Exploring holistic foundations for alleviating and understanding compassion fatigue

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PREVENTING BURNOUT & COMPASSION FATIGUE
AUGUST 2014
6Beginnings | American Holistic Nurses Association
by BETSY S. MURPHY MS, RN, HNB-BC, ERYT
Exploring Holistic
Foundations for
Alleviating and
Understanding
Compassion Fatigue
E
mpathy and compassion are essential qualities
for successful healing environments, vital for
both the providers and receivers of health
promoting interactions. They are also essential
elements of holistic care and nurse role satisfaction.
Holistic nurse theorists Rogers and Watson both
acknowledge this through their conceptual frameworks
for nursing, which are founded on the empathic
relationship and compassionate concern between
the nurse and patient (Dossey, 1997). Empathy and
compassion are foundational to both human caring and
the problem of compassion fatigue in nursing practice.
On the front line of care for the traumatized,
dying and chronically ill, nurses are continually
called upon to demonstrate caring, compassion and
empathy towards others. The natural empathy and
compassionate response that arises from exposure to
a traumatized person can provide both satisfaction
and stress in professional caregivers. However, the
act of continually providing empathic, compassionate
nursing care can contribute to stress symptoms and job
dissatisfaction, which can result in the development of
compassion fatigue (Lombardo & Eyre, 2011).
Defining Compassion Fatigue
The concept of compassion fatigue in nursing practice
evolved from Joinson’s (1992) research exploring
burnout in emergency room nurses. Since then, the
phenomenon of compassion fatigue has been widely
researched and linked to the caregiver’s response to
their patients’ suffering. Figley (1995) defines it as
a “state of exhaustion and dysfunction (biologically,
psychologically and socially) as a result of prolonged
exposure to compassion stress” (p. 253). Secondary
traumatic stress and compassion stress are often used
synonymously and are “a set of psychosocial and
emotional factors caused by a specific event or series of
events affecting helpers indirectly through another such
as a family member, friend or client” (Figley, 2007).
The development of a therapeutic relationship
between the nurse and patient, in which the nurse
demonstrates, acknowledges and provides compassion
and empathy, is central to the experience of compassion
fatigue. Those who display higher levels of empathic
behavior have been identified as more likely to suffer
from this condition arising from empathic distress and
an inability to respond compassionately to others (Sabo,
2011). Compassion fatigue evolves when the relational
heart energy that is expended by nurses surpasses their
ability to recover from this energy depletion, which
in turn causes psychological and physical symptoms
(Boyle, 2011).
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Symptoms of Compassion Fatigue
Compassion fatigue manifests as a psychosocial condition with
emotional, physical, mental, spiritual and social constructs.
Due to its multi-faceted expression in nurses, compassion
fatigue requires a holistic approach to help alleviate the
condition. The variety of symptoms that affect all aspects of a
person—physical, mental, spiritual and emotional—are most
often experienced together in multiples (rather than separately.
in cases of compassion fatigue (see list of symptoms on page 8).
The physical effects of compassion stress and fatigue
include a lower capacity and endurance to perform job
requirements, and may even lead to more clinical errors.
Emotional symptoms include feeling overwhelmed, irritability,
loss of enthusiasm, and indifference to suffering. Indicators of
compassion fatigue also include work-related symptoms such
as the frequent use of sick days, reduced levels of empathy
towards patients and families, avoidance of working with
certain patients, a lack of joyfulness and loss of objectivity
(Lombardo & Eyre, 2011).
The Role of Empathy
There is a close relationship between compassion and empathy,
but they are not synonymous. Compassion is often considered
a reaction to empathy which is defined as understanding
patients’ concerns and distress, which in turn initiates a feeling
of distress in the observer and a desire to alleviate or end it
(Kret, 2011). To empathize means to share and experience the
feelings of the patient, and this empathic understanding informs
the compassionate response of the nurse to care for the patient.
Various dimensions and constructions of compassion and
empathy have been discussed in the literature. Bentley (2007)
discusses the clinical role of empathy as multidimensional,
having three components: clinical, affective and cognitive.
Clinical empathy can be learned as a way to communicate
warmth and understanding, but this can also be found as a
way to define the affect of compassion. In an analysis by Sabo
(2006) between empathy and compassion, the term compassion
was considered the emotional construct that influences our
empathic response. Empathy was thus an attitude that is
sensed in communication through warmth and authentic
understanding, creating a cognitive construct for the term in
clinical application.
Kahn (1993) looked into “acts of caregiving” identifying
eight behavioral dimensions of caregiving as: accessibility,
inquiry, attention, validation, empathy, support, compassion
and consistency (p. 544). He theorized that primary caregivers
will more effectively perform their roles if coworkers are sources
of care and support for each other. Kahn (1993) also suggested
that when demonstrated in the context of an organization that
promotes care to its employees, compassion and empathy can
positively influence levels of burnout.
Prevalence of Compassion Fatigue
The incidence of compassion fatigue and its multi-factorial
development has been identified and widely discussed
in the literature. Emergency, oncology, forensic, hospice,
and pediatric nurses have been investigated in regards to
continued on page 8
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BURNOUT COMPASSION FATIGUE
• Builds over time
• Reactional stress from work environment such as
workload, staffing, and management
• Arises from many work-related sources, such as
frustration with the environment, colleagues, etc.
• Do I love my work?
No
• Acute onset
• Relational stress from patient caring, empathy
depletion, and the inability to affect healing
• Results from emotional engagement with patients
and prolonged exposure to compassion stress
• Do I love my work?
Yes
Burnout vs. Compassion Fatigue
Burnout and compassion fatigue are often used to define the same condition; however, distinctions have been made in the
literature between the two phenomena (Figley, 2007; Boyle, 2011).

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8Beginnings | American Holistic Nurses Association
Alleviating and Understanding Compassion Fatigue continued from page 7
compassion fatigue’s occurrence and incidence through a
variety of methods (Beck, 2011).
In one Midwestern hospital, the prevalence of compassion
fatigue among nurses, the situations that led to compassion
fatigue, and methods for coping with these events were
examined byYoder (2010). The method used for analysis
was a three-part questionnaire that included the Professional
Quality of Life Scale (ProQOL-IV) to measure compassion
fatigue, compassion satisfaction and burnout. This scale
was originated by Charles F. Figley in the early 90s and has
since been developed by researchers and contributors from
around the world. Participants in Yoder’s study were also
asked to describe a situation in which compassion fatigue
was experienced and the strategies employed to manage the
situation. Common themes that emerged from the survey
show that compassion fatigue is often closely associated with
the inability of the nurse to rescue or alleviate the suffering
of the patient, while other situations regarding workload and
an unsupportive environment are suggested to be classified as
burnout (Yoder, 2010).
In another study of healthcare providers working in the
critical care unit of a children’s hospital, researchers found
that increased levels of personal stress created higher levels of
compassion fatigue. Of the 185 participants, 62 percent were
nurses (Meadors & Lamson, 2008).
Methods for Managing Compassion Fatigue
Self-care is essential to managing compassion fatigue
(Shiparski, Richards, & Nelson, 2011). Methods include
healthy rituals of adequate sleep, exercise and nutrition as
the foundation for self-care and wellness strategies. Massage,
yoga and meditation are examples of additional approaches
that could be supported and encouraged to help employees
find balance both personally and professionally. Employee
Assistance Programs within hospital settings have provided
counseling and classes on stress management and work-life
balance (Coetzee & Klopper, 2010; Lombardo & Eyre,
2011). Some programs have been developed to help manage
the effects of compassion fatigue in nursing professionals;
however, these interventions often focus on the development
of specific skills such as communication, conflict resolution,
and rational methods to alleviate work stresses (Boyle, 2011;
Yoder, 2010). Further work must be done to address the issue
of compassion fatigue in not only areas of practice, but also in
education and research.
Programs that incorporate mind-body tools for self-
care may prove to be viable solutions for compassion
fatigue. Mindfulness based interventions have been studied
and shown to be effective for a variety of both physical and
mental conditions and disorders. Mindfulness Based Stressed
Reduction (MBSR) is a program developed by Jon Kabat Zinn
(1990) that utilizes mindfulness to increase self-awareness,
compassion and open heartedness to self and others. Escuriex
and Labbe (2011) conducted a review of the current research
on the use of MBSR programs with medical and mental health
professionals. Although the conclusions as to whether mindful
healthcare providers have better clinical outcomes than those
not trained in mindfulness proved inconclusive, all 11 studies
evaluated showed psychosocial function improvements.
Reduction in stress, anxiety and rumination were experienced
by participants in MBSR, along with improvements in self-
compassion and empathy. Five studies specifically focusing on
medical healthcare providers (as opposed to mental health)
demonstrated that mindfulness training can help them be
more “compassionate and present during patient interactions”
(Escuriex & Labbe, 2011).
Another example is the Healing the Healers program, which
is designed to help caregivers alleviate symptoms of compassion
fatigue through education and experience of mind-body, self-care
tools such as mindfulness meditation, movement, loving kindness
meditation, relaxation training, and reflective journaling. The
objective of this program is to restore the qualities of heart that
PHYSICAL
• Headache
• Insomnia
• Gastrointestinal
problems
• Depleted immune
system,
• Hypertension
• Fatigue
PSYCHO-BEHAVIORAL
• Anxiety
• Irritability
• Feelings of isolation
• Depression
• Lack of empathy
• Apathy
• Hopelessness
• Poor concentration
• Intrusive thoughts
BEHAVIORAL
• Absenteeism
• Substance abuse
• Impersonal work
communications
• Medication errors
• Avoidance of certain
patients
• Minimal patient time
SPIRITUAL
• Doubt
• Lost sense of purpose
• Non-reflective
• Withdrawal from community
• Lack of joy
(Lombardo & Eyre, 2011)
Symptoms of Compassion Fatigue

are often depleted from overwork, job stress and fatigue through
participation in specific mind-body practices (Murphy, 2012).
The Role of Self-Compassion & Self-Care
The lack of self-compassion contributes to loss of compassion
and empathy. Self-compassion, which is cultivated through
mindfulness practice, allows nurses to be aware of and respond
to their need to replenish one’s own well of compassion with
nurturing experiences. In holistic nursing, self-care is a core
value of practice (Dossey, 1997). The concept of self-care
includes six areas: physical, mental, emotional, relational,
choices and spiritual. As stated in the Holistic Nursing: Scope
and Standards of Practice, “Self-reflection and self-care, as well
as personal awareness of and continuous focus on being an
instrument of healing, are significant requirements for holistic
nurses” (AHNA & ANA, 2013, p. 20).
A recent study that explored the relationship between
self-care, compassion fatigue, and burnout in 96 nurses in a
California hospital found that there was “a…strong negative
relationship between self-care, compassion fatigue, and
burnout” (Shiparski et al., 2011, p. 28). The authors of the
study described guidelines of self-care that were originally
established for caregivers at a service organization. They
recommended applying the standards to healthcare settings as
a way to manage compassion fatigue: (1) do no harm to yourself
when helping or treating others and (2) attend to your needs
for physical, social, emotional and spiritual wellness in order
to maintain ability to provide quality care to those who look to
you for support (Shiparski et al, 2011).
Caregivers who suffer from compassion fatigue are often
inclined to justify their symptoms as part of the “cost of caring.”
Yet when the ability to provide health care is diminished by the
poor health and well-being of nurses, there is a serious need to
validate the presence of the condition, and integrate methods
for alleviation into the workplace. Coetzee and Klopper
(2010) believe that “if compassion fatigue is not effaced in
its early stages of compassion discomfort and compassion
stress, the power of recovery is lost and full restoration of the
previous level of compassionate functioning is unattainable
(p.241).” Self-care, self-compassion and the core values of
holistic nursing provide a viable solution to this condition
threatening nursing practice and the collective of health care.
As long-time champions for self-care, holistic nurses are in
a unique position to teach the nursing community how to
nurture and support the caregiver. If we don’t step up to the
plate, who will?
References
American Holistic Nurses Association (AHNA), & American Nurses
Association (ANA). (2013). Holistic nursing: Scope and standards of
practice (2nd ed.) Silver Springs, MD: NurseBooks.org.
Beck, C. T. (2011). Secondary traumatic stress in nurses: A systematic
review. Archives of Psychiatric Nursing, (25)1, 1-10.
Bentley, D. (2007). Mindfulness and counselling self-efficacy: The mediating
role of attention and empathy (Dissertation). Retrieved from http://
libres.uncg.edu/ir/listing.aspx?id=1235
Boyle, D. (2011). Countering compassion fatigue: a requisite nursing
agenda. Online Journal of Issues in Nursing, 16(1), Manuscript 2.
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nursing practice: A concept analysis. Nursing and Health Sciences,
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Dossey, B. M. (1997). Core curriculum for holistic nursing. Gaithersburg,
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children. Journal of Pediatric Health Care, 22(1), 24-34.
Murphy, B. (2012). Alleviating compassion fatigue: Practical applications
for nursing professionals (Unpublished master’s project). Saybrook
University, San Francisco, California.
Sabo, B. M. (2006). Compassion fatigue and nursing work: Can we
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Yoder, E. (2010). Compassion fatigue in nurses. Applied Nursing
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Betsy S. Murphy MS, RN, HNB-BC, ERYT has
been in private practice since 2003, providing
educational programs in mind-body medicine
to individuals, corporations, community and
professional groups. She is trained in the seminal
Mindfulness Based Stress Reduction program
from the Center for Mindfulness in Medicine,
Health Care and Society at the University of Massachusetts Medical
School as well as completed the Mind Body Medicine programs from
the Center for Mind Body Medicine, Washington, D.C. Betsy is co-
chair of the AHNA Practice Committee and has served on the Board
of Directors for The International Association of Yoga Therapists,
and is a member of Yoga Alliance.
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