Consider these simple practices.
- Nurses are at high risk for developing compassion fatigue, which can have a negative impact on nurses, patients, and organizations.
- Self-compassion practices are an evidence-based intervention for compassion fatigue.
- When nurses take steps to care prevent compassion fatigue by incorporating self-compassion into their work.
“I need help in here now,” Lisa* calls out, as her patient, Diane, suddenly vomits blood. Diane is a young woman with end-stage liver failure, resulting in coagulopathy and esophageal varices. Earlier, Diane was lethargic due to hepatic encephalopathy, but now her eyes are open, panic evident as blood pours out of her mouth and she struggles to breathe. Shortly after a physician speaks with the family to discuss limited measures and confirm a Do Not Resuscitate code status, Diane takes her last breath.
In similar past situations, Lisa would frequently wonder, “Could I have done something different to save my patient? Did I do all I could to prevent my patient’s suffering when I knew we couldn’t save them?” But now, as Lisa performs postmortem care, she feels detached and numb when reflecting on Diane’s suffering and death. “I used to care so much. Why don’t I feel anything?” Lisa asks herself. The only feeling Lisa can identify is a sense of futility because Diane had been slowly dying for weeks despite receiving full treatment almost until her death. In the following weeks and months, Lisa feels exhausted and dreads work. Involuntary memories of Diane’s traumatic death arise spontaneously, and Lisa feels anxious when caring for patients with similar disease trajectories. Within a year, Lisa leaves her position for one in an outpatient setting, hoping to regain her sense of self and well-being.
Lisa’s feelings and experiences reflect causes and symptoms of compassion fatigue, a state of secondary traumatization and emotional exhaustion that can result from the caregiver role. Up to 85% of nurses experience compassion fatigue symptoms.
Compassion fatigue defined
Compassion fatigue isn’t a mental illness or character flaw. Rather, it’s a condition that arises over time in response to prolonged exposure to suffering and trauma or occurs suddenly due to a precipitating event, such as the death of a patient. Defining attributes of compassion fatigue include perceived failure, helplessness, and anxiety, culminating in depersonalization and desensitization to patients. It’s most common among nurses under age 35 and in those with less than 4 years of experience. Caring for patients with life-threatening or terminal conditions poses a common risk factor for compassion fatigue. Unfortunately, the COVID-19 pandemic further compounds the risk, particularly as nurses encounter increased workloads and severe emotional distress associated with high patient acuity and mortality. (See Risk factors and triggers.)
Risk factors and triggers
The risk factors and triggers for compassion fatigue include the following:
- Sustained exposure to the traumatic experiences of others, including fear, pain, suffering, abuse, terminal diagnoses, and death.
- Perceived futility or failure arising from an inability to prevent suffering or alter the outcome despite the care provided.
- Personal identification with a patient’s suffering.
- Prolonged caregiver stress.
- Inability to maintain balance between empathy and objectivity.
- Lack of self-care, including inadequate rest.
- Decreased levels of self-compassion.
Compassion fatigue effects
Ethical nursing practice and high-quality patient care require compassion. However, many nurses experiencing compassion fatigue may be unable to demonstrate empathy and caring behaviors essential to establishing a therapeutic nurse–patient relationship. Decreased care quality can lead to an increased incidence of adverse events that negatively affect patient outcomes. Effects on nurses’ physical and psychological health result in decreased job satisfaction and quality of life. (See Symptoms.)
Compassion fatigue symptoms can manifest as physical, mental/emotional, and workplace performance.
- GI problems
- Muscle aches and pains
- Sleep disturbances, including difficulty sleeping and nightmares
Mental or emotional
- Anxiety (generalized or work-related)
- Existential crisis (questioning the inherent meaning of life or work)
- Feelings of helplessness or loss of control
- Inability to provide self-care or care for patients
- Irritability, anger, resentment
- Mood swings
- Unhealthy coping (with food, alcohol, nicotine, drugs)
- Depersonalization or lack of connection to patients
- Desensitization to patients’ experiences
- Difficulty concentrating
- Increased errors or impaired work performance
- Lack of empathy for patients
- Lack of joy or diminished work satisfaction
- Work dread or avoidance of patients
Compassion fatigue is closely linked to burnout syndrome, which includes feelings of exhaustion, cynicism, ineffectiveness, and reduced personal accomplishment. Burnout syndrome primarily is associated with workplace factors, such as limited resources, rather than secondary traumatization related to the caregiver role. However, compassion fatigue and burnout syndrome can occur at the same time, resulting in increased nurse turnover rates.
Compassion fatigue prevention and reduction
Intentional practices and training aimed at increasing levels of self-compassion may help prevent and reduce compassion fatigue. Self-compassion encompasses three overall aspects of mental well-being: mindfulness, self-kindness, and a sense of common humanity.
Mindfulness permits awareness of the present moment and feelings without exaggerating or minimizing suffering. Self-kindness refers to treating oneself with the same care and compassion you would a friend or loved one by offering yourself acceptance and kindness rather than judgment. Common humanity involves an understanding that the human experience inherently contains difficulty and sadness. It allows for a broad view focused on interpersonal connections rather than self-isolated perceptions of suffering
Research demonstrates that self-compassion is linked to psychological well-being and has an inverse relationship to anxiety, stress, and depression. Enhanced self-compassion increases resiliency (the ability to cope in the face of adversity). Among nurses, a significant inverse relationship between self-compassion and compassion fatigue exists regardless of individual or environmental variables. In addition, increased levels of self-compassion in nurses are associated with higher job satisfaction and significantly reduced burnout.
Self-care is important for nurses’ well-being, but it’s not the same as self-compassion. Self-care frequently takes place outside of work or during breaks and includes interventions such as exercise and other leisure activities. Most nurses can’t practice self-care during a busy shift or in a work environment with limited resources. Self-compassion, however, is well-suited to address empathic distress in the midst of caregiving. For example, it can include practicing self-kindness during traumatic experiences, such as the death of a patient, or acknowledging sadness when caring for a patient with end-stage disease.
As described by Neff and colleagues, interventions aimed at increasing self-compassion among nurses have been shown to lead to greater compassion satisfaction (positive feelings and a sense of fulfillment derived from caregiving). Nurses report that self-compassion practices improve coping skills and increase feelings of peace, positivity, and acceptance.
A supportive organizational culture that includes staff cohesion and collegial relationships strongly predicts an individual’s ability to resist compassion fatigue. Self-compassion also can improve interpersonal relationships and communication, which helps nurses effectively manage workplace challenges.
Self-compassion in the workplace
Neff and colleagues reported that mindful self-compassion training specifically adapted for healthcare workers results in significant increases in participants’ self-compassion, mindfulness, and compassion satisfaction. Participants with initially low self-compassion experience the greatest positive effects, indicating that a well-designed program can have a meaningful impact on healthcare workers at high risk for compassion fatigue.
Most healthcare environments aren’t conducive to formal mindful self-compassion training, so organizations should consider a multimodal approach. Opportunities to practice self-compassion techniques can occur in preexisting wellness programs or workplace routines, such as during shift huddles or meetings. Printed materials about self-compassion, such as badge cards, also may help nurses incorporate self-compassion into their work. Cultivating a culture of self-compassion requires that nurse leaders model it themselves, and organizations can support enhanced well-being among caregivers via staff education.
Microrestorative self-compassion practices
Integrate these short self-compassion practices into your shift and personal life to support your well-being and reduce your risk for compassion fatigue.
Mindfulness. Mindfulness means paying attention to your experiences with a nonjudgmental attitude. Awareness of mental, emotional, or physical discomfort cultivates clarity about what needs attention and supports accepting emotions and experiences.
Consider taking a moment for mindfulness during hand hygiene. As you wash or sanitize your hands, focus your attention on the present moment. Find your breath to anchor your awareness to the present. Take a deep breath and allow competing demands to move to the periphery of your awareness; immerse yourself in the simplicity of this sensory experience. Before moving on to the next task, take a moment to notice yourself, including your feelings, and appreciate your compassionate efforts.
Self-kindness. Self-kindness allows us to generate a deeper connection to ourselves and create opportunities to tend to our own needs in the midst of nursing. It provides opportunities to acknowledge our strengths and have compassion for our limitations, offering ourselves compassionate support as we would a good friend.
Pause when you notice uncomfortable emotions or are caught in thoughts that focus on the challenges of a difficult circumstance. If you feel comfortable, gently place your hand over your heart and take a deep breath. Quiet any tendency to believe your inner self-critic, and validate your feelings of distress. Visualize holding yourself and any distress you may be experiencing without judgment. In this difficult moment, offer yourself kindness and a warm presence and acknowledge that you’re doing the best you can.
Common humanity. Connecting with others through a sense of our common humanity allows us to recognize that everyone experiences moments of suffering and distress, and that we’re not alone. Feelings of frustration or fatigue can arise when caring for someone who’s suffering. Recognize that you also may need comfort from the stress of a difficult situation. The flow of compassion can be returned to yourself so you can then soothe, balance, and restore your capacity to offer it to others.
As you care for a patient, you may feel tired or overwhelmed. Take a moment to acknowledge these feelings and how you experience them in your body. Take a deep inhalation, imagine receiving compassion, and reflect on the following statements: “I’m not the cause of this patient’s suffering, nor is it completely within my power to make it go away, even though I wish I could.” and “Moments like these are difficult to bear, but I will try to help if I can.” Bring your attention back to your breath: inhale and draw in kindness for yourself, exhale and offer that same kindness to your patient. Continue this rhythm for a few breaths, notice the comfort and connection in this flow of compassion. Focus your attention on anyone needing extra compassion, including yourself. When you’re not at work, you can use this practice whenever you reflect on a difficult experience.
Support nurse well-being
Compassion fatigue presents a serious threat to healthcare organizations and nurses at all levels of practice. We may not be able to control some risk factors and triggers for compassion fatigue, making prevention and reduction challenging. However, self-compassion training in the workplace and organizational initiatives that reflect the unique experiences and needs of nurses can help support mental and emotional well-being.
*Names and scenarios are fictitious.
Salomé Loera is a clinical nurse specialist at Inova Health System in Northern Virginia. Melania Howell is a clinical nurse specialist and wound ostomy and continence specialist. Pamela Mulligan is a health and wellness coach and co-founder of Replenish Mind Body Spirit, LLC, in Guilford, Connecticut. Deborah Busch is an assistant professor at The Johns Hopkins University School of Nursing in Baltimore, Maryland.
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Key words: compassion fatigue, burnout, self-compassion