it is as if I was in the battle too."

 

A Clinical Perspective

The purpose of this article is to examine the physical and emotional cost of hospice/palliative care nurses caring for seriously ill, traumatized, suffering, and dying patients. Although it is recognized that caring for these patients can be considered a privilege, there is often associated costs (both physical and emotional) to nurses in this area of practice. Although some of the emotional and psychological symptoms of burnout, PCF, and STSD clearly overlap, negative consequences do occur as a result of the experience and may be difficult to reverse. It is the need to recognize and treat the distressed nurse experiencing these symptoms that is critically important.

Bruce and Boston[28] described the emotional impact that 7 nurses and physicians experienced while working in an inpatient palliative care setting. These health care providers described feelings of guilt, dissatisfaction, letting patients down, and concerns about the shift away from supporting patients and families during the dying process. Participants described the notion of the ripple effect with suffering. One participant described how the pain or suffering of the patient spreads out like the ripples of a pond after a stone is thrown in. This participant stated that, at times, she was unable to differentiate between what was her pain and what was a rippling effect of the patient's pain.[15]

Showalter[23] described the concept of "Krumpled Kleenex" when health care providers are not adequately supported and experience "remnants that become stuffed," in other words, that their own emotional pain becomes stuffed, much like Kleenex being crumpled in one's pocket. Furthermore, many professional caregivers report that in addition to the everyday work stressors, "there is a sense that one never has time, or recognition of the need to 'refill the well' in their personal life."[23] Showalter[23] also suggested that when health care professionals suffer with PCF, they become physically, mentally, and spiritually exhausted, yet they continue to provide care for their patients. Many have described this syndrome as "being sucked into a vacuum that slowly brings them down."[23]

Nurses who have the capability to be more resilient seem to cope better with distressing experiences within the work environment. Resiliency within a nurse is a highly positive trait that enables some nurses to more adeptly handle emotionally charged work stressors. The emerging field of psychoneuroimmunology provides evidence of a significant biologic link between the state of mind and emotions of an individual and the health and well-being of that individual. Stress, particularly prolonged stress, can have negative effects both physically and mentally.[29]

Recommendations

There is no universal recognition of the potential negative effects of nurses providing care to those who are suffering, traumatized, seriously ill, and/or dying. Resiliency may explain how some nurses cope better than others do. There are innate strengths that some nurses possess, including resiliency, as well as learned methods of managing stressful situations (self-care, support, spirituality, etc.) that clearly affect a nurse's ability to cope.

Grafton et al[30] describe resiliency as an accessible inner strength or resource within an individual that enables a positive stress response that can be enhanced or supported by external sources. In other words, resiliency does seem to be innate and is enhanced by external forces. Grafton et al[30] developed the Resilience Development Model, which described innate resiliency and the process of enhancing innate resiliency (Figure). In this model, resiliency was defined as a cyclical process of uncovering, using, and developing the innate self, motivating life force, human spirit, or strength that lies within. In addition, resiliency seemed to involve a spiritual component.[30] Resiliency seemed to positively affect a nurse's ability to cope with stress, recover from or prevent depletion of self, and reduce one's vulnerability to the impact of future stress.[31,32] According to Zautra et al,[33] resilience describes one's ability to recover easily and quickly from setbacks that occur during his/her life. Resilience is described as strength that people possess and people who are described as resilient are said to be able to persist in overcoming challenging obstacles.[34]

(Enlarge Image)

Figure.

Resilience Development Model. Copyright 2010 by ONS. Reprinted with permission.

Yoder [35] suggested strategies to address PCF/STSD, which included taking vacations, changing assignments, developing supports, developing personal awareness, having rituals, and changing jobs. If nurses neglected themselves and failed to recognize symptoms of PCF/STSD, they could compromise their ability to provide quality patient care.[36] Nurses need to be educated about their vulnerability when working with suffering, traumatized, seriously ill, and/or dying patients, as well as the signs and symptoms of PCF/STSD, risk factors, and coping behaviors.

Other self-care strategies included maintaining adequate sleep patterns, good nutrition, regular exercise, and relaxation. Developing techniques such as meditation, mindfulness, deep breathing, self-reflection, and humor and massage could also be therapeutic.[37] Engaging in nonwork activities often rejuvenated and restored the nurses' energy, commitment, and focus. The ability for the nurse to provide distance from the work environment is vital to healthy coping.

Another key self-care strategy included the need for nurses to be assertive, to express personal needs and values, and to balance work with their personal life. For example, 1 oncology registered nurse noted: "I learned to try to keep a piece of me aside—lock a part of my heart away just for me and my personal life."[38] Without this balance, the compassionate nurse is at risk for developing PCF.[39] Learning to say the word "no" is imperative as well. Showalter [23] described how important it is for health care professionals to be able to set boundaries to maintain personal/professional balance. "Professional caregivers must learn to live a balanced life, allowing their professional life to enhance their personal life, not compromise their well-being."[23] Thus, nurses should not feel guilty when turning down requests for overtime, extended shifts, and others.

Among mental health professionals, social support came from friends, family members, or significant others outside the work environment or from coworkers and supervisors within the work environment. Overall, the evidence suggested that coworker support is very important to the mental health professional and is applicable to nurses as well.[40–42]

In researching PCF/STSD, Figley[43,44] argued that social workers who did not have time to debrief after a traumatic session were more likely to experience compassion fatigue compared with those who did engage in debriefing. These findings have direct implications for nurses who often care for several seriously ill patients at a time. If nurses are not supported emotionally, the negative effects of PCF/STSD are more likely to develop. Establishing debriefing sessions for nurses after difficult clinical situations, which could be facilitated by a social worker, advanced practice registered nurse, or psychologist, could be highly beneficial. In the absence of formal debriefing, processing with a peer or friend may still prove beneficial.

Attending to one's spiritual needs is also important. Yoder [35] described the role of religion for some nurses. One nurse stated, "[I'm] praying for strength to be cool and calm…to be aware of patient's needs and have enough strength to meet them…that my support systems will support me…that I can be the nurse that that patient needs. "Other nurses found support through journaling, painting, quilting, and others. Still, others found it rejuvenating to be out in nature—walking or gardening—and described the miracle of growing things.

Jezuit [45] described the role of the nurse manager in identifying and assisting distressed nurses. Nurse managers have a unique ability to assist distressed nurses who are suffering as a result of the repeated exposure to patient and family trauma and suffering as well as the dying. Nurse managers must create a safe environment where a nurse may express his/her distress and discuss treatment strategies. The argument can be made that there is a potential ethical conflict with the nurse manager providing emotional support to a distressed nurse and then, at a later time, evaluating that same nurse. Inherent in this practice is a dichotomy between providing emotional support and subsequent evaluation. In many cases, it would be more appropriate for a third person to serve as the facilitator in providing emotional support. This person (facilitator) could be a colleague, social worker, advanced practice registered nurse, or psychologist. The facilitator could assist a nurse(s) in identifying emotional triggers and developing coping strategies. A group of ambulatory care gynecologic oncology nurses organized a compassion fatigue support group that met monthly and reported that they found the group highly beneficial.[46] Employee assistance programs for distressed nurses are additional resources.

In many cases, it is the nurse manager who establishes the working environment, albeit a supportive working environment or one that is not. Laschinger et al[47] found that lower levels of burnout (emotional exhaustion) were associated with work environments that fostered support of nursing practice and civil working relationships and promoted a sense of empowerment.

Nursing scholars have long advocated for the establishment of undergraduate nursing courses that address care of seriously ill and dying patients. The goal of specific clinical assignments would be to reduce death anxiety among student nurses, which would result in registered nurses being more prepared to care for these patients upon graduation.[1,48]

In addition, practicing nurses would likely benefit from continuing education programs that focus on the care of this patient population. Suggested topics include identifying personal coping strategies, developing caring communication styles, establishing boundaries in professional relationships with patients and families, understanding family systems theory, and resolving interpersonal relationship problems in the work place (Table ).[24] Through continuing education, nurses can learn ways to prevent PCF/STSD and learn strategies to increase resiliency. The study of Townsend and Campbell[25] indicated that peer support, experience as a nurse, and additional continuing education were positive factors that influenced a nurse's resilience to PCF/STSD.

Conclusion

Although burnout, PCF, and/or STSD may not always be preventable, they are certainly recognizable and treatable. There is the potential for significant long-term negative health and emotional effects on hospice/palliative care nurses who witness daily the suffering of others. Although this article focused on nursing, this information is clearly applicable for other professionals who provide care to suffering, traumatized, seriously ill, and/or dying patients (physicians, social workers, licensed nursing assistants, clergy, etc.). The American Nurses Association Code of Ethics for Nurses with Interpretive Statements states: "The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth."[49]

Strategies for addressing burnout, PCF, and STSD are essential in solidifying our nursing workforce to face the health care needs of the future. There is compelling evidence that nurses who have repeated exposure to people who are suffering, traumatized, seriously ill, and/or dying are at particular risk for these effects. Caring for the suffering potentially generates personal and emotional distress. Nurses need permission and support to deal with these emotions. It is only through careful planning, recognition of these effects in themselves and their coworkers, and intervention, when needed, that nursing's workforce can be preserved.