Book Review: Compassion Fatigue and Burnout in Nursing: Enhancing Professional Quality of Life. Vidette Todaro-Franceschi, 2013, Springer Publishing Co., LLC.

Reviewed by Laurie Barkin RN, MS., author of The Comfort Garden: Tales from the Trauma Unit

Vidette Todaro-Franceschi’s book, Compassion Fatigue and Burnout in Nursing, is heartfelt and academic, thorough, thoughtful, personal, and refreshingly non-formulaic. It is written by a nurse who cares deeply about nursing, nurses, and patients. In addition to being the consummate nurse— expert clinician, supervisor, manager, professor—she has experienced nursing as a cancer patient and freely shares the horrors of that experience. Her voice is unique in nursing literature—passionate and professorial, maternal and political, and delightfully unscripted.

The author, a nurse-scholar, educator, and peer-reviewer for many professional journals, is a tenured professor at Hunter-Bellevue School of Nursing. Her research focuses on end-of-life/palliative care, bioethics, and leadership. She is guided by a deep sense of spirituality—that we are all one—and her belief in the flap of a butterfly’s wing to effect change halfway across the globe.

Compassion Fatigue and Burnout in Nursing is divided into 5 parts:

Professional Quality of Life
Unity, Purpose, and the Good: An Ethic of Caring
The Bad and the Ugly: Compassion Fatigue and Burnout
Facing Death
Beating the Odds

In Part 1, Dr. Franceschi-Todaro introduces us to the concepts of compassion satisfaction, compassion fatigue, and burnout. She speaks about caring as heartful (compassionate), heart-heavy (compassion-fatigued), or empty-hearted (burnt out). She tells the story of John Doe, a homeless young man who landed on the ICU, unresponsive and without a known diagnosis, whose body systems soon collapsed. Many of us carry around the ghosts of former patients and this is one of hers. Dr. Franceschi-Todaro describes the emotional pain and struggle of taking care of this young man with no friends or family to claim him. She says, John was “…a turning point for me. I went from critical care nursing to focus on care of the dying. Most notably, I have come to appreciate that cases like John…help to reaffirm a sense of purpose, a sense that there is always a reason I do the things I do as a carer.” Dr. Franceschi-Todaro knows that making meaning of one’s work, especially when faced with a grim outcome, keeps the flame of passion alive.

She sites nursing theorists Martha Rogers, Jean Watson, Madeline Leninger, Patricia Benner and others on care and caring and sings the praises of magnet hospitals that empower nurses to take control of their professional lives.

In Part 2, Dr. Franceschi-Todaro relates stories of nurses that illustrate the transformational power of compassionate nursing, the reason why we get up and go to work each day. She delves into Aristotle’s concept of energy and discusses the work of three psychologists: Abraham Maslow on self-actualization, William James on second wind, and Mihaly Csikszentmihalyri on optimal experiences and flow. Later, she quotes the Dalai Lama, Buddhist nun Pema Chodron, and philosopher Martha Nussbaum on being compassionate, open-hearted, and heartful.

The author discusses the definitions of empathy, caring, sympathy, and compassion and quotes Schantz (2007) who notes that “…compassion is the only one that impels and empowers people not only to acknowledge but also act toward alleviating or removing another’s suffering or pain.” According to Dr. Franceschi-Todaro, being a compassionate nurse “…means we feel for others, display kindness to others, and act on behalf of others for their benefit.” By doing so, “…we are also caring for ourselves; it is virtually indistinguishable where one ends and the other begins.” This is another example of her oft-repeated phrase, “We are all one.”

Chapter 5 is devoted to ART: a Model of Professional Quality of Life, that she employs to solve problems that arise in a nurse’s work life.

A stands for “Acknowledge that there is a problem.”
R stands for “Recognize and explore one’s options.”
T stands for “Turn outward, to focus on self and other.”

Initially, the phrase “turning outward to focus on self and other” threw me. Shouldn’t we turn inward to find insight, clarify our values, and identify our feelings? Upon closer reading, I think she’s saying that we must turn outward to focus on the relationship between the nurse and the other. In other words, reconnecting with ourselves in relationship with our co-workers and our patients as an antidote for burnout and compassion fatigue.

Part 3 is devoted to discussing the ramifications of compassion fatigue, burnout, and moral distress and what to do about them. Because turning toward others—patients and colleagues—is an antidote for compassion fatigue, doing so can reverse the trend of nurse-to-nurse incivility, i.e.turning against each other, currently a big topic in nursing forums. Of course, the bullies are often burned-out themselves. Dr. Franceschi-Todaro shows compassion for the perpetrators of bullying as well as the recipients and concludes that incivility cannot be eradicated from the workplace. In my view, since bullying adversely affects patient care, nursing has an obligation to address this scourge directly and effectively.

Part 4 explores how nurses cope with death. Dr. FT says she is known as a “death educator.” With journalistic skill, she relates stories about taking care of dying patients, young and old. She laments that aside from learning about Kubler-Ross’s stages of dying and the mechanics of post-mortem care in nursing school, nothing was taught about how to talk with patients and families about dying and death. She implies that this lack in nursing education still exists. Instead of disconnecting and distancing ourselves from dying patients, she advises nurses to use the ART strategy: acknowledge our feelings about dying, recognize choices and take purposeful action such as taking classes (we are all invited to sit in on her classes!), speak with a spiritual advisor or a counselor, turn outwards toward ourselves and others and use the experience of working with patients approaching the end of their lives to feel appreciation for our own lives.

Part 5 suggests solutions to the problem of compassion fatigue. Individual nurses can become mindful about the meaning and purpose of our work and use the ART model to enhance the quality of their professional lives. Nursing schools can teach compassion skills, advocacy, end-of-life care, nursing ethics, and self-care strategies. “Not just a dab of it…,” she admonishes. “…at least a full course immersion of it,” adding that nurses must practice what we preach in terms of self-care as well. The author suggests that we can impact the profession by developing nursing leaders capable of transformational change and routing out toxic managers. She calls for nursing leaders to provide “…quality health care and quality caring to enhance the quality of living-dying for all people.” I would add that we need nursing leaders who support nurses’ professional autonomy, insist on accountability, are trained in group dynamics with commensurate skills in conflict management, and know how to create the conditions for a healthy staff environment.

Finally, Dr. Franceschi-Todaro asks us to imagine the possibilities for nurses and nursing. She imagines a time when compassion will be valued, when it will figure into acuity levels and staffing calculations, and when advanced practice nurses will assert themselves by vetoing a treatment plan with which they disagree. She advises leaders to allow staff time to tell stories of healing moments and to share their feelings in the process. While this is music to my psych nurse/writer’s ears, it may not grab newer nurses who have been force fed evidence-based practice to the exclusion of practice-based knowledge and the clinical intuition that comes from it.

For my taste, a few of the many “we are all one” comments could have been edited out without losing the message. Also, some important questions are not addressed: If compassion, connection, and caring are foundational to nursing, how can we assess these qualities in potential applicants to our schools of nursing? Will we deny admittance if we find these qualities lacking? How do we evaluate nurses’ understanding of the healing potential of relationship and how do we assess a nurse’s skill in creating such a relationship with her patient? Also, how should organizations monitor nursing leaders? Specifically, how can they differentiate—-and rid themselves of—-fascist control-freak nurse leaders from those who support and elevate nursing within the organization? Those of us who have kicked around nursing for a long time are all too familiar with the former and not familiar enough with the latter.

At the end of the book Franceschi-Todaro says nurses should reaffirm our purpose, imagine a different way of being, speak up, appreciate ourselves and others, and get help for “the bullied and the bullies.” She acknowledges that the profession needs healing and that “…it is ours to heal.” (p. 186) She repeats that only by recognizing that “we are all one” can we transform nursing. As compared to the first half of the book, this part of the book feels rushed and breathless, like a professor trying to pack too much into the last few minutes of class or a nurse struggling to balance the competing urgencies of family/work/self-care. This brings us to the next question: How can nurses heal the profession when they are exhausted by inadequate resources and a healthcare system that de-priortitizes caring? Curiously, the author acknowledges that there is strength in numbers but does not mention the value of nursing unions to effect change.

Dr. Vidette Franceschi-Todaro is energized by butterflies and all they symbolize: “purposeful energy transformation, a sign of renewal, and through their continual metamorphosis, a symbol of everlasting change.” (p. 183) At the book’s conclusion, she asks us to imagine working together in harmony, like migrating monarch butterflies.

It’s an unfortunate metaphor with which to end the book. Compassion Fatigue and Burnout in Nursing was published in 2013. The following year marked the lowest population of monarchs ever counted. A severe weather storm in 2002 killed 500 million of them, a huge blow to the population. In addition to that storm, ongoing climate change, logging, and the agricultural use of herbicides that kill the milkweed necessary for monarch reproduction have contributed to the low counts of Monarchs for most of this century. According to the Center for Biological Diversity, although the count has slightly rebounded in the last two years, it remains 78% lower than the population highs of the mid-90s.

Like the monarchs, our nursing goals have been impeded by poisonous work environments and resource deficits—-among other factors—-that have contributed to compassion fatigue, burnout, and large numbers of nurses leaving nursing. To counter these environmental stressors, Dr. Franceschi-Todaro advises us to turn outward—to value and heal relationships with our own selves, our colleagues, and our patients. By doing so, we can harness the collective energy of positive relationships to surmount obstacles and thrive. I’m all for giving it a try. How about you?

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Since publishing The Comfort Garden in 2011, I’ve had the opportunity to speak to groups of nurses and other healthcare professionals about compassion fatigue, vicarious trauma, and self-care. Looking out upon my audience, I notice much head nodding and sometimes dramatic aha! moments when I describe the signs and symptoms of the first two topics. However, the phrase “self-care,” uttered only in the last third of my talk, elicits an immediate eye-roll response from nurses, followed by an audible exhalation of withering disapproval—as if it’s OK to experience nightmares, shortness of breath, emotional and physical exhaustion but definitely NOT OK to do something about it.

In a recent post on Jonathan Turley’s blog, guest blogger Charlton Stanley recounts the story of Elizabeth Jasper, a 38- year-old nurse and mother of two young children, who was killed after allegedly falling asleep at the wheel on her way home from work where she had been asked to stay beyond her 12-hour shift. In his piece, Worked to Death: Fatigue and the Health Profession, the Dirty Little Secret, Mr. Stanley describes how his wife, also a dedicated nurse, was often summoned to work on her days off for “emergencies” and frequently worked 16-hour shifts only to return to duty 8 hours later. Eventually, his wife developed idiopathic cardiomyopathy which forced her retirement. To the bafflement of her cardiologists, during her forced time away from work, her heart recovered enough to allow daily functioning. In other words, he says, her work was killing her.

Mr. Stanley devotes much of his post to the problem of inadequate sleep and society’s denial of the importance of this despite a body of research such as the Whitehall II Study that correlates decreased sleep with a “doubling of risk from all causes.”

This made me recall something I heard at a recent psychological trauma conference—that childhood trauma disrupts normal sleep cycles such that children cannot reach the stage of sleep that refreshes and renews the body. One wonders if many chronic sleep disruptions are holdovers from childhood trauma as depicted in Kaiser’s ACE (Adverse Childhood Events) study which correlates the onset of chronic illness in adulthood with a history of childhood sexual abuse, emotional abuse, neglect, parental substance abuse, and/or a history of growing up with a relative who committed suicide, was incarcerated, or was mentally ill.

When I ask the eye-rollers in my audiences what they associate with “self-care,” they invariably say, “self-centeredness,” “self-indulgence,” and “selfishness.”

(Sigh.) Fellow nurses and other caregivers: If this is what “self-care” means to you, you may be placing your patients at risk for harm due to medication errors, neglect, and inattention. By working too hard and too long, you may also be placing yourself in danger.

The next time I address a group of nurses, I plan to talk about “self-compassion.” I have a feeling that when I do, instead of rolling, the eyes will tear up. If so—if the tears indicate we have moved beyond judgment and cynicism—we just may be able to have a heart to heart about taking good care of ourselves in order to take good care of our patients.

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Last week, bombs exploded at the finish line of the Boston Marathon. In West, Texas, a fertilizer factory exploded. Elsewhere in the country it was trauma as usual: car crashes, gunshot wounds, stab wounds, rape, burns, and on-the-job accidents. In my work as a psychiatric liaison nurse on the trauma unit at San Francisco General Hospital, I spoke with hundreds of survivors and their family members. Here are a few important things to know about trauma and recovery.

In the aftermath of trauma, when the mind and body continue reacting to danger, violence, and loss, many people fear they are losing their sanity. They cannot close their eyes without re-experiencing the scenes they witnessed. They feel confused, their minds race, their hearts pound, their moods swing, and they sweat in the absence of exertion. Breathing is shallow and rapid. People feel jumpy, hypervigilant, and overwrought or they feel numb and detached. Grief is mixed with guilt and anxiety. Parents fear for their children. Children fear for their parents.

All are normal reactions to abnormal events. The best medicine is a combination of self-care and social support.

Advances in neuroscience now demonstrate that trauma resides in the body long past the event itself. That’s why my cousin, Matt, who saw the second airplane crash into the World Trade Center 12 years ago, experienced an electrical surge down his back as soon as he heard about Boston. It’s not surprising that Kaiser Permanente’s ACE study (Adverse Childhood Events), conducted in collaboration with the Center for Disease Control, correlates the onset of many chronic emotional and physical illnesses in adulthood with traumatic experiences endured during childhood.

For a number of weeks after the event, survivors will be primarily concerned with physical recovery, especially when it involves multiple surgeries and taxing physical therapy sessions. In the hospital, psychiatric professionals can provide support by encouraging survivors to express difficult emotions and to explore ways of coping with anger, frustration, sorrow, and fear. They can also teach survivors breathing techniques and lead them through relaxation exercises.

Out-patient support groups with others who have experienced trauma validate and normalize discomforting thoughts, feelings, and perceptions and in so doing, decrease the survivor’s emotional isolation.

Survivors of traumatic events—and caregivers who may be vicariously traumatized–need to be active partners in the healing process. To calm the physiological arousal of trauma, find a quiet, comfortable space and breathe slowly, deeply, and rhythmically at least a few times a day. Some find it helpful to focus on pleasant imagery or listen to relaxation tapes at the same time.

Physical exertion–walking, running, swimming, yoga, tai chi, weight-lifting, dance, gardening, and the like—also mediates the effects of stress hormones on the body, quiets the mind, and re-synchronizes normal body rhythms as does meditation, prayer, chanting, and singing.

While everyone reacts to traumatic events in a unique way, some themes are common to most. In a support group I co-facilitated for three years, survivors often spoke about their post-trauma experiences in the following ways:

“In an instant, everything changes.” People often commented on the cruel transformation from a being a self-sufficient person to one who is dependent on others.

“It’s like a tape playing over and over in my head.” Memories of the trauma scene may flash uncontrollably during the day or startle survivors awake at night.

“If only I had (fill in the blank) maybe this wouldn’t have
happened.” The mind obsessively revisits every microsecond preceding the event, looking for a way it could have been prevented.

“You find out who your friends really are.” Family members and friends are also profoundly impacted by the traumatic event. Some rise to the challenge of providing support and nurture. Others abandon the survivor, fleeing the reminder that life is unpredictable.

“They tell me I should get over it already!” Some survivors feel ashamed when they can’t just “get over it.” Friends and family members may silence victims because they need to deny the fact of randomness in the world. Many feel helpless and fear worsening the trauma by saying the wrong thing.

“No one really wants to know how you are.” Self-conscious about feeling needy and wary of others’ responses to their ordeals, survivors often withdraw from friends and family, causing them to feel lonely and disconnected from others, positioning them perilously close to the abyss of major depression.

Social support cannot be overemphasized. Trauma patients need rides to appointments and religious services, trips to grocery stores and pharmacies, cooked meals, and aid in rearranging living space to accommodate physical disability. Mostly, though, they need our compassion and willingness to listen. Although we can never truly fathom the fact and depth of another person’s experience of trauma, “being with” the survivor (and family members, for that matter)–offering to listen without censorship, without judgment, and without compulsively needing to “fix” them–is hugely beneficial.

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These days, very few hospitals employ psych liaison nurses. We are told it’s because we’re expensive but the other reason is that much of our work is hidden and therefore unknown. How does an institution measure the cost of incidents in which patients injure themselves, leave against medical advice, verbally abuse or physically assault staff, damage property, burn out caregivers, and upset other patients and their families? How does an administrator balance these potential costs against paying for the time, experience, and skills that advance-practice psych nurses bring to bear in preventing critical incidents and supporting staff?

Like soldiers in war-zones, experienced psych nurses have a sharply honed ability to predict and prevent volatile situations. Sniffing trouble, we reflexively intervene before feelings escalate. In the general hospital unit this means spending time with troubled or troubling patients, using empathic listening skills to identify the cause of irritation, doing something to relieve the patient’s distress, setting compassionate but firm limits when necessary, organizing patient-care conferences, and putting a prevention plan in place for all treatment staff to follow.

Psych liaison nurses also spend time with patients who, while not homicidal or suicidal, nonetheless feel anxious, fearful, sad, depressed, frustrated, apprehensive, hopeless, distrustful, paranoid, depersonalized, dehumanized, demoralized, neglected, or abandoned. Medical-surgical nurses don’t have time to address these emotional issues directly with patients. But these feelings affect patients’ motivation and compliance which affects their health and recovery process.

During the hospital mergers and reorganizations of the 90s, many psychiatric liaison nursing positions were lost. A new generation of nurses has since been hired who have never even heard of the role. But here’s a glimmer of hope: shortly after publishing my book, I was contacted by an excellent Bay Area hospital about applying for a psych liaison nurse position they had just created. Had it been closer to home, I would have jumped at the chance. I hope someone else did.

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In my world, the wheels of progress turn slowly but steadily. You can now download The Comfort Garden from Amazon, Barnes & Noble, and Kobo, and soon we hope from iTunes.

The other piece of good news is that I will be joining the new nursing website, RNsights, as one of the “ask the experts” staff.

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In Life Support:Three Nurses on the Front Lines (1997), Suzanne Gordon, a non-nurse journalist who writes passionately about nursing, showcases the personal and professional lives of three expert nurses at Boston’s Beth Israel Hospital during the glory days of primary nursing. Before the mergers and cuts of Managed Care in the mid-90s, these nurses practiced at full capacity, improving their patients’ lives and experiencing professional satisfaction in the process.

Even though the book was published in 1997, fifteen years later, with our healthcare system still languishing on the critical list, this book remains valuable and relevant for patients and professionals and everyone who wonders why nurses are so unhappy.

For almost three years, just before the botched merger of Boston’s Beth Israel Hospital with Deaconess Hospital in 1996, Gordon shadowed three B.I. nurses: Jeannie Chaisson, a clinical nurse specialist on a general medical floor; Nancy Rumplik, a nurse working in an out-patient oncology clinic; and Ellen Kitchen, a geriatric nurse practitioner working in Beth Israel’s home care department. Shining a journalistic light on the lived experiences of these three nurses illuminates the all-too-invisible world of what nurses know and how they use their knowledge to benefit patients. With clarity and sensitivity, Gordon shows how these nurses create therapeutic relationships with patients that establish foundations of trust upon which all care rests.

Early in the book, Gordon recounts the implementation of primary nursing at Beth Israel Hospital in the 70s under the leadership of Joyce Clifford and Trish Gibbons. Primary nursing, as developed by Marie Manthey and others, is a decentralized system of delivering nursing care to patients in which bedside nurses are given the authority to make nursing decisions for which they are responsible and accountable. At the core of primary nursing is a therapeutic relationship between the nurse and her patient and the patient’s family. Ideally, the primary nurse works with the patient throughout his or her hospitalization and during readmissions whenever possible. In contrast to primary nursing, team nursing relies on less well-educated workers providing direct care under the supervision of an RN.

Historically, the best clinical nurses were pulled from the bedside and plopped into head nurse positions, usually with little training. At Beth Israel Hospital, career ladders were introduced whereby clinical nurses could advance professionally and still remain at the bedside. Although not a necessary component of primary nursing, Beth Israel hired an all RN-BSN staff and encouraged RNs with two and three years of training to return to school for undergraduate and graduate degrees. It is worthwhile noting that during the nursing shortages of the 80s, Beth Israel had to turn qualified nurses away.

Interspersed with details of the three nurses’ personal and educational stories, Gordon deftly recounts the history of nursing and describes the differences in preparation among associate degree, diploma, and baccalaureate degree nurses; the differences between team nursing and primary nursing; the role differences between nurse practitioners and clinical nurse specialists; and the differences between medical and nursing approaches to patient care. Few physicians and other healthcare professionals are aware of these dynamics. Gordon lays out the sometimes contentious relationships between doctors and nurses–much of it based on ignorance–and contrasts this with collaborative relationships that result in better patient outcomes.

Later in the book Gordon details how managed care has mangled care for patients and strangled the professional hearts and souls of nurses. Even though I lived this reality and wrote about the same issue in my book, reliving it again still makes my blood boil.

Suzanne Gordon does not try to hide her exasperation for nurses who consider unionization “unprofessional.” Nurses not protected by a union contract have little recourse if they blow the whistle on unsafe patient care practices such as premature discharges, inadequate staffing, and the use of unlicensed personnel. Although Life Support is not preoccupied with gender politics, Gordon’s feminist roots are evident throughout the book.

Nurses know that far from stanching the flow of blood from our healthcare system, cutting nurses will hasten the bleeding. As Suzanne Gordon suggests, “…we should target the real health care cost escalators–the exorbitant salaries of hospital administrators and insurance executives, the incomes of high-priced medical specialists, the outrageously inflated cost of drugs and medical equipment, the construction of unnecessary hospital facilities and purchase of redundant technology, and wasteful health plan and hospital marketing and advertising.”

Gordon makes a point that bears repeating: “Investor-owned managed care companies are legally mandated to increase profits for shareholders.” They do so on the backs of caregivers, patients, and physicians.

Here’s where I make a pitch for nurses to shed the invisibility cloak and reveal what they do, why they do it, and how it makes a difference in their patients’ lives. Equally important is for nurses to explain what they COULD BE doing but can’t because of short-sightedness and limited resources AND how it costs more in the long run. We can’t force people with decision-making power to listen, but with three million plus nurses in this country, surely enough of us can raise a ruckus so that they must.

That said, here is your writing assignment: In your practice area, given a reasonable budget to enact your plan, what measures would you institute anywhere in the system that would result in improved patient care and significant cost savings five years down the road?

I look forward to publishing the best of your suggestions in these pages. Please send them to me at thecomfortgarden2011@gmail.com.

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The term “vicarious traumatization” describes the emotional, psychological, and spiritual changes that take place within an empathic person as a result of regular exposure to other peoples’ traumas. It is also known as “secondary stress.” Vicarious trauma is a component of  “compassion fatigue.”

Vicarious trauma affects nurses, therapists, social workers, teachers, police officers, firefighters, journalists, human service volunteers, members of the clergy, physicians, criminal defense lawyers, judges, and others who regularly bear witness to victims’ stories of violence, abuse, and neglect.

Symptoms include social withdrawal, increased sensitivity to violence, cynicism, despair, nightmares, disturbing images while awake, hopelessness, emotional numbing, spiritual distress, disconnection from oneself and loved ones, decrease in emotional and psychological coping skills, and increased fear and anxiety. Physical symptoms may include shortness of breath, palpitations, digestive upsets, fatigue, headaches, sleep disruptions, and muscular aches and pains.

Working with traumatized clients is a transforming experience. Most of the time, the positive aspects of the work overshadow the negative aspects. However, sometimes the negative aspects interfere with one’s ability to function effectively at home and at work. Untreated, vicarious trauma can lead to ineffectiveness on the job and eventually, to burn-out. Vicarious trauma disrupts a person’s sense of safety in the world, one’s trust in human decency, one’s hope for the future, and one’s overall sense of well-being.

While a number of academic and self-help books have been written about vicarious trauma, compassion fatigue, and burn-out, The Comfort Garden: Tales from the Trauma Unit tells a personal story of how VT develops in a professional caregiver over time. The major lesson of The Comfort Garden is that people who routinely witness other people’s pain and suffering need support to do the work they do.

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My friend Carol, an ICU nurse in her fifties, told me about one of her patients, a 62-year-old real estate agent who had been hospitalized for seven months. He asked that ‘older nurses’ be assigned to his care. As an ‘older nurse,’ I wanted to hear why Chuck had this preference. Carol got the OK from Chuck and I was soon talking to him by phone.

“I was thinking about their talents and capabilities, and that their bedside manner was mothering,” he said. “Most of them have raised children. They are more sensitive. Maybe I was giving up nurses who were trained in new technologies. Maybe I was sacrificing something for having that mindset, but I don’t think so.”

Yes, many of us older nurses have the nurturing thing down. For better or for worse, even the name of our profession is etymologically entwined with nurturing children. Like children, patients often feel vulnerable, frightened, and powerless. They fear disability and death. They may also be in pain. For these reasons, behavioral and emotional regression is normal during hospitalization. Empathic nurses sense this vulnerability and respond accordingly. Over the last few years, advances in neurobehavioral research support what nurses have always known: providing care and comfort helps patients heal.

Although the public associates the nursing profession with nurturing, most people do not associate nursing with thinking. With patients being admitted sicker and leaving quicker than ever, nurses need to be able to observe, assess, analyze, and act decisively. They need superior organizational skills and excellent communication skills. They need to know the doses, actions, and side effects of hundreds of medications. They need to know when to closely monitor changes in symptoms, and when to sound the alarm. Dissociating nursing from thinking is a critical misperception, one with serious implications for patient care and for recruitment.

Nursing has a long history of being devalued, in part because of our association with frailty, vulnerability, and intimate bodily processes. Doubtless, some of this misperception is traceable to the portrayal of nurses in the media. Unlike real life, nurses in most medical dramas play minor roles in patient care. Physicians are shown saving lives, spending time with patients, holding their hands, and looking deeply into their eyes. Nurses are often invisible.

Patients are hospitalized because they require 24-hour nursing care. In real life, physicians see hospitalized patients for a few minutes in the morning and maybe a few minutes in the late afternoon. That’s it. Nurses are the ones at the bedside most of the time. While caring for a patient—bathing her, dressing her wounds, feeding her, medicating her—the nurse is also evaluating her mental status, assessing her respiratory status, looking for signs of infection, interpreting information on cardiac monitors, checking intravenous sites, observing the patient’s mood and coping capabilities, and monitoring fluid balance—all the while maintaining a calm, empathic presence. It takes a long time for a nurse to learn to meld multitasking, critical thinking, and nurturing responses and make it look easy. I bet this is what my friend’s patient, Chuck, was responding to in his request for “older” nurses.

While the media’s portrayal of nursing is problematic and inaccurate, nurses themselves contribute to the problem of devaluation and invisibility by avoiding opportunities to speak publicly about what we do. Relatively few nurses write about nursing for the general public. To the frustration of many of us, our profession still can’t agree that a four-year degree should be the entry level to nursing practice.

In light of the serious nursing shortage looming as boomers—including boomer nurses—age and retire, we need to recruit smart young men and women to our profession. To do that, we need to shed our cloak of invisibility and reveal the mental competence that nursing requires. And, as Chuck does, we should value the seamless blend of mothering and thinking that our best nurses have mastered.

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During the five years that I worked as a psychiatric liaison nurse on the surgical/trauma unit at San Francisco General Hospital with people who had survived motor vehicle and other major accidents, fires and injuries, I listened to hundreds of trauma stories. In the course of conducting thorough psychiatric evaluations, I asked my patients about prior traumatic events in their lives. More upsetting than the circumstances necessitating hospitalization were my patients’ stories of untreated childhood trauma. These included stories of children who witnessed parental suicide and domestic violence, children who were sexually abused and worked as prostitutes, and children who endured punishment at the hands of sadistic parents.

For the first few years, I took pride in my work with these patients. Many had never told their stories to another person. By listening deeply and without judgment I validated their experiences and thus, their humanity. In our work together, I helped them identify words that best described their feelings, taught them relaxation techniques to manage these feelings, and coached them in constructing a coherent narrative to give shape to those feelings.

But such witnessing comes with a price. After a few years, I began to experience some discomforting symptoms: nightmares, palpitations, shortness of breath, anxiety, and an inordinate fear for my children’s safety. Later I learned that my symptoms had a name: vicarious trauma, a component of compassion fatigue. Unfortunately, appeals that I had made to the director of our consult service to allow staff process time were dismissed. When it became clear to me that I needed to take care of my own mental health, I resigned my position.

Nursing school does not prepare nurses for the experience of witnessing pain and suffering. Although nurses value a holistic approach to patient careone that emphasizes prevention and health maintenance—many of us wait for a crisis to ensue before we take our own medicine. (1) Not surprisingly, our bodies bear the brunt of our stress. This may be expressed in irregular eating and sleeping, musculoskeletal tension, respiratory problems, substance abuse, and decreased immune system functioning. Too many of us teeter too close to the precipice of chronic illness. It is not surprising that a study by Welch found that 35% of nurses sampled were clinically depressed. (2)

It stands to reason that happier nurses have more to give their patients than those depleted by compassion fatigue. With so much time and energy spent at work, efforts to create a supportive workplace environment should be paramount. Nurse administrators can support nursing staff members by regularly allocating time for nurses to discuss how they are coping with the stress of caregiving. They can encourage staff members to practice good self-care such as mindfulness meditation and self-compassion.(3) And they can use psychiatric liaison nurses to teach good communication skills, facilitate support groups, and consult with individual nurses, particularly newer staff members. Nurses must also take responsibility for their own care. The Academy of Traumatology/ Green Cross has proposed the following standards of self-care: do no harm to yourself in the line of duty while helping others, and, attend to your physical, social, emotional, and spiritual needs as a way of (providing) high quality services to those who look to you for support as a human being. (4)

This means that in order to take good care of others, we must take good care of ourselves. We must be fit for duty.

1. Hooper C, Craig J et al. Journal of Emergency Nursing (2010) Sept; 36(5): 420-7. Epub 2010 May 18.
2. Welsh, D. (2009) Predictors of depressive symptoms in female medical surgical nurses. Issues Mental health Nursing; 30:320-6.
3. Neff, Kristin. Self-Compassion for Caregivers. May 23, 2011. Psychology Today
4. Academy of Traumatology/Green Cross Proposed Standards of Self-Care

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