National Cancer Institute NCI Cancer Bulletin: A Trusted Source for Cancer Research News
July 24, 2012 • Volume 9 / Number 15

Special Issue: Oncology Nursing

Emotional Rescue: Addressing Compassion Fatigue in Oncology Nursing

Nurse consoling a colleague
Recognizing the symptoms of compassion fatigue is the first step in treating the condition.

People who choose a career in nursing understand that there are many rewards in the profession and that they can expect to work hard. The hours may be long and workplace conditions may, at times, be grueling.

What many nurses don’t expect is that their relationships with patients and patients’ families involve a special kind of work, a type of often-taxing emotional labor. Too many of these experiences without healthy recovery can lead to compassion fatigue, a combination of secondary traumatic stress and burnout.

“Secondary traumatic stress is when caregivers suffer from witnessing or providing care to someone who is directly experiencing trauma. Burnout is the perception of work demands exceeding resources,” explained Dr. Patricia Potter, who directs research for patient care services at Barnes-Jewish Hospital in St. Louis. “Combined, compassion fatigue results in an array of symptoms that can intrude upon caregivers' lives and lead them to want to avoid the patients they must care for,” she continued.

Nurses who experience compassion fatigue usually don’t know what they are experiencing; they just know that they don’t like nursing anymore. They may even want to leave the field. They don’t feel sympathy for their patients and may be emotionally numb. Some become hostile toward co-workers, and many feel cynical.

Research has shown that there may be a relationship between the symptoms of compassion fatigue and the risk of committing medical errors. And, unsurprisingly, numerous studies have found that when nurses lose enthusiasm for their work, patients are less satisfied with the care they receive.

Fortunately, there are programs and tools that can help nurses recover from compassion fatigue relatively quickly. A crucial first step is to recognize the symptoms of compassion fatigue and to understand that it is normal.

Emotional Withdrawal

Compassion fatigue affects caregivers when they help someone through a traumatic or life-threatening event without acknowledging their own physical and emotional needs.

Emergency first-response teams, mental health professionals, and medical professionals who work in fields such as oncology are particularly at risk for compassion fatigue. The risk goes up if someone works in an inpatient setting, which presents more opportunity to become emotionally attached to patients facing death.

According to various studies, at least one-third of nurses who work in high-risk settings may be suffering from compassion fatigue at any given time.

If someone has gone through caring for two or three patients who have suffered a cancer recurrence and died, those are the nurses who may need our help.

—Brenda Nevidjon

“Some of the clues are that they don’t smile anymore, they don’t spend as much time in patient rooms as they used to,” said Brenda Nevidjon, a professor in the nursing program at Duke University and former president of the Oncology Nursing Society. “Other clues are when people start calling in sick, being late, or just not engaging in typical activities. You see them pull away.”

Research has shown that younger nurses and nurses who have more education and higher levels of certification may be at greater risk for developing compassion fatigue.

Nevidjon, whose research focuses on cultivating leadership skills in nurses, says that this relationship makes sense. In 2010 she gave a presentation as part of the Oncology Nursing Society’s Leadership Development Institute to help nurses understand the risk of burnout and compassion fatigue and how these troubling conditions can be avoided.

“Nurses are the last to say, ‘I need help’,” Nevidjon said. “We’re always willing to offer help, but to ask for help is very hard.”

Learning Self-Care and Reflection

When nurses have the courage to ask for help dealing with emotional stress at work, it’s important for their managers and hospital administrators to have appropriate support systems in place.

Dr. Ann Berger, chief of the Pain and Palliative Care Service at the NIH Clinical Center, faced this situation less than 2 years ago, when multiple groups of nurses and physicians contacted her staff after a rash of patient deaths and the deaths of several clinical staff members.

“We couldn’t handle this alone; the need was too great,” Dr. Berger said. So, she formed a work group from various hospital departments and the NIH Office of the Director to develop a plan.

Their first step has been to assemble a volunteer group of approximately 40 staff members at the NIH Clinical Center who will receive training to conduct debriefing sessions for hospital staff who are struggling with emotions on the job. Pairs of volunteers will customize a plan for each person who requests help and walk them through the process. Later this fall, the clinical center plans to begin Schwartz Rounds, a forum where clinicians can talk about emotionally difficult experiences at work. (See the box titled "Treating Compassion Fatigue.")

Dr. Potter encountered a similar situation nearly 3 years ago when two nurse managers from her hospital’s outpatient infusion centers came to her with concerns about burnout.

Members of the compassion fatigue team at Barnes-Jewish Hospital.
Barnes-Jewish Hospital’s compassion fatigue team includes (from left to right) Marty Clarke, cancer psychiatry consultations service; Kathleen Walton, social worker; Dr. Julie Berger, chaplain; Brent Brazell, human resources; Dr. Patricia Potter, director of research and patient care services; and Cathy Powers, clinical nurse specialist.

Dr. Potter surveyed the oncology nursing staff using a 30-point scale instrument called ProQOL R-IV and found that a significant proportion of the nurses scored in a range indicating compassion fatigue. She sought the guidance of Dr. Eric Gentry, a traumatologist who has worked with emergency first-responders and mental health professionals, including those who assisted with recovery efforts after the terrorist attacks of September 11, 2001.

Dr. Potter and her colleagues implemented a pilot program among the oncology nurses at the Siteman Cancer Center, the NCI-designated cancer center affiliated with Washington University and Barnes-Jewish Hospital. They used a program based on Dr. Gentry’s Accelerated Recovery Program, which includes a train-the-trainer session, techniques for relaxation, and exercises to remind nurses why they became nurses in the first place.

Six months after the intervention, the oncology nurses at the Siteman Cancer Center had significantly reduced symptoms of compassion fatigue and felt rejuvenated at work. The results were so encouraging that Dr. Potter expanded the program hospital-wide earlier this year. The program teaches participants to care for themselves, how to reduce the body’s response to stress, and to recognize that the most that they can do is their best, and no more. All of these help lessen the symptoms of compassion fatigue, noted Dr. Potter.

It’s Okay to Struggle

Dr. Potter says that one of the most valuable exercises they offer is called The Silent Witness. Everyone in the group has an index card on which they write three negative effects that caregiving has had on them. Participants then circulate around the room sharing their cards with each other, reading the notes in silence.

“What they see is that everyone has the same symptoms,” Dr. Potter said. “They realize that what they have been feeling is normal. They may have been hesitant to recognize these issues before, because they felt guilty about their emotions and didn’t know what they might mean. This exercise teaches them that they are not alone.”

When Dr. Potter asks workshop participants if they’ve heard of compassion fatigue before, usually only a few people raise their hands, she said.

That may change as nurses and nursing school faculty members become more familiar with the term and with the consequences it can have, both for staff retention and for nurses who may find themselves losing a sense of purpose in their career because of it.

“We have to pay attention to each other,” Nevidjon says. “If someone has gone through caring for two or three patients who have suffered a cancer recurrence and died, those are the nurses who may need our help. We need to make it safe for them to ask for it. And we need to have a venue where they can express their grief and deal with loss.”

Brittany Moya del Pino

Treating Compassion Fatigue

“The treatment for compassion fatigue has to do with communication and communication skills,” Dr. Ann Berger said. “It’s about self-care and self-reflection.”

Self-care includes getting exercise, eating well, and getting enough sleep. But it also includes maintaining hobbies, friendships, and interests outside of work.

Some of the tools the NIH Clinical Center pain and palliative care staff have used to help clinicians manage grief and emotional overload include art therapy, healing gardens, and journaling.

Other interventions and programs that deal specifically with compassion fatigue include

  • Mindfulness-Based Stress Reduction: In a series of classes, participants learn how to analyze their physical perceptions from head to toe—what they smell, if they have any aches or pains, and if they are hot or cold. These exercises help people block out thoughts about what happened in the past or worries about what may happen in the future so they can better understand and respond to their sources of stress.
  • Accelerated Recovery Program: Developed in the 1990s by Drs. Charles Figley and Eric Gentry, this program helps participants develop self-management plans and learn self-regulation skills, which may help nurses control symptoms that are triggered by the sympathetic nervous system in response to stress.
  • Schwartz Rounds: Developed by the nonprofit Schwartz Center for Compassionate Healthcare, this program is held once or twice a month and allows clinicians the opportunity to share their most emotionally difficult experiences at work and offer each other support, with the help of a trained facilitator.

Hospital administrators who want to develop a compassion fatigue program for their clinical staff would do well to work with an experienced professional, rather than improvising on their own, Dr. Patricia Potter advised.

“It makes a big difference to have professional guidance in this area,” she said. “You can’t have an effective program without having a sense of what is at the root of an individual person’s compassion fatigue, and linking that with appropriate interventions.”