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NursingFatigue.pdf

Practice Article

Contributions from Christian ethics and Buddhist philosophy to the management of compassion fatigue in nurses

Neil Pembroke BTH, BA(HONS), PHD School of Historical and Philosophical Inquiry, University of Queensland, Brisbane, Queensland, Australia

Abstract The aim in the article is to demonstrate how insights from Christian ethics and Buddhist philosophy can make contributions to the management of compassion fatigue. There are already helpful resources available that pro- vide principles, tips, and practical guidelines for self-care. The approach here is centered on attitudinal, ethical, and philosophical issues. From the Christian tradition, the ethical principle of “equal regard” is employed. Equal regard is the notion that agape (disinterested, universal love) requires of a people that they love others neither more nor less than they love themselves. When the ethical principle that a nurse operates out of in her everyday life is self-sacrifice, self-care is much less likely to be set as a personal priority. From the Buddhist tradition, the principle of compassion with equanimity is engaged. The Buddhist ideal is opening oneself to the pain of the other while maintaining calmness or stillness of mind. It is contended that inculcation of this skill means that a nurse can be exposed to suffering without running down their store of compassion.

Key words Buddhist philosophy, Christian ethics, compassion fatigue, equal regard, equanimity, spirituality mindfulness.

Every day, nurses encounter people who are in pain and distress, and who are, therefore, very vulnerable. An important part of a nurse’s role is to remove or alleviate suffering. One way in which nurses achieve this is through the administration of medical therapies. Equally importantly, nurses minister to suffering patients through a caring and compassionate pres- ence. It is widely recognized that in the current climate of tight healthcare budgets in which nurses – and other clinicians – are asked to do more with less, it has become increasingly difficult to maintain adequate personalized care for patients alongside the administration of prescribed medical therapies. Neverthe- less, compassionate nursing care is a value that is widely held by individual nurses, hospital and other healthcare facility managers, and various other stakeholders. The continual stimulation of an empathic response in nurses

often takes its toll. A significant number of nurses experience a running down of their store of emotional, physical, intellectual, social, and spiritual vitality (Yoder, 2010; Hooper et al. 2010; Hegney et al. 2014). This condition has been referred to as com- passion fatigue (CF). The main aim in what follows is to demonstrate how insights

from Christian ethics and Buddhist philosophy can contribute to the management of CF. There are already many helpful resources available in both the scholarly nursing literature and more popular outlets that provide principles, tips, and practical guidelines for self-care. The approach in this essay is centered on attitudinal, ethical, and philosophical issues. From the Christian tradition, the ethical principle of “equal regard”

is employed. Equal regard is the notion that agape (disinterested, universal love) requires of people that they they love others nei- ther more nor less than they love themselves. When the ethical principle that nurses operates from in their everyday life is self- sacrifice – Christian nurses may be especially vulnerable here, for reasons that I will outline further – self-care is much less likely to be set as a personal priority. A shift to equal regard means giv- ing oneself permission to make time to look after oneself.

From the Buddhist tradition, the principle of compassion with equanimity is engaged. The Buddhist ideal is opening one- self to the pain of the other while maintaining calmness or still- ness of mind. It is contended that inculcation of this skill means that nurses can be exposed to suffering without running down their store of compassion.

WHAT IS COMPASSION FATIGUE?

“Compassion fatigue” was first used in a nursing context by Joinson in 1992. It is the end-point of a progressive and cumu- lative process, the antecedent stages of which are compassion discomfort and compassion stress (Coetzee & Klopper, 2010). Defining the term is a complicated task; it is beyond the scope of this work to finally settle definitional issues. Through refer- ence to commonly cited definitions, the following working def- inition is offered: CF is the state of significant depletion or exhaustion of the nurse’s store of compassion, resulting from repeated activation over time of empathic and sympathetic responses to pain and distress in patients and in their loved ones (Figley, 1995, p. 15; LaRowe, 2005, p. 21; McHolm, 2006, p. 14; Coetzee & Klopper, 2010, p. 237). It begins with compassion discomfort, evolves into compassion stress that exceeds the nurse’s level of endurance, and, in its final form,

Correspondence address: Neil Pembroke, School of Historical and Philosophical Inquiry, Forgan Smith Building, St. Lucia 4072, Brisbane, Queensland, Australia. Email: [email protected] Received 22 June 2015; revision 23 August 2015; accepted 8 September 2015.

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manifests through the depletion of emotional, physical, social, and spiritual resources.

The task of defining CF is complicated by the fact that it is used interchangeably in the literature with terms such as burn- out, vicarious traumatization, secondary traumatic stress disor- der, and post-traumatic stress disorder. While on one level this is problematic, the salient issue is not what label one chooses to employ, but rather that the effects of this exhausted state are a negative impact on the health and well-being of the nurse, on the one hand, and negative effects on patient care, such as a generally poor attitude, disengagement, and lack of concern, on the other (Smart et al. 2014). There is clearly a need for individual nurses, their supervisors, and senior management to address this issue more effectively.

EQUAL REGARD AND COMPASSION RESILIENCE

A dictionary definition of compassion is a “feeling of deep sym- pathy and sorrow for another who is stricken by suffering or misfortune, accompanied by a strong desire to alleviate the pain or remove its cause” (Merriam-Webster, 1989, p. 229). Im- plied in the second half of this definition is the translation in a genuinely compassionate person of desire into action. Compas- sionate nurses do whatever they can to mitigate or remove suf- fering. This mitigation or removal involves both technical therapeutic action and personal kindness expressed in acts of care. In a Christian theological framework, such acts of kind- ness are referred to as the agape response. Agape is impartial or disinterested self-giving for the sake of the other. Agapists see someone who is in a situation of need and suffering and act to meet the need and, as far as possible, to alleviate or re- move the suffering; the “someone” is literally anyone. Outka’s (1972) term for this kind of love is “equal regard.” Friend or en- emy, intelligent or dull, attractive or not – everyone in need and distress is deserving of help, kindness, and care. Nygren (1932, 1939), in his classic treatise on agape, refers time and again to the fact that this form of Christian love is sovereign and is not dependent, spontaneous, and not motivated. What he means by these terms is as follows. First, a sovereign act of love is one in which the agent acts not out of compulsion but rather out of free choice. Second, the person who acts spontaneously in love is not motivated by considerations of reciprocity or any other calculation of potential personal gain. The agape re- sponse has been referred to in nursing literature as: “The willingness and commitment of the nurse to want the good of the other before self, without reciprocity” (Fitzgerald & van Hooft 2000, p. 481). This unselfish approach has long been held as an ideal for nurses who sees their profession as a vocation rather than as a job. For example, in their survey of nurses’ letters to the editor of the American Journal of Nursing from 1900-2005, Anthony and Barkell (2008, p. 97) cite the following sentiments: “What does nursing imply…? Complete self-effacement, obedience to others, gentleness and unselfish- ness… [T]he purpose of every good nurse is to make her patient comfortable and happy, and that we go to each case, not to be ministered unto, but to minister…” Further, Pask’s (2005, p. 251) interpretation of narratives compiled by nurses

is that they show “dedication of a particular kind, dedication that incorporates an inclination towards self-sacrifice.” It is clearly the case that nurses are repeatedly called upon to

put the needs of the patient and their family members before their own needs. Nurses care for people who are suffering and highly vulnerable. It is inevitable that nurses will occasion- ally not particularly feel like extending themselves for the good of the patient. But as expressed in the views of nurses cited above, self-giving for the sake of the patient is a requirement of the profession. While this setting aside of personal prefer- ences and refusing to think first of self is quite appropriate in the context of a nursing shift, if it characterizes the nurse’s life beyond the hospital, it is unhealthy and will contribute to the problem of CF. The word “characterizes” is used quite deliber- ately. Nurses tend to be caring people; it is a major reason that most of them choose the profession in the first place. There is no reason to expect that nurses will suddenly become selfish and thoughtless as soon as they step outside the hospital. They are generally quite ready to think of the needs of others in do- mestic, friendship, and other relational contexts, and to give of themselves for the good of the others when it is required. While a willingness to engage in self-sacrifice is admirable –

and certainly required for the agape response – it is neither emotionally nor spiritually healthy to install sacrifice of self as the leitmotif of one’s life. Self-sacrifice appropriately features in a compassionate and kind person’s life, but is not helpful when it characterizes it. A healthy love ethic incorporates both giving and receiving. It involves balancing care for others with care for self. In the context of our discussion, commitment to self-care requires making time and space for filling oneself, so to speak. Nurses who seek to build compassion resilience will refuse to allow the needs of others – family members, friends, and other acquaintances – to so dominate their time and energy that they are unable to replenish their physical, emotional, social, and spiritual resources. It is widely acknowledged in the nursing literature that such

commitment to self-care is central in coping with CF. In her empirical study, Yoder (2010) noted that nurses use strategies, such as mentally detaching, debriefing, introspection, or self- examination, and employ personal spiritual or religious re- sources. A number of authors observe that coping with CF involves enacting the strategies generally aimed at coping with a stressful professional life, such as balancing work and leisure, talking with others, engaging in regular physical exercise, find- ing an emotional outlet, and, for those so inclined, using spiri- tual resources, such as prayer and meditation (McHolm, 2006; Perry, 2008; Flarity et al. 2013). In relation to this last men- tioned practice, Walton and Alvarez (2010) report positive re- sults achieved through the use of an oil-cleansing ritual incorporating music and singing bowls. The stated aim is “let- ting go of fatigue” (p. 400). McHohm (2006) connects cleansing with receiving forgiveness from God, self, and others. Christian nurses may be especially vulnerable to a tendency

to self-harm through a failure to make enough time and space for self-care. Christian preachers and teachers have very com- monly taught that the self-sacrifice of Christ is the ideal for faithful disciples. Talk of the need for care of self is viewed in this frame as a failure in agape. Academic theological ap- proaches to the love ethic do not always support appropriate

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self-care. For example, Nygren’s (1932, 1939) treatment finds no place for it. More recently, Badcock (1998) discusses self- sacrifice at length with virtually no mention of self-love. He states that Christians are called to share in the ongoing mission of Christ; that is, to bear his cross. In order to live in the way of suffering love in the world, they must enter into the mind of Christ. To live in and through a mind conformed to Christ is to take up his attitude of selflessness and his willingness to sac- rifice himself for others. This (legitimate) exhortation is, unfor- tunately, not set in the context of self-care. There is, however, an important school of ethical thinking on

the nature of agape that balances self-giving for the sake of others with appropriate care of self. It is centered on a particu- lar understanding of equal regard. Two important thinkers in this approach are Outka and Browning. Outka (1972, 1992) begins his analysis of Christian love by

suggesting that a good general principle to start with is impar- tiality or equal regard. Christians are called to love others. They are called to love not only those who are likable, or who have done something good for them, but all people. Loving only one’s “favorites” is not an option. Christians must love each and every person God puts in their path. Outka argues that this principle of equal regard should also be applied to the attitude one has toward one’s self. The notion that every other person is to be loved simply because he or she is a child of God should operate in the Christian’s relationship with herself. Others are neither more nor less deserving of a person’s love than she is; one should regard others and oneself equally. Browning has taken up Outka’s suggestion and developed

it in a number of contexts (Browning, 1987; Browning & Browning, 1991). He helpfully points out that the principle of equal regard constitutes a middle path between the extremes of independence, on the one hand, and self-sacrifice, on the other. In the independence or self-actualization model of love, it is assumed that self-love comes first, and that love of neighbor will follow automatically. That is, the focus is largely on self- fulfillment and the extent to which a particular act or relation- ship is likely to contribute to it. At the other end of the scale is an understanding of love that requires sacrificing the self for others. The equal regard approach, Browning suggests, picks up values from the other two models, but it manages to avoid their excesses. A person living according to the principle of equal regard will take the needs and claims of the other as seriously as her own. The needs of others are seen to be very important, but so are one’s own. Love for others and self-love are assigned an equal weighting. It is contended that embrace of the ethic of equal regard en-

courages appropriate self-care. It serves as a strong reminder to nurses that though they need to adopt a self-sacrificial stance in caring for patients who are highly vulnerable and coping with a very distressing experience, they must also take cognizance of their own legitimate physical, she must also take cognizance of her own legitimate physical, emotional, social, and spiritual needs and ensure that they are appropriately met. An important practical question is this: How do nurses enact

equal regard in everyday experience? Put differently, how do they live out this ethical principle in their day-to-day relations with those they share life with in a way that supports personal wellbeing, while appropriately valuing the legitimate needs of

others? Recall that equal regard involves considering one’s own needs as neither more nor less important than those of others. In practice, this means regularly engaging in a process of assessment, evaluation, and action. This is where the ethical principle can easily be subverted. Self-care is an important per- sonal need for a nurse; but so are the needs of others. Getting the balance right is the practical challenge. What is being advo- cated in this essay is not self-centeredness, but rather love expressed through equal regard. In order to adjust for self- centeredness, Outka (1992) suggests building in a “practical swerve” away from self and toward the other in everyday rela- tionships. This in-built bias ensures that a person achieves a genuine balance of the needs of self with those of others.

For those nurses with personal faith, spiritual practices, such as prayer, worship, and meditation on the scriptures are vitally important in establishing genuine equal regard. Personal spiri- tuality, psychological wellbeing, and moral practice are all in- dissolubly linked (Sperry, 2002; Pembroke, 2007). However, it is not necessary to have faith in order to embrace equal regard; it is an ethical principle with universal application. Living in love through equal regard is supported by the practices of quiet meditation, personal reflection, and honest self-assessment.

We turn now to another major religious tradition – namely Buddhism – in search of a philosophical asset in the task of building compassion resilience. In particular, the central Buddhist practice of equanimity will be discussed.

CARE WITH EQUANIMITY AND COMPASSION RESILIENCE

In the texts of early Buddhism, compassion often refers to a mental state to be radiated out to all sentient beings (cf. Aronson, 1980; Harris, 1997). This is usually taken to be its primary reference. In the meditation on compassion, a phrase such as “May you be free of your pain and sorrow” is used (Salzberg, 1995). The one meditating first directs the blessing toward a person who is experiencing great physical or mental suffering. He or she then directs the benevolent wish toward a series of other select individuals. Included in the list is himself or herself, a benefactor, a friend, a neutral person (someone about whom the meditating person has neither pos- itive nor negative feelings) and a difficult person. Finally, the blessing is radiated out to all sentient beings.

A central tenet of Buddhist philosophy is that the person on the path to enlightenment needs to strive to attain equanim- ity. Equanimity (upekkhā), along with compassion, is one of the four brahma-vihāras or sublime attitudes (the other two are loving-kindness and sympathetic joy). Upekkhā is even- mindedness or impartiality. It should not be confused with feel- ing equanimity – a stance that will become important for us below. The former attitude refers to extending one’s compas- sion impartially and, therefore, to all sentient beings; the latter indicates “the experience of neither pain nor pleasure… and it can arise in wholesome, unwholesome, and neutral states of mind” (Aronson, 1980, p. 81). Importantly, the stance of feeling equanimity should not be equated with the absence of feeling or emotion.

In the Māhāyana tradition, the bodhisattva is one who has “the great compassion.” Although the primary reference to

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compassion is the meditative practice, it is also closely linked to liberative action. Out of compassion for the suffering of sen- tient beings, bodhisattvas commit themselves to helping others on the path to enlightenment. They postpone complete enlight- enment and the attainment of nirvana in order to make them- selves available for this service.

A distinction is made between bodhisattvas who are begin- ners and those who are advanced. Both types are intensive and impartial in their expression of compassion, but only begin- ning bodhisattvas are overwhelmed by compassion. They are deeply moved by the suffering of other beings and sometimes weep in their distress. Advanced bodhisattvas, on the other hand, develop equanimity (i.e. feeling equanimity).Their com- passion is even stronger than that of the beginners, and it is more balanced in the sense that it does not result in emotional outbursts.

The cultivation of compassion with equanimity is considered to be vitally important as it ensures that encounters with suffer- ing by those on the path will not lead to emotional turmoil. The Buddhist ideal is calmness or stillness of mind combined with a heart of loving-kindness and compassion:

Equanimity allows one to feel compassion for the suffering of others without becoming overwhelmed by or neglecting it… This completely open mental atmosphere depends on achieving a state of emotional nonattachment in which perception is not directed by our self-ascribed interests (Friedland, 1999, p. 39).

The Buddha taught that three feeling states are associated with all experiences in life – namely, pleasure, pain, and neutrality. The aim of those on the path is the cultivation of a non-reactive stance in relation to the various states. In order to do this, they must counteract their natural tendencies. When experiencing some- thing that is pleasant, a person naturally wants it to continue; she clings to it. Here, she encounters a fundamental cause of dukkha – suffering or, more appropriately, disquietude or unsat- isfactoriness. That cause is attachment. When someone suffers a painful experience, they view it as negative and instinctively wants to push it away. Another basic cause of dukkha surfaces here – namely aversion. If the experience is neutral in tonality, a person habitually falls into inattention; a lack of stimulation means that they are unable to stay interested and focused. A third fundamental cause of dukkha is unveiled here, and that is delu- sion. The way of the Buddha is balanced response or non- reactivity to the differently toned experiences that make up our lives. It may seem that equanimity indicates an unfeeling stance – and some scholars of Buddhism have argued this (see e.g. Spiro, 1970) – but this is not the case. In the Pāli scriptures, it is clearly indicated that abandonment of the negative emotions of attach- ment, hatred, and delusion does not mean the destruction of all emotion (cf. Aronson, 1980, p. 95). Those who have chosen the path of non-attachment may experience a rich and fulfilling emo- tional life. As Salzberg (1995, p. 144) puts it, equanimity “does not turn us into gray, vegetative blobs with all feelings washed out.”

In sum, compassion in the Buddhist tradition is construed as opening to the suffering of others while maintaining a stance of non-attachment. However, non-attachment should not be interpreted as indicating a lack of emotion or feeling. It is held that it is possible to sorrow with those who are sorrowing, while maintaining a calm, balanced state of mind.

It is suggested that adoption of the stance of compassion with equanimity is an important aid in the management of CF. It is not that taking up this Buddhist attitude requires refusing to feel and to care. As we saw above, karuņā, compassion, literally means, “experiencing a trembling or quivering of the heart in response to a being’s pain.” What equanimity offers in terms of compassion resilience

comes into sharp focus when one takes cognizance of a key el- ement in the problem that is CF: the felt need to rescue or save the patient from pain and distress, coupled with an inability to do so (Valent, 2002). The result is guilt and distress. It is painful to stand with a suffering person and not be able to save them. One significant aspect of the pain nurses feel is guilt. They feels guilty because they make the judgment that they have failed the patient who needs to be saved and they are unable to do so. Another important dimension of personal pain is anger. The nurse is angry: first, because they live in a world in which people must suffer, often for no good reason, and, second, be- cause they cannot do anything to rescue the suffering patient in their care. The Buddha teaches that in this situation one should allow oneself to feel the pain without hating it. Further, one must not cling to the anger and guilt one feels. Letting go of these feelings is the path to freedom. In order to experience the benefit of non-reactivity in one’s

nursing practice, training is obviously required. Mindfulness training is closely associated with inculcating equanimity Shapiro et al. 2006; Desbordes et al., 2015; Lomas et al. 2015). Mindfulness is variously understood; however, the most fre- quently cited definition is the one offered by Kabat-Zinn (1994, p. 4): “Paying attention in a particular way: on purpose, in the present moment, and non-judgmentally.”Bishop et al. (2004) posit the two components of mindfulness as: (i) self- regulated attention that is focused on maintaining attention on present moment experience, and (ii) an attitude of openness and acceptance. A person committed to mindfulness training seeks to attend to moment-by-moment experience in a non- judgmental way (neither favoring nor opposing it). Those who advocate mindfulness contend that it is possible

for anyone to train the mind so that one is able to be interested in an experience without clinging to it. What is required is con- sistently bringing an attitude of patience, compassion, and de- tachment in attending to internal and external experience. This is the basic form of mindfulness practice; anyone can culti- vate it through intentional mental training. Further develop- ment of the skill requires regular practice of concentration (samatha) and insight (vipassana) meditation.

CONCLUSION

Compassion fatigue has a personally deleterious effect on a nurse and impacts negatively on their capacity for optimal care. Insights from Christian ethics and Buddhist philosophy have the potential to significantly contribute to the management of CF. The approach adopted centered on attitudinal, ethical, and philosophical issues. From Christian ethics, the principle of equal regard was

employed. According to this principle, people required to love others neither more nor less than they love herself. It was

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argued that adopting a stance of equal regard is vitally impor- tant in building compassion resilience. The alternative ideal for Christian love is self-sacrifice. It is widely advocated and adopted. When the ethical principle that informs a nurse’s total way of life is self-sacrifice, self-care is much less likely to be set as a personal priority. From the Buddhist tradition, the principle of compassion with

equanimity was engaged. The Buddhist ideal is opening oneself to the pain of another while maintaining calmness or stillness of mind. This ideal can be helpfully employed in building compas- sion resilience. Following the teaching of the Buddha, nurses who are faced with the distressing situation of being powerless to rescue a suffering person will allow themselves to feel the pain without hating it, and without clinging to anger and guilt. Nurses who practice the skill of non-reactivity to adverse situa- tions will accrue the asset of compassion resilience.

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