MAKING IT WORK AT WORK

Burnout and Fatigue Watch for the Signs

BY DENNIS PORTNOY, M.F.T.

or Catholic leaders, balancing mission with regulatory and fiscal care managers, as Anne M. realities means facing up to a future that demands delivering higher quality Nordhaus-Bike has shown.5 health care to more people at lower cost. In the struggle to provide quality, In terms of dollars and F cents, researchers Deborah compassionate care in a climate that offers fewer resources and, at the same time, Jones, Takeshi Tanigawa adapt to new business models, leaders can underestimate the strain on their front- and Stephen Weiss place line . But losing sight of burnout and compassion fatigue — which is a associated costs at $300 bil- type of burnout — puts both the health care workers and their patients at risk. lion annually. This figure includes estimates of the It takes a multi-pronged approach and often leads to a heightened sense of dollar effects of reductions in operat- to minimize the negative impact. The vulnerability.2 ing effectiveness, medical expenses organization and its policies play a key Researchers have described how and attrition resulting from .6 role by creating conditions that not burnout among nurses affects the Professional caregivers and their only reduce the risk of burnout and quality of treatment for patients, low- employers also need to learn to recog- compassion fatigue, but also promote ers morale and increases absenteeism, nize signs of burnout and compassion healthy, more effective workers. with an accompanying financial impact fatigue, because people in helping roles Workers involved in direct patient on the hospital. Nurse turnover due to are at great risk. care are exposed to and stress takes a financial toll, as well.3, 4 In the early stages, burnout symp- negativity on a daily basis. They face Hospital leaders need to understand toms include frequent colds, reduced increasing demands in the workplace, how downsizing, re-engineering and sense of accomplishment, headaches, while at home they juggle family life, staff turnover causes burnout in health fatigue, lowered resiliency and moodi- personal interests and often care for ness and increased interpersonal con- their own children and their aging par- flicts. If not treated, burnout gradually ents as well. The organization and its moves into an advanced stage display- Psychologists Ayala Pines, Ph.D., policies play a key role ing symptoms of somatic complaints, and Elliot Aronson, Ph.D., describe social withdrawal, depersonalization, burnout as a state of physical, emo- by creating conditions cynicism, exhaustion, irritability, low tional and mental exhaustion caused that not only reduce energy, feeling underappreciated and by long-term involvement in emotion- overworked. In time, a helper becomes ally demanding situations. It is accom- the risk of burnout and numb, disillusioned, hardened and panied by disillusionment and nega- overwhelmed. Often, caregivers don’t tive feelings.1 Psychologist and author compassion fatigue, but realize the negative effects until they Judith Herman writes that repeated also promote healthy, experience a health crisis or other sig- exposure to people’s suffering can nificant trauma. diminish the helper’s trust in humanity more effective workers. Compassion fatigue is a type of

HEALTH PROGRESS www.chausa.org JULY - AUGUST 2011 47 46 JULY - AUGUST 2011 www.chausa.org HEALTH PROGRESS Compassion fatigue is caused by Much of the research on com- . It is the natural consequence passion fatigue has focused on of stress resulting from caring for and counselors and first respond- ers who work with trauma vic- helping traumatized or suffering people. tims. Laurie Anne Pearlman and Lisa McCann, who have done burnout. It emerges suddenly and with little warn- research on the long-term effects of compas- ing, and it is usually more pervasive than burn- sion fatigue, report helpers develop a diminished out. In addition to regular burnout symptoms, a sense of personal safety and disrupted schemas person experiencing compassion fatigue can feel around trust, vulnerability, meaning and control. 7 a loss of meaning and hope and can have reac- There is overlap between burnout and com- tions associated with Post Traumatic Stress Dis- passion fatigue, and an individual can suffer from order (PTSD) such as strong feelings of anxiety, both. They share some symptoms, and both take a difficulty concentrating, being jumpy or easily toll on health and on relationships. Both affect the startled, irritability, difficulty sleeping, excessive workplace in low morale, absenteeism, decreased emotional numbing, intrusive images of another’s motivation and , though people suffering traumatic material. Past traumas can also be acti- from compassion fatigue often love their jobs. vated. Long-term effects include reduced empa- Compassion fatigue is caused by empathy. It is thy, diminished sense of personal safety, reduced the natural consequence of stress resulting from sense of control, hopelessness, increased involve- caring for and helping traumatized or suffering ment in escape activities and chronic overeating, people. It involves a preoccupation with an indi- drug or alcohol use. vidual or his or her trauma, and it doesn’t require being present at the stressful event. Simply being exposed to another person’s painful narrative can be enough. Author and researcher Beth Hudnall COMPASSION FATIGUE BURNOUT SYMPTOMS Stamm defines compassion fatigue as the con- vergence of primary stress, secondary traumatic Cognitive stress and cumulative stress in the lives of helping 8 Lowered concentration, apathy, rigidity, disorientation, professionals and other care providers. minimization, preoccupation with trauma For those in the helping professions, early rec- ognition and improved self-care both in and out of the workplace are key to creating wellness. Many Emotional caregivers focus on others at the expense of their Powerlessness, anxiety, guilt, anger, numbness, fear, helplessness, own well-being. It is crucial for them to replenish sadness, depression, depleted, shock, blunted or enhanced affect. themselves and commit to having a life outside Experiencing troubling dreams similar to a patient’s dream. of work that includes daily nurturing activities. Suddenly and involuntarily recalling a frightening experience while People often understand this concept intellectu- working with a patient or family ally, but the knowledge doesn’t necessarily lead to taking better care of themselves. Behavioral It is important for individuals and their Irritable, withdrawn, moody, poor sleep, nightmares, appetite employers to recognize and challenge the psycho- change, hyper-vigilance, isolating logical obstacles that get in the way of self-care, such as the belief that focusing on personal needs Spiritual is selfish or indulgent. Enlightened self-interest is Questioning life’s meaning, pervasive hopelessness, loss of quite different from narcissistic preoccupation. purpose, questioning of religious beliefs, loss of faith/skepticism Self-care actually increases a ’s capac- ity to care for others. Self-care, however, is not just about making healthy lifestyle choices — it Somatic is about being present with one’s feelings, sen- Sweating, rapid heartbeat, breathing difficulty, aches and pains, sations and intuitive guidance in order to detect dizziness, impaired immune system, headaches, difficulty falling or what is best in any given moment. staying asleep A 2010 study done on nurses and compassion fatigue revealed that compassion fatigue was sig-

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nificantly higher in nurses who worked 8-hour life balance as a way to build resilience to stress shifts compared with nurses who worked 12-hour shifts.9 Compassion satisfaction was significantly Incorporating elements from existing pro- higher in intensive-care-unit nurses than in emer- grams such as the approach developed by ther- gency department nurses. Nurses with the least apist J. Eric Gentry, Ph.D., can also help.10 Gen- experience reported significantly higher rates of try’s approach has several components. The first compassion satisfaction compared to the more involves what he calls intentionality, in which he experienced nurses. focuses on helpers becoming more self-directed Compassion satisfaction was strongly nega- and developing an internal locus of control. This tively correlated with numerous items on the includes articulating a personal and professional compassion fatigue and burnout subscales. mission statement focusing on goals and what’s Nurses who had higher compassion satisfaction important to them. scores were more interpersonally “fulfilled,” as The next component is recognizing and defined by scores on “being happy,” “being me,” accepting symptoms and committing to address- and “being connected to others.” These nurses ing personal issues. This includes identifying trig- did not feel as trapped and did not experience dif- gers and which client issues activate the symp- ficulty separating personal life and work. They toms. His program emphasizes learning skills to were less likely to feel exhausted, bogged down deal with responses to stress — self-soothing and or “on the edge.” grounding, self-care, boundary setting, eye move- Compassion fatigue was often triggered by ment desensitization and cognitive restructuring. patient care situations in which nurses: There are programs that focus on stress man- Believed that their actions would “not make agement for staff that incorporate mind- a difference” or “never seemed to be enough” fulness training, relaxation techniques and self- Experienced problems with the system (high care practices. Anderson Torres, Ph.D., director patient census, heavy patient assignments, high of health initiatives, at Bon Secours New York acuity, overtime and extra workdays) Health System/Schervier, has implemented a pro- Had personal issues, such as inexperience or gram using guided imagery, cognitive desensitiza- inadequate energy tion and breathing exercises to help nurses cope Identified with the patients with stress. Overlooked serious patient symptoms These sessions, a part of Bon Secours’ cor- porate wellness program, are scheduled when To offset and reduce the risk of burnout and departments identify a need. Torres notes that compassion fatigue in staff members, organizations and managers can: Create an open environment Caregivers need to be able to where employees have a venue for deliver service excellence without mutual support. Encourage employ- ees in meetings and with supervisors compromising their well-being. to talk about how they are affected by their work It is important for them and for Offer training that educates their employers to recognize early employees about burnout and compas- sion fatigue and how to recognize the warning signs of burnout and symptoms compassion fatigue. Share the caseload among team members, particularly the most diffi- cult cases frequent focus on in a sup- Make time for social interaction among portive environment — in daily staff “huddles,” teams. Social events and a yearly retreat away for instance — helps to normalize feelings related from the workplace can build cohesion and trust to stress. As I note below, these stress-related feel- Encourage healthy self-care habits such as ings can be accompanied by feelings of anxiety good nutrition, sleep, taking work breaks and isolation and even guilt, further compound- Reward effort and offer flexible work hours ing the problem and making it harder for staff Offer training that focuses on self-care and members to seek help.

HEALTH PROGRESS www.chausa.org JULY - AUGUST 2011 49 While anecdotal evidence suggests such pro- They are often very productive, but in the long grams are helpful, more research on effectiveness run, they crash and burn. of such methods is needed. More research also is Another example is helpers whose worth is needed to demonstrate the effectiveness of vari- defined by the good they do for others. They put ous techniques and programs in addressing prob- everyone else’s needs before their own needs and lems related to compassion fatigue. absorb the suffering of others. My own approach emphasizes underlying fac- Caregivers need to be able to deliver service tors that block helpers from implementing self- excellence without compromising their well- care strategies, attitudes that increase susceptibil- being. It is important for them and for their ity to burnout and compassion fatigue and identi- employers to recognize early warning signs of fying beliefs that lead to over-identifying with the burnout and compassion fatigue. It is also essen- role of helper. tial that workers in all levels of health professions For example, when helpers’ self-concept engage in self-care practices, learn to modulate and sense of worth is based primarily on their their responses to the stresses around them, be strengths, accomplishments, dependability, com- aware of destructive attitudes and reach out for petence and self-sufficiency, they often take on help. too much and have an excessive need for control. They have difficulty delegating, recognizing their DENNIS PORTNOY is a licensed psychotherapist need for support and are much better at giving who has been in private practice for over 25 years. than they are at receiving. Since they are dis- Located in San Francisco, he also specializes in connected from their emotional needs, they are training helping professionals in preventing and unable to focus on self-care. counteracting burnout and compassion fatigue. Their inability to embrace their vulnerability, to let go and get support makes them susceptible to NOTES burnout and compassion fatigue. It’s hard for them 1. Ayala Malakh-Pines and Elliot Aronson, Career Burn- to acknowledge their limitations and mistakes, and out: Causes and Cures (New York: Free Press, 1989). they equate limitation with failure and being weak. 2. Judith Herman, Trauma and Recovery: The Aftermath They are rescuers and thrive on fixing problems. of Violence — From Domestic Abuse to Political Terror (New York: Basic Books, 1997). 3. Cheryl Bland Jones, Michael Gates, “The Costs and ADDITIONAL RESOURCES Benefits of Nurse Turnover: A Business Case for Nurse Retention,” OJIN: The Online Journal of Issues in Nursing WEBSITES 12 no. 3 (Sept. 30, 2007): Manuscript 4. www.proqol.org 4. D. Ragsdale, E.L. Burns and S. Houston, “Absen- Professional quality of life information, including tee Patterns among OR Staff,” AORN Journal 53, no. 5 compassion fatigue/burnout (1991):1215-21. Professional Quality of Life Scale self-test 5. Anne Nordhaus-Bike, “The Battle Against Burnout,” www.myselfcare.org Hospital and Health Networks 69, no. 10 (1995): 36-40. Self-care quiz, articles 6. Deborah Jones, Takeshi Tanigawa and Stephen Weiss, “Stress Management and Workplace Disability in the www.compassionfatigue.org U.S., Europe and Japan,” Journal of Occupational Health Information for caregivers 45, no. 1 (2003):1-7. www.giftfromwithin.org 7. Lisa McCann amd Laurie Anne Pearlman, “Vicarious Information and articles for post-traumatic stress Traumatization: A Framework for Understanding the syndrome survivors and their caregivers Psychological Effects of Working with Victims,” Journal of Traumatic Stress 3, no. 1 (1990): 131 BOOKS 8. Beth Hudnall Stamm, Secondary Traumatic Stress: How Can I Help? Stories and Reflections on Service, Self-Care Issues for Clinicians, Researchers, and Educa- by Ram Dass and Paul Gorman (Knopf, 1985) 256 tors (Sidran Press, 1999). pages, $12 9. Elizabeth A. Yoder, “Caring Too Much: Compassion Fatigue in Nursing,” Applied Nursing Research 23, no. 4 The Truth about Burnout: How Organizations (2010): 191-197. Cause Personal Stress and What to Do About It, 10. Information about J. Erik Gentry’s programs is avail- Christina Maslach and Michael P. Leiter (Jossey- able through his website, www.compassionunlimited. Bass, 1997) 200 pages, $25 com.

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Reprinted from Health Progress, July-August 2011 Copyright © 2011 by The Catholic Health Association of the United States