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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