Compassion and fatigue
January 3, 2012 -- Recent press items have highlighted the devastating effects of nurse under-staffing on patients and nurses alike. Today, Laura Landro's "Informed Patient" column in The Wall Street Journal discussed compassion fatigue among nurses, especially those who regularly care for terminally ill patients. Landro's Health Blog provided additional information about the problem, which may contribute to burnout and high turnover, which in turn add to compassion fatigue. That cycle can lead to worse patient care. The Wall Street Journal pieces include expert comment from several nurses, and the items convey that nurses play an important role in care, though they might have focused more on the danger that impaired nurses pose to patients because of the critical nature of nursing. And on December 31, 2011, the Daily Mail (UK) ran a piece by Sam Greenhill about a woman who, though not a nurse, had "nursed" her 89-year-old grandmother back to health at a hospital, after the physicians and other health professionals had apparently written the patient off. The woman reportedly fed, washed, and advocated for her grandmother while the hospital's actual nurses were too overworked to do so. We're generally critical of media accounts that suggest lay people have acted as "nurses" by providing unskilled care, since that suggests nursing requires no special education or skills. But here it sounds like the lay person did a better job than the real nurses. Of course, despite the happy ending, the piece also presents a distressing picture of what happens when nurses are so overworked that they cannot do the most basic part of their jobs--saving lives. We thank those responsible for these pieces.
Informing patients about nursing
Landro's "Informed Patient" column in the Wall Street Journal is headlined "When Nurses Catch Compassion Fatigue, Patients Suffer." The piece gives helpful information about the causes and effects of compassion fatigue, with a focus on the experience of Barnes-Jewish Hospital in St. Louis. Early on, Landro succinctly sums up the issue this way:
Compassion fatigue is a combination of secondary traumatic stress from witnessing the suffering of others and burnout. It can lead nurses to feel sadness and despair that impair their health and well-being. Hospitals are tackling the problem amid a worsening shortage of nurses and concerns that patients may suffer. Compassion fatigue can reduce nurses' empathy and lead them to dread or even avoid certain patients, raising the risk of substandard care.
The piece notes that compassion fatigue was "identified as a special problem for nurses in the early 1990s," though it does not come out and say why nurses are particularly affected. We assume it's because, contrary to the physician-centric Hollywood vision of health care, nurses are the professionals who spend the most time with patients. The column explains that compassion fatigue has been "linked to decreased productivity, more sick days and higher turnover among cancer-care providers," and it explains that turnover and the higher workload on those who remain "can result in higher death rates and reduced patient safety, studies show." The piece also provides expert comment from Patricia Potter, "a nurse researcher and director of research for patient-care services at Barnes-Jewish," who explains that nurses who avoid patients don't form the relationship necessary to truly understand the patient, identify their problems early, and adapt therapies to their needs." Potter says nurses who become rude may discourage patients from asking for help, and that nurses who are less observant may make more errors.
The piece provides considerable detail about Barnes-Jewish's own efforts to address compassion fatigue. Concerns about turnover in oncology and "evidence of stress among nurses" led nurse managers to ask "Dr. Potter and the head of the hospital's patient and family counseling program, Theresa Deshields, for help in 2009." Apparently a survey showed significant evidence of compassion-fatigue symptoms, with those who cared for the very ill seeming especially susceptible to stress and disengagement from patients. We like that the piece refers to Potter as "Dr. Potter" after making clear she is a nurse. The hospital consulted Florida psychotherapist Eric Gentry, who "specializes in teaching stress-management techniques to disaster responders and emergency physicians." Gentry created a pilot program for nurses that eventually became a compassion fatigue course "open to all staffers at the hospital, from physicians to housekeepers." This is a revealing, but unhelpful, suggestion of the perceived hierarchy at the hospital; obviously the idea is to show a range from highest to lowest. The course includes a checklist of symptoms, as well as ways to help, such as stress-relieving exercises, creating a support network, and finding a balance between health workers' "caring intention" and the practical limits on what they can do for patients. Potter adds that "being a caregiver is difficult and full of challenges," but nurses can be taught to "self-regulate their stress and restore the energy they need to provide the best patient care."
Providing some context, the piece notes that the Barnes-Jewish program is one of "a growing number of efforts by hospitals and nursing groups" to address the problem. These programs may include meditation, stress-reduction workshops, support groups, and staff retreats. The piece quotes Holly Carpenter, a "senior staff specialist" at the Center for Occupational and Environmental Health of the American Nurses Association, who notes that "recognizing, managing and relieving these issues are critical for nurses and their employers." Carpenter is in fact a nurse, and it would have been helpful to identify her as one. In any case, the piece notes that ANA's Healthy Nurse program recently began offering workshops on the issue at its annual conference. And the column includes a helpful chart listing the major physical and emotional symptoms and effects of compassion fatigue, citing the ANA as its source.
Landro frames her piece with anecdotes about two oncology nurses who have participated in the Barnes-Jewish program. Nurse Wilhelmina Roney "sometimes feels overwhelmed by demands from patients," and in some weeks, patients "may die in such quick succession that she barely has time to cope." Roney said that she (in the piece's words) "found herself discouraged when patients or families weren't satisfied with her care or had a negative outlook," citing a patient in his 40s who pressed her about whether she liked her job and declared that he was dying, though treatment could likely extend his life. Compassion is harder with a patient like that, but Roney said the hospital's program had helped her learn how to handle such situations better. Nurse Jamie Bugg pointed to the "daily toll when you see so many sad aspects of things and people at the end of life, knowing how sick they are and knowing this could be their last holiday." She said nurses "need better ways of coping than internalizing everything," and although she found some aspects of the training "awkward" (like "a session in which participants team up and look into each other's eyes silently for a minute, and then say positive things about what they observed"), she hopes colleagues will take the course.
Landro's health blog about the column goes over some of the same ground, but also has helpful additional detail, particularly about the projected shortage of nurses. Landro notes that interventions like those the ANA has proposed "may only become more important as demands increase on a shrinking supply of nurses, who shoulder the heaviest burden of patient care." We like that last phrase, but more detail would have been better; is it just that nurses have a huge quantity of work, or is the work complex and critical to patient survival, and do nurses spend more time with patients than any other health professionals do? Landro reports that a recent study in Health Affairs (abstract, or full text (scroll down)) found that "even with a recent rise in young nurses entering the profession, the supply of registered nurses will be roughly 15% below the projected need by 2030, assuming entry into the field remains at current levels."
The blog includes good additional comment from nurse experts. Lucia Wocial, "a nurse ethicist at Indiana University Health in Indianapolis," explains that compassion fatigue is "often compounded by moral distress -- the feeling of being unable to help a suffering patient or do what [nurses] feel is the right thing, such as withdrawing life support from a patient who won't recover when a doctor or family asks for additional interventions." Noting that Indiana University Health offers resources like retreats to help staffers, Wocial says they stress "how important it is to rejuvenate, because you can't take care of people unless you are taking care of yourself." Similarly, the blog includes input from Lawrence Marsco, "a 25-year nursing veteran who manages the leukemia and lymphoma floor" at Barnes-Jewish. Marsco says that the hospital's day-long compassion-fatigue program for staffers tells nurses that the hospital's leadership is aware of the issues and wants to help.
'In nursing, if you are giving your heart and soul to caring for patients, it is very difficult not to be affected by compassion fatigue' he says. 'This is a way to bring awareness of the issue so you don't turn into a nurse who is perceived as cold and uncaring, when in fact you are probably the most caring and compassionate nurse of all.'
Thomas Lowe, a "health and safety representative for the New York State Nurses Association," conducts workshops on compassion fatigue last year that use relaxation and stress-reduction techniques and says such programs could be offered at nursing schools. (Lowe is a nurse and might have been identified as one.) He also notes that compassion fatigue may be exacerbated by (in the blog's words) "an already stressful work environment, where nurses may be pulling extra shifts because of understaffing, and may face verbal abuse or bullying from [physicians] or other members of the care team." These excellent points underline the links between compassion fatigue and other problems in modern nursing, particularly those rooted in poor relations with physicians and other colleagues (the moral distress and bullying issues), and we wish there had been room for them in the main piece. The piece might have also have made clear that because these issues originate partly outside of nursing, nurses' compassion fatigue should be addressed not only by self-development by nurses, but by serious efforts from others with the power to improve nurses' working conditions. This is not something nurses can or should have to solve by themselves.
Much of what we read here about nurses' role in health care is consistent with an angel-oriented vision of the profession--which suggests that the measure of a nurse is how kind he is--but the blog does provide a little additional background on "the connection between compassion fatigue and patient outcomes." Landro notes that a 2009 analysis by the Regenstrief Institute and Indiana University School of Medicine linked compassion fatigue to "decreased productivity, more sick days and higher turnover among cancer care providers." And in "numerous studies, higher turnover and understaffing among nurses has been linked to worse patient outcomes and higher mortality rates." This is very helpful, though the blog might have explained why it might be: nurses do complex, life-saving work, so if they are impaired, it matters. Fortunately, Landro's column does include a little more on this in the quotes from Patricia Potter, who notes that affected nurses may fail to observe patients closely and that patients may be less likely to ask them for help. On the whole, Landro's column blog and column give readers a good look at an important nursing problem and efforts to address it.
"He telephoned to say . . . I was the best nurse he had ever met, though of course I'm not a nurse"
The December 31 Daily Mail piece on the lay "nurse" has a revealing headline: "Family nurse 'dying' gran back to life after doctors give up on her: Granddaughter sleeps on floor to give her 24-hour care." That is, even in a piece about how an untrained person "nurse[d]" someone "back to life," what matters is whether the "doctors" gave up on the patient. The basic idea is that 41-year-old Hazel Carter refused to accept that her 89-year-old grandmother Margaret Park was actually dying, as the family had been led to believe by a hospital to which she had been admitted. So Carter ignored "the doctors' grim prognosis" and took over Park's basic care, feeding her, persuading nurses to stop giving her morphine that supressed her cough, and providing "round-the-clock-care" for three weeks to help her overcome what turned out to be non-fatal pneumonia.
Park's family apparently at first thought she was just in the Blackpool Victoria Hospital for a bad back, but they were soon told she had only hours to live and summoned to say goodbye to her. "Doctors found" that Park had pneumonia, and she "was put on a saline drip and given oxygen through a mask"--a classic formulation, in which physicians think and act, but what nurses do is described in the passive tense, with no actor, hiding their contributions. Carter herself thought Park was in the hospital only for a bad back and a chest infection, and it was actually this misunderstanding that contributed to her initial refusal to accept that her grandmother was dying. After everyone else had said goodbye and left, Carter returned:
"I began to realise there were things I could do. She kept knocking off her oxygen mask, so I put it back and held it in place. Then she was trying to clear her chest, but the drugs were hampering her efforts. As the morphine wore off, she was getting better at it, so I asked the nurse to stop the morphine altogether and it helped. She had the strength to clear her chest. . . . The morphine meant my grandmother had no will to fight back, and she had always been a very strong person. When she stopped getting it, she was able to fight for her life." Also against doctors' advice, she fed Mrs Park despite the "nil by mouth" on her notes. "I gave her custard because it was easy to swallow," she said. "It's obvious you'll never get better unless you have food to give you strength."
For three weeks, Carter "slept on the hospital floor and provided round-the-clock care with the help of her 20-year-old son John," and Carter is "convinced her grandmother . . . would now be dead without her intervention." On the second day, a consultant (senior physician) told Carter that Park had pneumonia and was unlikely to survive, given her age. Carter was unconvinced, and she stayed on, cleaning her grandmother, feeding her, and ensuring she got her usual medication. Carter
believes that much of the care she was providing should have been given by nurses, but she found they were simply too busy. . . . "The nurses on the ward work horrendous hours, and it wasn't their fault, they were just so busy. And everyone was saying she was going to die anyway. I can't really knock anyone at the hospital. When they realised my grandmother was actually getting better, they dealt with it properly."
Awesome. It sounds like Carter also had to deploy some good psychosocial skills, because caregivers in many developed world settings would not necessarily welcome a family member living in a patient's room for three weeks and providing much or most of her care. Carter says she "didn't want to make a fuss or interfere, because I didn't want the nurses to throw me out."
As Park began to recover, "the family were told she would not walk again or be able to return to live with her 89-year-old husband Jack." But Carter again "refused to accept" that, helping her grandmother to walk around (something else the real nurses should have done), and after three weeks, Park was back home with her husband. Carter says one hospital physician was particularly struck by this:
There was one junior specialist who was genuinely overwhelmed by it, and he was crying. He telephoned me after we went home to say I was the best nurse he had ever met, though of course I'm not a nurse.
However misguided the consultant's statement was, it's a telling comment on what does appear to be a terrible breakdown in both nursing and physician care. Carter herself now believes, not surprisingly, that "old people are too easily written off by hospitals." And it seems likely that that modern care problem, the tendency to assume that the elderly become ill and die simply because they are elderly, was a big part of why the family was "told" that Park was about to die. We assume that what the family was "told" is mainly a reflection of what the physicians thought.
The piece gives some background on Park and an update on her current status. Carter explains that Park has been an "inspiration" to her because "she and my grandad were married after the war and were farmers, and worked so hard . . . They are still an amazing couple. She could make something out of nothing. My grandad still drives and brings her to visit us." Speaking apparently at a party to celebrate the couple's 65th wedding anniversary, Park says:
What Hazel did is keep me alive. Everybody seemed so busy in the hospital. I didn't feel I was getting a lot of attention. She was a right little gem. I think they would have let me fade away if Hazel hadn't been there.
The article's final line is itself a little gem: "The hospital declined to comment." We bet.
It sounds to us like Carter deserves the credit she is getting for saving her grandmother's life, though we do wish that the newspaper could have accomplished that without repeatedly calling her a nurse, which implies that nursing is something any committed lay person could do. It's not, because nursing is a profession that requires years of university-level science training, though a committed layperson clearly can do some things that have traditionally been within nurses' scope of practice. Many people could do some of the things within physicians' scope of practice also, but no one is calling lay people "doctors." Of course, we won't object too strongly given Carter's impressive instinct for some of the elements of good nursing, and the reported lack of skilled care provided to Park (and to describe the morphine prescription here as a lack of good care may be charitable). We do note that although what Carter did is newsworthy, real nurses save lives every day in part through some of the same vital if unglamorous tasks; however, society rarely seems to notice. It's also worth noting that neither Carter nor Park really says that the nurses were incompetent or uncaring. Instead, they say that the nurses were so overwhelmed that they did not have time to care for Park. Understaffing remains endemic in care settings worldwide. Perhaps the nurses paid Park even less attention because the physicians had evidently given up on her and because Park had an unusually attentive family. But the fact that both Park and Carter note how busy the nurses were suggests that any patient could encounter similar problems.
We thank the Wall Street Journal and the Daily Mail for pieces that reveal some of the stresses under which modern nurses work--and what can happen when those stresses are too much.