6 January 2020
Having compassion for others has inspired many people to become nurses. On the flipside, many nurses complain of ‘compassion fatigue’ - work-related distress and exhaustion from absorbing the emotional stress of others, which can lead to depersonalised, sub-optimal care of patients that may lack empathy and compassion.
Now a new article co-authored by Dr Anne Hofmeyer Adjunct Associate Professor from the Adelaide Nursing School, The University of Adelaide; Ms Kate Kennedy from the Rosemary Bryant AO Research Centre; and Professor Ruth Taylor from The University of Aberdeen has reported social neuroscience evidence that confirms compassion does not cause fatigue.
Published in the Collegian journal, the article, Contesting the term ‘compassion fatigue: Integrating findings from social neuroscience and self-care research, presents evidence to explain that the debilitating condition known as ‘compassion fatigue’ in nursing is actually ‘empathic distress fatigue’.
The fatigue and exhaustion experienced by nurses due to caring for others is not ‘compassion fatigue’.
It is time to stop using the term ‘compassion fatigue’ because it is incorrect. The cause of the caring fatigue is ‘empathic distress’ (Singer & Klimecki, 2014).
Fatigue is the foremost global nursing professional issue requiring urgent attention because many countries are experiencing the second and third wave of the COVID‐19 pandemic. So it is essential that nurses understand what triggers their caring fatigue and how they can manage their emotions better and self-care during these challenging times.
Patients with COVID‐19 and others with chronic diseases are seeking care from healthcare systems and nurses are at the forefront of the care response. Every shift is exhausting, and nurses feel that doing their best is never enough, there is barely enough time to take a break.
Nurses globally are experiencing fatigue and anxiety due to a myriad of reasons such as: the inadequate supply of personal protective equipment (PPE), physical and emotional exhaustion, constant exposure to disruption in the workplace and society, lack of control, concerns about colleagues who have contracted coronavirus and who have died, upsetting political news, worries about the health and wellbeing of older family members (and young children who have contracted the virus), challenges of home‐schooling, and stressed and fearful children and teenagers. At home, housework piles up, bills need to be paid, and family members want attention and reassurance.
Nurses need to understand the difference between empathy and compassion. Empathy is the ability to understand the perspective of others and ‘feel with’ them when we are exposed to their distress and suffering, while recognising that the emotions we feel are external to ourselves (Singer & Klimecki, 2014).
Compassion is ‘feeling for’ others who are in distress and pain with warmth and empathic concern and have the motivation to act with compassion to relieve their pain (Singer & Klimecki, 2014).
Empathy is essential for understanding others’ emotions and how we can help, but if we become overwhelmed and distressed, we are less effective in our ability to respond.
Dr Hofmeyer, Adjunct Professor in Clinical and Health Services at the University of SA, says recognition of empathetic distress fatigue is a “powerful opportunity to correct a misunderstanding”. The profession must use current neuroscience evidence to inform the understanding and decision‐making in order to treat the condition which is known as ‘empathic distress fatigue’ (Klimecki & Singer, 2012).
Neuroimaging studies conducted by Singer and colleagues using functional magnetic resonance imaging (fMRI) confirmed the experience is not compassion fatigue. The ‘fatigue’ experienced by nurses is related to over‐identifying with distressed patients and their relatives (other) and feeling their distress and pain as your own pain (self). This fatigue experience is called ‘empathic distress fatigue’ that results from blurring boundaries of the ‘self‐other distinction’.
fMRI shows empathy and compassion trigger different areas in the brain. When we empathise with a person who is in pain and distress, our brain will show activation of similar circuits as the brain of that person. This is the reason why we need to be aware of our reactions to others in distress and manage (regulate) our emotions to ensure we do not experience a sense of fatigue, physical exhaustion, anger, powerlessness, and emotional withdrawal (as a form of self‐protection).
As nurses we aim to use high quality, current evidence in caring for patients to ensure effective outcomes. Nurses must also use the best evidence in caring for themselves, promoting their wellbeing, and fitness to practice and care for others. Surely this is a potent argument. The relevant evidence about fatigue, empathy, and compassion has been generated by neuroscientists. Translating the evidence for implementation in nursing is critical and never more urgent that during the ongoing COVID‐19 pandemic.
Fatigue is due to intense prolonged care of others while neglecting to care well enough for ourselves and restore our spirit and wellbeing. This distinction matters because the alleviating strategy for ‘empathic distress fatigue’ is compassion training (Hofmeyer et al., 2020, p. 234). Compassion for self and others is an antidote to fatigue (Vachon et al., 2015).
Individuals are more likely to experience anxiety, exhaustion and disengagement if they do not cultivate the ‘self‐other distinction’. This term means we need to understand that the distress and pain we are witnessing belongs to the other person, it is not our pain, even though we may feel distress when witnessing their pain.
This empathic response is called ‘emotion contagion’ – for example we may have tears in our eyes when we see another person crying. But we must recognise it is not our pain, so we must not to absorb the distress of others as our own. If we do – we blur the ‘self‐other distinction’ or ‘boundary’ and become distressed due to our unchecked empathic response. We are then unable to support others due to our debilitating feelings of distress, fatigue and emotional withdrawal that is a form of self-protection (Singer & Klimecki, 2014).
Becoming detached from patients actually triggers more distress and disappointment because nurses realise they are not the sort of person they want to be for their patients, the reason why they chose to become a nurse to care for others, but they think by putting up barriers they will protect themselves emotionally. This dilemma leads to moral distress and sadness and burnout. If someone thinks they are experiencing compassion fatigue then they are likely to resist learning about compassion. As a nurse said: ‘Why do I want to learn more about compassion when I believe that is the source of my distress?’
We need to work out what calms us, restores us, and keeps us emotionally, physically, spiritually and psychologically strong so we can effectively manage our experiences – whether they be irritating, demanding, or catastrophic. Therefore, the evidence‐based understanding of empathy and the self-other distinction is critical to ensure we remain well ourselves so we can be of service to others – i.e., our patients, families, friends, co‐workers and communities.
Evidence‐informed education is urgently required in higher education institutions and universities (Taylor et al., 2020) and clinical settings (Hofmeyer et al., 2020) to raise awareness and understanding of the neuroscience processes, implications of misunderstandings, and proven strategies to stay well in demanding times.
How can nurses better care for themselves so they can better care for others? Nurses can access local and international public health and professional websites for current information about self‐protection and managing wellbeing and anxiety during the Covid‐19 pandemic and beyond. Online resources provide ideas for self‐care plans and supportive rituals (see articles listed in ‘further readings’ for ideas). Individuals and organisations have a joint responsibility to participate in training and building cultures where all can feel safe and valued. There are many free online quality programs offered by reputable organisations and researchers such as Dr Kristin Neff and the Schwartz Centre for Compassionate Health Care in Boston, Massachusetts, that teach compassion training and self‐care techniques.
Self‐compassion is treating ourselves with the same kindness and compassion that we would give a good friend (Neff, 2011). Psychologist Kristin Neff was the first researcher to measure and define the term self‐compassion. She describes self‐compassion as being kind, supportive and understanding toward oneself (particularly when we fail) rather than being harsh or judgmental. Self‐compassion can be practised when feeling upset by taking deep breaths and putting a hand on your heart. Caring touch releases oxytocin, a hormone that makes people feel safe and connected (Neff, 2011). Self‐compassion guided meditation practices developed by Kristin Neff are available at:
http://self‐compassion.org/
Self‐care is an intentional: ‘proactive, holistic, and personalised approach to the promotion of health and wellbeing through a variety of strategies, in both personal and professional settings, to enhance capacity for care of patients and their families’ (Mills et al., 2018, p.1). The Schwartz Centre (2020) encourages us to accept that it’s normal to feel sad, stressed, confused, and angry so it is important to monitor our stress levels and develop a daily self‐care routine to meet our needs.
Self-compassion can be taught in schools. We cannot be compassionate toward others unless we are self-compassionate and understanding. It is critical to teach self‐compassion across the lifespan – beginning with young children and teenagers. Karen Bluth, PhD, Department of Psychiatry Fellow, University of North Carolina is one of the co‐developers of the program Making Friends with Yourself: A Mindful Self‐Compassion program for Teens. Her book is titled: The Self‐Compassion Workbook for Teens: Mindfulness and Compassion Skills to Overcome Self‐Criticism and Embrace Who You Are
http://www.karenbluth.com\
Healthcare leaders and managers must improve organisational structures and educational initiatives to support nurses in their practice, improve adequate staffing numbers, skill mix, and staff ratios. Leaders have a key responsibility to ensure adequate supply of PPE for all staff. These actions would be measures to relieve burnout, stress and concerns experienced by nurses.
In summary, neuroscience researchers used fMRI imaging to generate evidence that shows ‘compassion fatigue’ does not exist – the distress felt by exhausted caregivers is ‘empathic distress fatigue’. Compassion training is an antidote to distress and is an investment to sustain one’s career longevity.
It is critical to teach nurses to regulate their emotions and to develop the ‘self‐other boundary’. This means we clearly understand that the pain and distress we are witnessing belongs to another person so is not our pain, even though we may be affected by it because it triggers similar pathways in our brain (emotion contagion). Blurring the boundary between the pain of others and ourselves puts us at risk of experiencing empathic fatigue, distress and feeling overwhelmed and unable to care. To protect ourselves from further distress, we may distance ourselves from patients which compromises care and leads to more sadness and lack of fulfillment.
Compassionate self‐care is even more important and challenging for nurses amid the pressures of the COVID‐19 pandemic. At the end of a shift, some nurses find it difficult to leave concerns about the day behind. Everyone needs effective end‐of‐shift habits to help them feel better going home, for example: a coffee with a friend, or walking in nature, or maybe talking with a therapist. ‘Self‐care’ is an example of personal discipline, meaning that we need to engage in physical and mental wellbeing‐promoting practices (i.e., healthy eating, exercise, saying no to toxic people, mindfulness, having a flu shot, health screening, disconnecting from electronic devices) even when we don’t feel like making those better choices.
For many, the COVID‐19 pandemic continues to be a time of significant upheaval, uncertainty, grief, stress and anxiety. In order to keep going, to care with empathy and compassion for our patients and their families, and to work to our full potential with colleagues, we need adequate resources and practical support from hospital system administrators and managers (i.e., adequate PPE, staffing, breaks), and adopt strategies to support our health and wellbeing. Importantly, nurses need more than mindfulness and meditation to preserve their wellbeing and morale during these challenging times.
“Being empathic without absorbing another person’s suffering as our own. This is such an important lesson for us to learn now during the pandemic and in the aftermath.’’
Further Reading
- Bartels, J.B. (2014). The Pause. Critical Care Nurse. 34(1), 74‐75. https://vimeo.com/143628865
- Hofmeyer, A., Kennedy, K. & Taylor, R. (2020). Contesting the term ‘compassion fatigue’: Integrating findings from social neuroscience and self‐care research. Collegian, 27(2), 232‐237 https://doi.org/10.1016/j.colegn.2019.07.001
- Hofmeyer, A. & Taylor, R. (2020). Strategies and resources for nurse leaders to use to lead with empathy and prudence so they understand and address sources of anxiety among nurses practising in the era of COVID‐ 19. Journal of Clinical Nursing, https://doi.org/10.1111/jocn.15520
- Hofmeyer, A., Taylor, R. & Kennedy, K. (2020). Fostering compassion and reducing burnout: How can health system leaders respond in the Covid‐19 pandemic and beyond? Nurse Education Today, 94(11), 104502 https://doi.org/10.1016/j.nedt.2020.104502
- Hofmeyer, A., Taylor, R. & Kennedy, K. (2020). Knowledge for nurses to better care for themselves so they can better care for others during the Covid‐19 pandemic and beyond. Nurse Education Today, 94(11), 104503 https://doi.org/10.1016/j.nedt.2020.104503
- Klimecki, O. M., & Singer, T. (2012). Empathic distress fatigue rather than compassion fatigue? Integrating findings from empathy research in psychology and social neuroscience. In B. Oakley, A. K
Taylor, R., Thomas‐Gregory, A. & Hofmeyer, A. (2020). Teaching empathy and resilience to undergraduate nursing students: A call to action in the context of Covid‐19. Nurse Education Today, 94(11), 104524 https://doi.org/10.1016/j.nedt.2020.104524
- Mills, J., Wand, T. & Fraser, JA. (2018). Exploring the meaning and practice of self‐care among palliative care nurses and doctors: a qualitative study. BMC Palliative Care, 17:63, 1‐12. https://doi.org/10.1186/s12904‐018‐0318‐0
- Neff, K. (2011). Self‐Compassion. Harper Collins Publishers, New York.
- Schwartz Centre (2020). The Schwartz Center for Compassionate Healthcare, Boston MA. https://www.theschwartzcenter.org/
- Singer, T. & Klimecki, O.M. (2014). Empathy and Compassion. Current Biology, 24(18), R875‐78. https://doi.org/10.1016/j.cub.2014.06.054
- Vachon, M. L. S., Huggard, P. K., & Huggard, J. (2015). Reflections on occupational stress in palliative care nursing. Is it changing? In B. R. Ferrell, N. Coyle, & J. Paice (Eds.), Oxford textbook of palliative nursing (4e) (pp. 969– 986). Oxford University Press.