Compassion fatigue and burnout—it’s a popular topic in nursing. It’s tough to know how to maintain a good work/life balance and show compassion for patients while still preserving your own mental and physical health.
Vidette Todaro-Franceschi, PhD, RN, FT, Professor, The College of Staten Island & Graduate Center, both of the City University of New York, is also the author of Compassion Fatigue and Burnout in Nursing. As the second edition of the book recently published, we asked her questions about how things have changed.
What are some of the
biggest changes that you’ve observed regarding compassion fatigue and burnout
in nursing since the first edition of the book?
Since the first edition in 2012, a greater emphasis is being
placed on the relation between nurse well-being and patient care, as evidenced
by the growing body of research and practice literature. There are more studies
being performed in the area of professional quality of life, and the
significance of having a “happy” as well as “healthy” workforce is finally
getting proper attention.
A number of nursing organizations have advanced various programs to foster a healthy work environment and promote work-life balance. For example, in 2013 the American Nurses Association (ANA) launched an initiative with the development of a professional issues panel to address nurse fatigue. Since then other professional issues panels have been formed to focus on moral resilience and workplace violence, among others. In 2017, the ANA began a critical initiative called the Healthy Nurse, Healthy Nation Grand Challenge (HNHN GC), which is geared toward enhancing both nurse well-being and the health of the nation—a win-win for all.
Lastly, years ago I would have been tarred and feathered for
saying that no one coming to work should be asked to leave their baggage at the
door, or that it was ok for a nurse to say, “I need a mental health day” or “I
just cannot do it.” Today, I think,
there is recognition that we—nurses—are human beings; we feel, we hurt, we cry,
and it’s ok.
What are the
biggest challenges for nurses experiencing poor professional quality of life?
The biggest hurdles for nurses who are experiencing professional
quality of life issues (related to: compassion fatigue, moral distress,
incivility, lack of preparedness to care for patients who are dying, death
overload, PTSD, burnout, unhealthy work environment) are: acknowledging that there
is a problem, recognizing that there are choices and actions that they can
take, and lastly, turning toward self and other(s) in ways that foster health and
contentment. These three things form the basis of ART©, a mindful awareness model, which I developed to
assist nurses and other carers to enhance their professional quality of
Mindful awareness is the key to acknowledging how one feels (the A of ART). However, this
can be challenging, since the majority of nurses work in fast-paced, chaotic
places and are not paying much attention to how they feel as they go about their
work. In fact, coworkers, friends, or family members may identify that there is
a problem before the suffering nurse becomes aware. Hence, nurses should engage
in mindfulness at work (and at home) in order to acknowledge both the good and
the bad feelings associated with their work (with the goal to maximize the good
and minimize the bad).
Once a problem has been acknowledged, it is essential to
figure out what choices one has and what actions can be taken to fix whatever
needs fixing. This can be another difficult hurdle for some nurses. A nurse might
think that she/he has no choice(s), or may be fearful of change. Nurses need to
recognize that there are always choices
(doing nothing is a choice), and then intentionally choose and take action to change
their work circumstances (the R of ART).
The last part of ART is turning toward self and other(s) (the T of ART), which entails connecting and/or reconnecting with the things that contribute to health and happiness, whatever those things might be. Nurses need to put the oxygen mask on their own faces first, figure out what makes them happy, and what will contribute to their well-being. Of course, this is easier said than done because nurses are typically self-sacrificing and altruistic. But nothing good can come from self-sacrifice that results in an unhealthy, unhappy person, especially one who is responsible for the health and well-being of others.
Making changes in eating, drinking, sleeping, and
exercise habits can be difficult. Motivating oneself to go out with friends or
family, or even to go out for a walk around the block may seem incredibly daunting
when one is physically or emotionally exhausted and unhappy. Turning towards
self and other(s) has to be taken one small step at a time, mindfully. Eventually,
new good habits can replace old bad ones.
have occurred for nurses who experience professional quality of life issues
such as compassion fatigue and burnout?
With greater awareness of the importance of nurse well-being
for patient care quality, in many settings, health care administration is focusing
efforts on creating a healthier, happier workforce. For example, many
workplaces now have wellness, meaningful recognition, and resiliency programs.
What do you think is
most surprising to people and/or nurses regarding compassion fatigue and
The fact that many individuals are compassion fatigued or burned
out (or other things), without realizing it. Whenever I teach and/or talk about
it, there seems to be this reverberating AHA!
People who work with all
living beings (humans and animals)
should be educated about professional quality of life issues. They should know
how to identify compassion fatigue, moral distress, death overload, PTSD, and
burnout as well as the effects these things can have on their health/well-being,
work productivity, and patient safety.
Sharing personal information with patients sometimes is
just natural for nurses. Working closely with patients while caring for them
and giving them compassion warrants it.
The adage says that you don’t discuss some things with
other people: religion, money, and politics. But is this really true, though?
Mindy B Zeitzer, PhD, MBE, RN, Visiting Assistant Professor of Nursing at the Linfield College, School of Nursing, has worked a lot with self-disclosure—when it’s okay to share information and when it’s not. She took time to answer our questions.
Nurses who work
with patients may practice a particular religious faith or have none at all.
When is it appropriate to share their faith with patients? When is it not
Self-disclosure of any type including religious beliefs and religious practices should or can be done when the purpose benefits the patient. Meaning religion beliefs or practices can/should be shared when its purpose is to either help with patient goals or help develop a better nurse-patient relationship, a therapeutic relationship. For example, if the patient had particular religious beliefs and perhaps felt alone in those beliefs or was struggling with a certain aspect of health and religious beliefs and the nurse shared similar beliefs, the nurse might connect with the patient by discussing those beliefs and expressing empathy through understanding.
It would be inappropriate to share religious beliefs or
practices if the purpose or intent was to serve the nurse’s goals rather than
the patient’s. It also would be inappropriate if the nurse does not feel
comfortable with sharing or divulging such information. When it comes to self-disclosure
of any kind, the nurse should only share information and as much information as
they feel comfortable sharing.
When can talking
about their faith actually help patients?
Many patients turn to faith in difficult times with health. For some patients, turning to faith may be “new” to them, and they may not feel totally comfortable with it. As nurses, we are often at the bedside at those vulnerable times. Expressing empathy and understanding through shared beliefs—or even if they are not shared—can help a patient feel understood and talk about their current feelings, emotions, and experience. It can also help “normalize” the experience of thinking about faith at these difficult times, if that is what the patient needs.
Are there instances
in which expressing their faith can get nurses in trouble?
Anytime a nurse discusses information pertaining to themselves (self-disclosure) to fulfill the nurse’s own goals such as trying to convince a patient to receive a certain treatment or refuse a certain treatment—based on the nurse’s beliefs—could be considered coercive. The nurse, rather, should try to help the patient understand/recognize their own beliefs and values so the patient can make an informed, well thought-through decision based on their own values and beliefs in order to make the best decision for the patient—rather than what is best for the nurse.
What advice would you give to nurses about sharing their faith in general—whether it’s with patients, families, or coworkers?
First, only share information about your beliefs if you
feel comfortable doing so.
Second, before discussing your own beliefs, think about
what will be accomplished by doing so. Does it help meet patient goals or personal
Should they ask
patients about their beliefs in a way to be cross-cultural?
An important aspect of being culturally sensitive is to make sure we meet [the] patient’s need related to cultural and religious beliefs. In order to do this, it’s important to ask if patients have a particular belief system, particular beliefs, or religious or cultural practices. Perhaps they would like to see a particular clergy member or have various care aspects modified—in particular: diet, modesty, the way we approach medical treatments, aspects pertaining to death and dying, pain control, etc. If we don’t ask about these needs, we likely will miss an important aspect of the patient and won’t be able to help the patient holistically.
When transplant cardiologists at the Debakey Heart and Vascular
Center at Houston Methodist Hospital, began to use percutaneously placed
axillary intra-aortic balloon pumps (PAxIABPs) in 2007, there was one problem.
Not with the procedure, which would act as a bridge to heart transplants. But
rather, with the nursing care that would take place after. When CICU nurses
searched for literature on the subject, there was one problem.
There wasn’t any.
The procedure was so new, so no patient care protocols existed. So they developed them. And now an article about the problems and solutions developed by the nurses is out.
Frederick R. Macapagal, BSN, RN, CCRN, RN, Cardiac Intensive Care Unit, Houston Methodist Hospital, was a part of that team and is a lead researcher on the article. What follows is an edited version of our interview with him
Q: Were you on the original team that discovered that no nursing literature existed on PAxIABPs in 2007?
I was part of the team at Houston Methodist Hospital that
searched the literature in 2007 and did not find any nursing articles about
caring for patients with PAxIABPs. Medical journals had a few articles about
similar procedures, but they focused on the surgical intervention with nothing
about nursing care.
Since this was a relatively new procedure, the lack of
nursing articles was not surprising. Our protocols were developed over time,
using evidence-based nursing care and lots of “learning by doing.” After about
10 years of developing, reevaluating, and taking care of more than 100 patients
with PAxIABPs who are awaiting heart transplant, our staff has become more
competent and comfortable taking care of these patients.
Q: Explain how the
nursing and medical teams collaborated to develop these protocols. Did you work
together to determine what to try and what not to? Please explain.
The cardiologists informed us about the new procedure and
what the change meant for the patients. They gave us parameters and guidelines
on what to do and not to do to take care of the balloon pump and the insertion site.
Overall, the doctors trusted the nursing staff to figure out how to walk these
patients safely and provide the care needed at the bedside. The
multidisciplinary team of nurses, doctors, physical therapists, and ancillary staff
collaborated to devise interventions to mitigate the problems that arose and
incorporate them into the standard of practice.
Q: How did you decide
how to develop and implement clinical practice guidelines if there was no
previous literature with evidence-based practice backing it?
We did not have a choice. Our patients with intra-aortic
balloon pumps needed us to find a way to get them moving. Our patients needed to
walk to keep up their strength while waiting for a transplant, and we had to
develop our own nursing care protocols based on existing evidence-based
practices in order to safely incorporate walking and mobilizing into their care.
Q: What are the
resulting clinical practice guidelines that reflect nursing care practice and
The mobility guidelines we developed address issues such as where
patients walk within the cardiac care unit, for how far, and how long. We
defined the number of staff who need to walk with the patient, based on each
one’s individual strength. The guidelines also cover how often laboratory tests
and x-rays need to be completed. For example, laboratory tests such as complete
blood count and basic metabolic panel are obtained every other day to minimize
blood loss and the need for blood transfusions. On the other hand, chest
radiographs are obtained every day to determine the PAxIABP position.
Our nursing team also developed a PAxIABP repositioning kit so
that transplant cardiologists can perform simple repositioning of the PAxIABP
at the bedside as needed. This kit
contains sterile gloves, masks, surgical cap, stabilization device adhesive,
CHG scrub stick, and a prepackaged central catheter dressing kit. The kit,
stored in a clear plastic bag, is hung on a pole attached to the IABP console
for easy access.
Q: The article lists
some really interesting morale boosters used. Why are these so important to patients
in these situations?
Our pre-heart transplant patients with IABPs wait anywhere
from a few days to months for a donor heart. Anyone would get depressed with waiting
for so long under such stress. So the nursing staff came up with different ways
of helping our patients cope.
We consider these patients part of the CCU family and treat
them as such. We call them by their first names, chat with them about anything
and everything whenever we pass by their rooms, and get to know their family
and other visitors. We celebrate birthdays, anniversaries, holidays, and other
special occasions. We’ve found ways for patients to enjoy the occasional
home-cooked meal, have their pets come for a visit, and more, in an effort to
keep their spirits lifted.
Our patients from 10 years ago regularly come to our unit
when they are in town, chat with us, and offer to visit with current patients
who might need a pep talk and some cheering up. Patients appreciate the extra
effort we put into making their stay with us enjoyable.
Q: What else is important
about the nursing protocols for patients with PAxIABPs?
We started with existing evidence-based practice, but our journey didn’t end there. Whenever a challenge arose, we found solutions to address the situation. We documented each lesson learned and worked through the unique challenges encountered with our patients. We gained confidence throughout this process in our ability to innovate and improve the care we provide to all of our patients. We hope that this article helps other nurses who are caring for patients with PAxIABPs or who may do so in the future. In addition, we hope it inspires nurses to trust in their abilities to be innovative and courageous as they strive to provide the best care for their patients.
To learn more about the protocols, visit https://www.aacn.org/newsroom/nurses-develop-protocols-for-patients-with-paxiabps.
A 2018 study by the American Enterprise Institute (AEI) called “Nurse Practitioners: A Solution to America’s Primary Care Crisis,” by Peter Buerhaus, suggested that NPs can help with the problems of not having enough primary care physicians in particular areas of the United States.
David Hebert, JD, Chief Executive Officer of the American Association of Nurse Practitioners (AANP), recently explained how NPs can make a difference and what can stand in their way.
What follows is an edited version of the interview.
How many states restrict NPs scope-of-practice? What are the limits—what are they not allowed to do in these states that other states allow them to do? If they are allowed their total scope-of-practice, are they able to do everything that a primary care doctor can do?
Currently, 28 states don’t allow NPs to practice to the fullest extent of their training and licensure. Twelve of these—including California, Texas, and Florida—are “restricted practice” states, where the law restricts NPs ability to provide care without a formal contract with a physician. Sixteen other states, including Pennsylvania, Ohio, and Kentucky, are “reduced practice” states, where state regulations limit NPs’ ability to treat patients in certain care settings.
In 22 states, the District of Columbia, and Guam, NPs have full practice authority. This means NPs evaluate patients, diagnose, order and interpret diagnostic tests, as well as initiate and manage treatments under the exclusive licensure authority of the state board of nursing.
NPs and physicians both have the skill set to provide the full range of primary care services to patients. It’s not really about the provider—it’s about giving patients a choice of provider and ensuring them access to high-quality health care. NPs are a critical component of care teams. We work with all kinds of providers in every care setting to make sure patients get the best possible care. When it comes to scope-of-practice laws, we want NPs to be allowed to practice to the fullest extent of their training and licensure.
With the lack of primary care physicians, especially in rural and medically underserved areas, what can the NP bring to the community?
NPs ensure patients in rural communities have greater health care access, especially in primary care. The AEI report confirmed that while the NP workforce is growing significantly, the physician workforce is growing at a much slower rate. The study also concluded what we’ve seen in our own work: primary care NPs (PCNPs) are more likely to practice in rural areas, where the need for primary care is greatest.
It’s important to remember that primary care can prevent additional health complications for patients, making NPs a vital resource for rural communities. People living in states with laws that reduce or restrict NPs’ scope-of-practice have significantly less access to PCNPs. This finding indicates that such state regulations have played a role in impeding access to primary care. This alone should be cause for concern among policymakers seeking to improve public health.
When NPs have moved into areas and had the complete ability to practice, what have been some of the results?
In U.S. News & World Report’s 2018 Best State Rankings, nine of the top ten states for best health care allow patients full and direct access to NP care. According to Buerhaus, author of AEI’s report, people living in states that do not restrict NP scope-of-practice have significantly greater geographic access to primary care. More and more people are choosing NPs because the quality is high and accessible as well as because NPs take into account the needs of the whole patient, which resonates with today’s families.
What would you say to patients who might be afraid that they are getting lesser care in being treated by an NP as opposed to a doctor? How can NPs and other health care providers help patients to understand the benefits?
It’s important for patients to feel comfortable in their selection of a health care provider. Research shows that NPs achieve health outcomes for their patients equal to—and in some cases—greater than their physician counterparts. We encourage patients to consider an NP, take time to learn more about the care NPs provide at www.WeChooseNPs.org, and if it’s the right choice for them, to visit NPfinder.org, where they can find an NP in their area.
We’ve launched a nationwide campaign called We Choose NPs that showcase patients who choose NPs as their primary care providers. We believe it’s important for patients to have access to high-quality primary care and to have the information available to make the right health care choice for their family.
NPs are strengthening health care in a variety of important ways. Recently, Congress passed comprehensive opioid legislation that makes permanent the temporary authorization granted nurse practitioners (NPs) and PAs to provide lifesaving medication assisted treatments (MATs) for patients battling addiction. After conducting a billion patient visits last year alone, we’re very excited about the future and the opportunity to help patients nationwide.
Barbara Stilwell, PhD, RN, FRCN, is on a mission. She wants nurses to be empowered. As the Executive Director of Nursing Now, a three-year global campaign run in collaboration with the International Council of Nurses and the World Health Organization, she and all those involved want nurses’ voices to be heard.
She took time to explain what Nursing Now is and what they hope to accomplish.
What is the Nursing Now campaign? Why did you
start it? Why do you think it’s important?
The purpose of the campaign is as follows: Nursing Now aims to improve health and health care globally by raising the status and profile of nursing, demonstrating what more can be achieved by enabling nurses to maximize their contribution to achieving universal health coverage.
Strengthening nursing will have the additional benefits of promoting gender equity, contributing to economic development, and supporting other Sustainable Development Goals. This “Triple Impact” was identified by a British All Party Parliamentary Group in 2016 which reviewed the contribution of nursing to global health and identified the triple impact—improving health, promoting gender equality, and contributing to economic growth.
specific outcomes of the campaign are:
investment in nursing
in global policy
nurse leadership and influence
evidence of impact
ways of sharing effective practice
The strategy for achieving these outcomes has two interconnected elements—influencing policy globally and supporting action locally. The first involves adopting a high-level influencing approach working with partner organizations and the campaign champions to influence decision makers and organizations at global and regional level to include nurses at every level of decision making.
The second involves providing support to partners
locally, including professional associations and national Nursing Now groups,
to influence policy nationally, and support the development of nursing and
midwifery in their countries. We
want the local groups to create a social movement among nurses and midwives
that will support the aims of Nursing Now and result in changes being locally
The campaign is important because all countries face
enormous challenges in improving health and providing health care due to growth
in non-communicable diseases, changing demography, and the impact of emerging
factors such as climate change and migration, all coupled with rising demand
for health care with its associated costs. Achieving this will require massive
increases in health workers.
Nursing can make an even greater contribution to health
in the future. This is partly because nurses and midwives between them make up
almost half the professional health workforce globally. As importantly,
however, that nurses are particularly well-suited to contribute even more in
the future because of the way in which the whole health environment is
changing. The core arguments are:
- The burden of diseases is changing with increases in long term non-communicable or chronic diseases and—as populations age—more people with multiple morbidities who are living longer (often at home) and dying at home too. There is an increasing concern to care for those with mental health problems too, especially young people. Nurses are already central to much of this home care, and their role will continue to expand.
- These changes require new, more community-based
and holistic models of care as well as greater focus on health promotion and
disease prevention. Implementing new
models of care will require teams that, at times, should most appropriately be
led by nurses because they may be best suited to plan and manage care pathways.
- Nursing philosophy, values, and practice mean
that nurses are particularly well-suited to planning, implementing, and
managing patient centered, community-based care with a view to the full bio-psycho-social-environmental aspects
of health. Moreover,
nurses often work closely with their local
communities and constitute the majority of most health teams; they are ready to step up to the challenge.
To learn more about Dr. Stilwell and the global campaign, visit www.nursingnow.org or check out the radical advocacy special issue of Creative Nursing.