Chapter 8: Developing Compassion Resilience: Overcoming and Preventing Burnout, Secondary Traumatic Stress, Vicarious Trauma and Compassion Fatigue

As we have discussed throughout this book, nurses are exposed to suffering on an almost daily basis. Exposure to high levels of suffering can take a toll on a person’s emotional and psychological resources. In this book, I have attempted to give you, the readers, the information and tools you need to prevent, mitigate or heal from compassion fatigue, burnout, vicarious trauma and secondary traumatic stress. However, sometimes life, or work, gives us more than we can handle. Sometimes we lack the resources such as time, knowledge, social support, to heal from the trauma and suffering we witness. When this occurs, we may experience burnout, secondary traumatic stress, or compassion fatigue. In this chapter I will briefly define these concepts and will discuss some of the current science as it relates to these concepts. I have included some tools to determine if you are experiencing any of these conditions and will offer some suggestions for healing.

Compassion fatigue, burnout, vicarious trauma and secondary traumatic stress are overlapping concepts. It is probably more useful for researchers to differentiate between these concepts than it is for nurses who are experiencing loss of joy at work, stress over work and decreased ability to connect with patients to be overly concerned about a precise label for their experience. Indeed, one researcher has labeled all of these concepts as “empathy-related stress”, which seems to be a more useful way of looking at these conditions for most of us (Rauvola, et al., 2019). Unlike a condition such as diabetes or heart disease, the road to recovery from any of these conditions is not dependent on an exact diagnosis since the strategies for preventing and mitigating the consequences of each of these conditions are remarkably similar. However, because you may have questions about the differences between the three concepts, I do want to take a little time discussing each. First, we will explore the concept of burnout.

Burnout

Research on burnout has been ongoing since the 1970s, however the concept was only recently recognized as an occupational hazard by the World Health Organization (WHO) in 2019 in the 11^th Revision of the International Classification of Diseases (ICD-11). This document states that burnout is characterized by “feelings of energy depletion or exhaustion, increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy” (WHO, 2019). Symptoms of burnout are believed to develop gradually over a period of time as a result of repeated workplace stressors (Maslach & Leiter, 2017) While there are individual factors that may predispose some people to burnout, research suggests that workplace conditions play more of a role than individual characteristics (Maslach & Leiter, 2017).

People who experience chronic, unrelenting, and demanding workloads with no opportunity to recover are more likely to experience burnout (Maslach & Leiter, 2017). If you are thinking that this sounds like your workplace, you are not alone! In one study of nurses who worked in skilled nursing facilities (long-term care), participants reported that “understaffing, lack of management support, lack of resident care resources, and difficult interactions with residents and families” (Steinheiser, 2018, p. 98) led to burnout.

Many nurses work in fast-paced settings where they are unable to take regular breaks. When I worked in the hospital, I rarely took my allotted 15-minute breaks, and counted myself lucky if I got a full 30 minutes for a meal. A quick trip to the bathroom was sometimes the only break I got (and sometimes that didn’t even happen). Furthermore, I was often asked (or coerced) to work overtime to cover a shortage on the next shift, and then had to come back the next day on just a few hours of rest. While I cannot speak to the situation in the rest of the world, I know that this type of workload is typical for hospital nurses in the United States, and it has only been exacerbated by the COVID-19 pandemic.

A negative social climate, specifically one in which there is workplace bullying, as well as incivility from patients and their families, can also lead to burnout (Maslach & Leiter, 2017; Wing et al., 2015). Unfortunately, healthcare workers experience higher levels of incivility and workplace bullying than other occupational sectors (Johnson, 2018). During the COVID-19 pandemic, abuse from patients and their families escalated (El Ghaziri, et al., 2021). During the early phases of the pandemic, nurses also experienced tensions and conflicts related to work outside of the workplace, which meant that they often had no break from the job-related stressors created by COVID (El Ghaziri, et al., 2021).

As I mentioned earlier, organizational factors seem to be more predictive of burnout than individual factors. A few organizational factors that contribute to burnout are low levels of job control, and a feeling that the workplace is not fair in how rewards and punishments are meted out (Maslach & Leiter, 2017). Leadership style is also associated with burnout. Ethical leadership, authentic leadership, empowering leadership and transformational leadership styles, which are characterized by leaders who are attentive to the needs of employees, and to reducing role ambiguity and job stress, are all associated with lower levels of burnout among staff (Vullinghs, et al., 2020; Wei et al., 2020). In contrast, absent, lassiez-faire, and passive leadership styles are associated with increased levels of staff burnout (Vullinghs, et al., 2020; Wei et al., 2020). Taken together, the research indicates that if people work in a stressful environment where they do not feel in control of their work, and do not have supportive leadership, it does not matter how resilient or strong they are, they are more likely to experience burnout than someone in a workplace that is empowering and supportive.

Maslach & Leiter (2017) have proposed a model of explaining burnout that takes into account the organizational and the individual contexts. In their model, when there is an unmanageable workload, a mismatch between the values of the employee and the organization and an imbalance between the demands of the job, support from co-workers and leaders and individual resources (e.g. the ability to recharge from work, the ability to find joy in work), workers can start to feel anxious and exhausted. When the espoused values of the organization clash with their expressed values – for example if a healthcare organization states it values quality of patient care, but their decisions indicate they are more concerned with saving money – workers become cynical. When people feel they cannot do their job effectively due to role ambiguity, role stressors or unreasonable expectations, they may become emotionally detached from their work, and reduce the effort they put into their job in order to conserve energy. Workers in these conditions are more likely to exhibit the symptoms of burnout; namely exhaustion, detachment, cynicism and reduced professional efficacy {Maslach & Leiter, 2017).

While a poor working environment is the antecedent of burnout, there are things that individuals can do to prevent burnout, or at least to stave it off. Active coping, such as taking care of one’s physical and mental health, seeking a new job, and working to change the workplace, have all been associated with decreased levels of burnout. Passive coping, or not taking any direct action, is associated with higher levels of burnout (Maslach & Leiter, 2017; Spence Laschinger & Nosko, 2015). Burnout also appears to be contagious and is spread when workers ruminate about negative workplace conditions with each other without taking action to change them (Meredith, et al., 2020). To counteract a negative spiral of emotions in a group, co-workers can work together to identify strengths in their workplace, and from there work to change the issues that are leading to burnout. I do recognize that this suggestion will only work in organizations where workers are empowered to make changes, and where management and leadership are truly open to bottom-up initiatives.

The compassion and self-compassion exercises in this book may help prevent or mitigate burnout. However, if you are already experiencing burnout, or feel you are on the brink of burnout, I would like to offer you some additional resources and ideas for active coping. The exercise that accompanies this section includes a brief question to help you assess your level of burnout, and then guides you in the development of active coping to help you recover from burnout, or to prevent slipping into burnout.

EXERCISE: Assessing Your Level of Burnout and Developing an Active Coping Plan

I suggest you do this exercise on your own first, however it may be helpful to share your results with your study group. As a group, you can help each other develop a plan for coping with incipient or full-scale burnout and can support each other in putting your ideas into action.

1. The following question comes from a study by Dolan et al. (2015) and can be used to help you decide if you are experiencing burnout.

“Overall, based on your definition of burnout, how would you rate your level of burnout?” (pp. 583-4)

a. “I enjoy my work, I have no symptoms of burnout”

b. “Occasionally I am under stress, and I don’t always have as much energy as I once did, but I don’t feel burnout out.”

c. “I am definitely burning out and have one or more symptoms of burnout such as physical and emotional exhaustion.”

d. “The symptoms of burnout that I’m experiencing won’t go away. I think about frustration at work a lot”

e. “I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help”.

If you answered a or b, you are not experiencing burnout, but you may want to proactively take measures to relieve stress. Or keep doing what you are doing if you are already engaged in stress reduction activities and have a job that you love. If you answered c, d or e you are experiencing burnout (severity depends on which answer you chose), and may benefit from a plan to address your stressors and to take care of your physical and mental well-being.

2. The research indicates that active coping can protect people from burnout. In this part of the exercise, develop a plan to actively cope with burnout. I have listed some suggestions, but you may also come up with some of your own. If you need more information, the book “Compassion Fatigue and Burnout in Nursing” by Vidette Todaro-Franceschi may be helpful.

• Social support seems to be protective of burnout (Martínez, et al., 2020). This can include developing supportive relationships at work or spending quality time with family or friends. While discussing workplace stressors can be therapeutic, It is important to make sure that you do not fall into a pattern of rumination and helplessness – especially when discussing issues with co-workers. Research has shown that negative feedback loops can develop in workplaces and that this excessive negativity can increase individual levels of burnout. On the other hand, if you and your co-workers cannot identify anything positive about your workplace, and cannot band together to change things, it might be time to seek new employment.
• Spend some time thinking about what you enjoy about your work. Do the positives outweigh or at least counteract the negatives? This is called emotional reappraisal, and people who regularly engage in this mental exercise also seem to have lower levels of burnout (Martínez, et al., 2020). For example, when I felt particularly stressed about work, I would reflect on why I continued to work at the hospital, and the nursing unit in which I was assigned. Ultimately, I stayed there because I enjoyed my co-workers, I had a degree of flexibility in making a schedule that fit the needs of my family, and the pay was good. A lot of my stress came from management, and given the constant turnover of nursing managers, I always hoped the next one would be better - and sometimes they were!
• Make sure to take frequent mini vacations. Even if you do not take an extra day off, schedule some staycations where you are not just doing errands or taking care of household activities on your days off (unless these types of activities make you feel accomplished and are restorative!). When away from work, make an effort to leave work behind. Do not answer emails, texts or engage in group chats. I had a 40 minute commute from work, and I used this time to process my shift, reflect on the patients I cared for, and to disengage from work. Sometdays that worked better than others! When I got home, I tried to put all thoughts of work out of my head until it was time to get ready for the next shift. I’ll admit, after a hard shift, or when a patient I had bonded with had a poor outcome, or after working overtime, it was hard to disengage, and I did not always succeed at putting thoughts of work aside when not at work.
• If you are experiencing mental health issues related to work – depression, anxiety, insomnia, lack of enjoyment in everyday activities, extreme cynicism, the only cure might be to find a new job. Counseling or talk therapy may also be needed, even if you do change jobs.

3. If you are working on this exercise with a group, you may decide to share your scores with each other and discuss your active coping plans. Regular check-ins with each other may be part of your plan. You might also consider getting together periodically for fun group activities where you do not discuss work – go on a hike together, arrange a family day at the zoo or local museum (check to see if they have group discounts!), or have a picnic or barbeque. People might be more willing to engage in activities with co-workers that allow them to bring their families, since they already spend so much time away from their families. When activities with colleagues from work include families, we may be less likely to discuss work. Furthermore, these activities humanize us, by meeting our co-workers loved ones, we are more likely to subsequently view our co-workers as whole humans. On the other hand, you may decide that even though you enjoy the company of your co-workers at work, you will not benefit from seeing them outside of work!

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Empathy-Based Stress: Secondary Traumatic Stress, Vicarious Trauma and Compassion Fatigue

Just as our understanding of diseases and the causes of diseases have changed over time, our understanding of workplace stressors and the way that they affect people have also changed. Most researchers now subscribe to the notion that burnout is a result of poor workplace conditions and is a distinct phenomenon from secondary traumatic stress (STS), vicarious trauma (VT) and compassion fatigue (CF). However, consensus about the distinction (and indeed if there is any) between STS, VT and CF has yet to be reached (Isobel & Thomas, 2021). Some researchers use these terms interchangeably and seem to view them as the same concept, while others are more interested in drawing clear lines around each of the concepts. While I have not done a deep dive into the scholarship around these concepts, I like to think of STS, VT and CF as part of a larger concept, which Rauvola et al. (2017) have labeled empathy-based stress.

Rauvola et al. (2017) define empathy-based stress as the “experience of adverse psychological and/or physical reactions to trauma exposure at work, resulting from empathic engagement following trauma exposure” (p. 300). They suggest that STS, VT, CF and other negative mental and physical health outcomes are a result of empathy-based stress that exceeds the capacity of individuals to cope with or recover from. Further on in this chapter I will discuss some of the ways in which nurses can prevent and/or heal from STS, VT and CF. But first I want to explore each of these concepts in a little more depth.

Secondary traumatic stress (STS) and vicarious trauma (VT) are conditions that arise when nurses and other care providers are exposed to traumatic events that are experienced by another person. These events could be witnessed firsthand, for example a traumatic birth experience where the mother or baby (or both) die, or they can arise after hearing a patient or client recount a trauma they experienced. VT is thought to develop over time after multiple exposures to vicarious trauma (Rauvola et al., 2019), whereas symptoms of STS can develop suddenly after just one exposure to trauma (Beck, 2011). Nurses (and other people) experiencing STS display physical and psychological symptoms similar to post-traumatic stress disorder (PTSD). In contrast, VT results in cognitive and emotional changes. Primary symptoms of VT are a shift in outlook and feelings about the world in general (Kim, et al., 2021). For example, people experiencing VT who have been caring for victims of childhood sexual abuse may begin to view the world more negatively, where they once believed in human kindness and justice, they may begin to feel hopeless, angry and disillusioned (Isobel & Thomas, 2021; Rauvola, et al., 2019). Nurses and other care providers who take care of patients with incurable diseases who suffer immensely (e.g. pediatric oncology patients) may begin to question their spiritual or religious beliefs (Wang et al., 2014). If the result of this period of questioning is an abandonment of faith or spirituality, and profound hopelessness and anger, the caregiver has experienced VT. However, spirituality can also be protective against VT (Wang et al., 2014). I will explore that later in the chapter.

Compassion fatigue is used interchangeably with the term secondary traumatic stress by some researchers (e.g., Figley & Figley, 2017) who view it as a “more user friendly substitute to secondary traumatic stress” (Rauvola, et al., 2019, p. 303). After looking at all of the research that had been done on compassion fatigue, several authors concluded that compassion fatigue is “a euphemism for a broad family of occupational stresses uniquely attributed to healthcare providers that lacks construct validity” (Sinclair, et al., 2017, p. 20). These authors, and others, suggest that what we have commonly called “compassion fatigue” is not an inability to react compassionately to the suffering of others because we have used up our compassion stores (think of muscle fatigue), but instead is the suffering that is caused by occupational stressors that impede our ability to relieve suffering – such as an overwhelming workload, lack of time to rest and recuperate, and hostile work environments (Gilbert & Mascaro, 2017; Ledoux, 2015, Rauvola, et al., 2019; Sinclair et al., 2017). In other words, compassion fatigue is a result of the environmental factors that impede our ability to act with compassion to relieve suffering. People who exhibit compassion fatigue in an unsupportive environment should be able to react with compassion in an environment that is supportive. If they cannot, they might be experiencing VT or STS, or there might be other factors blocking their ability to access compassion such as a difficult childhood, or unresolved anger (Gilbert, 2013).

Throughout this book I have invited you to identify environmental and personal factors that impede your ability to engage compassionately with patients, students, and co-workers. These factors are the root causes for the very real distress that caregivers experience that we have come to call “compassion fatigue.” Enhancing your ability to recognize and move towards suffering, and to act with compassion to try to alleviate suffering should not in and of itself lead to compassion fatigue. Instead, as Sinclair et al., (2017) write:

Recent research, history and spiritual traditions suggest…increased opportunities to express compassion seem to sustain baseline compassion, mitigate work-related stress, and are beneficial for responders and recipients, within and outside of healthcare…It is more likely that healthcare providers are experiencing the negative consequences associated with a broad range of occupational stressors that inhibit their ability to be compassionate, and as a result, patient care becomes compromised. (p. 21).

So, if you are feeling you have nothing left to give to your patients, and that your compassion is all dried up – as many healthcare providers have felt after the COVID-19 pandemic - the problem may not be that you have become incapable of ever being compassionate again, it may be that you have experienced multiple occupational stressors that you have not had time to recover from. You may need to take a rest from direct patient care or find a workplace that has supportive managers and co-workers who take care of each other. Yes, those workplaces exist, but sometimes you have to search a bit to find them!

In the next exercise I invite you to explore whether you are experiencing empathy-based stress. I also invite you to create a plan for starting the road to recovery and healing. These injuries take time to heal, and you may need to seek assistance from a therapist, counselor or spiritual advisor.

EXERCISE: Are you Experiencing Empathy-Based Stress?

There are several instruments that you can use to assess whether you are experiencing empathy-based stress. Rather than reproduce one of them here, I invite you to google “self-assessment for compassion fatigue” if you are interested. I suspect that you can probably figure out if you are experiencing diminished ability to feel compassionate or if you are experiencing symptoms of secondary or vicarious trauma. However, it is possible that you have just been feeling “off,” or “not like yourself,” and have not realized what has been going on.

In this exercise I invite you to do some self-reflection about your general mood, emotions, physical and mental health over the past few weeks. I will then invite you to come up with a plan for addressing any issues you might be experiencing. Even if you are not experiencing full-blown STS, VT or CF, perhaps you will discover you need to take some time to restore, recharge and reassess your nursing career in order to maintain your sense of compassion satisfaction.

Self-Assessment:

Complete the following self-assessment to help you determine if you are experiencing, or if you are at risk for experiencing, empathy-based stress. (Note the questions were derived from several self-assessment tools and have not been scientifically validated. This is not meant to be diagnostic, but to serve as a self-awareness exercise.)

If you answered often or sometimes to one or more of the above questions, you are either experiencing or are at risk of experiencing empathy-based stress or compassion fatigue, vicarious trauma, or secondary traumatic stress. The next step is to develop a plan to recover from or to prevent these symptoms.

Plan for Active Coping:

While I have listed some ideas for active coping, my list is not all inclusive and they may not resonate with you. Feel free to come up with your own ideas. Remember, you do not have to go through this alone, seek help if needed – from a counselor, spiritual advisor, or from supportive friends or co-workers. I particularly encourage you to seek professional help if you answered “often” to some of the questions above. Finally, if you are feeling profoundly anxious, depressed, and if you are feeling suicidal, seek professional assistance.

In the first column, I have listed some common symptoms of empathy-related stress. In the middle column I have listed some suggested actions you might take. In the final column, I invite you to write actions you could take.

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Conclusion

The nursing profession can be an intensely rewarding profession. It can also require a lot of physical and psychological energy to care for people who are sick, stressed and suffering. It can take a lot of physical and psychological energy to be a leader of a nursing unit dealing with staff shortages, an inadequate budget and beaurocratic requirements. It can also take a lot of physical and psychological energy to be a nursing instructor or professor who needs to juggle teaching and service to the university or college while trying to maintain a research agenda or to stay on top of the latest evidence based science. Nurses in multiple settings can be at risk for burnout, compassion fatigue, secondary traumatic stress and vicarious trauma. It is my hope that in this chapter, and throughout the book, I have given you some tools to begin to treat these conditions if you are experiencing them, to keep them from getting worse if your symptoms are mild, or to prevent them if you are not experiencing any of these conditions.

In the long run, to protect the health of nurses and to allow us to build and sustain a compassionate nursing practice, reforms are needed to change the environment that we work in. No amount of self-compassion and self-care will protect the nurse who experiences daily abuse from patients and co-workers, who is asked to work long hours with minimal or no breaks, who feels they do not have the resources that are needed to adequately care for their patients, and who feels that healthcare executives are unfairly compensated while they are barely getting by or while nursing units are run on a shoe string budget. It is my hope that through infusing compassion and self-compassion into nursing education, nursing leadership, our relationships with co-workers, and our interactions with patients and their families, we will also be inspired and empowered to work together to improve the healthcare system.

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