Compassion Fatigue

The Chaplains Role among Health Care Workers

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Charles Figley was one of the first to use the phrase in 1995 in his book Compassion Fatigue: Coping with Secondary Stress Disorder (New York: Brunner Mazel). Figley described CF (Compassion Fatigue) as, “A state of exhaustion and dysfunction physically, psychologically, and socially as a result of prolonged exposure to compassion stress and all it invokes”. He added, “Care giving inevitably includes the caregiver absorbing some of that suffering”.    

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In short, CF is the physical, emotional, social and spiritual cost of caring for others in their pain.                                  

Later contributors included Vidette Todaro-Franceschi in her 2013 book Compassion Fatigue and Burnout in Nursing ( Springer Publishing: New York).  Todaro-Franceschi echoed Figley, based upon her experience, “All of us who attempt to heal the suffering of others will, at some point, also share their suffering”. This unique fatigue is found across all health care settings in our post-pandemic world, but especially among those who serve where the reality of death permeates the hallways. As one candid nurse added, “For most patients here, their journey ends on a gurney.” CF also impacts the countless family and friends who care for a loved one in their home, a setting in which there is no "end of shift".

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Nurses and other health care workers are expected (perhaps “ordered”) to excel at both medical competencies and personal compassion, even though these two demands often compete for the limited time and energy of a nurse or care aid on their shift. Nurses offer medical treatments to address the pain and suffering of patients, but they also desire to linger long enough to offer a calming presence. Time often limits their ability to do both well.

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Despite these challenges, research polls consistently place nurses among the most trusted of all professionals. They can-and should-embrace their great worth and respect in society. However, every RN, LPN, therapist and care aid is still human and exhausted at the end of the shift. I know because in my work as a chaplain I watch them as they head home.

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CF is most prevalent among care givers who serve those with a low likelihood of recovery (e.g. senior acute care, dementia care communities, acute home care, hospice and trauma wards). Death overload happens in these settings where there is a higher incidence of acute illness and death. As one care aid confessed to me, “I am too busy to stop and grieve, somebody else needs me.”

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Where is She?

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When Ellen, a care aid, did not arrive for her shift, the ward nurse called her home phone to find out why she was late. When Ellen’s husband answered the phone, he anxiously reported that Ellen left home at the usual time but he did not know where her whereabouts. The hospital chaplain headed out in search for her with the intent of driving the route she would have taken from home to work. He did not have to go far. He found Ellen sitting in her car in the parking lot of the health facility. Still fastened in her seat belt and staring blankly out the windshield of the car, she quietly responded, “I got to work and decided I can’t do it anymore. I just can’t do it”. That was her last day at work.

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What are the symptoms of CF?

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Although the list of potential CF symptoms is long, everyone experiences this syndrome in unique ways. As with Ellen, CF can appear suddenly. In other cases the symptoms gradually emerge.

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Some of the frequent symptoms include:

• an inability to concentrate

• sleeplessness

• anger

• depression

• fear

• growing cynicism

• isolation

• workplace absenteeism

Overall, CF feels like a heavy heart and a diminished sense of personal accomplishment. Sufferers feel very alone. As Todaro-Franceschi noted, “One clear sign of CF is the feeling of, 'I hate my job and I hate having to get up and go to work'.”

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What are the Causes of CF?

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Researchers have noted several possible contributing factors:

• Wards and communities where patients usually decline in physical health and quality of life

• Helicopter families who hover about with unrealistic expectations for recovery. The family wants all measures taken to care for their loved one. Medically futile treatments have become a mainstay of western health care. Although the nursing team knows that some of these radical and painful procedures will only cause trauma with little hope of recovery, the procedures are implemented as required.

• A diminished sense of success in the workplace due to perpetual staff shortages and longer shifts

• Difficult or aggressive patients and/or residents that cause threatening situations

• A Toxic workplace in which the staff feel a lack of support from others

• Personal injury in the workplace

• Relentless needs in the midst of trauma and frailty. Residual grief- the always present sense of death and dying

• Family members who care for a loved one at home with little or no respite

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Three Categories of CF:

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Although not all medical staff experience its effects, CF lurks around every ward and nurses’ station.

When the many causes are distilled down, researchers suggest there are three broad cause categories for CF:

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Fear of Personal Harm or Death: Health care workers experience risks of personal injury or worse. An aggressive resident who assaults the nurse; long hours that wear the caregiver down to the point of exhaustion and illness.

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Feeling of helplessness and low work satisfaction: Patient clinical needs become so overwhelming that holistic care becomes impossible. The staff are too busy to stop for the special care moments such as giving a back rub, talking and comforting. An acute health crisis of a patient may lead to death which might have been preventable with proper resources and adequate staff.

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Frustration with the workplace culture and toxicity: An real or perceived lack of support from the administration or other team members that leads to staff complaining, “We simply are not given the resources need to be effective”. “Don’t they get it? We can’t do our job!” Some older health care workers take pride in acting like “bullies” toward new and younger team members- a kind of initiation rite. “You have to learn the hard way about this job.” Other long-standing staff become cynical and do only their own job without helping others on the team when needed.

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What is the role of the Chaplain?  “AAA support”

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Health care workers serve as the front-line soldiers in our ongoing war against suffering. Anna’s response to the pamphlet, captured this reality: “Now I have a name for what I have long experienced.” Chaplains can help to raise awareness of the crisis with team members and administrators.

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Western culture has exalted medical science to a place of worship where the physician, nurse and other medical personnel become our endeared priests. “Doctor, do something.” “Nurse, give me something!” Yes, medical research has provided countless and effective treatments for the specifics of suffering and we are all the benefactors. However, those who dare to care still do so at considerable cost to themselves- especially where recovery is unlikely.

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Health care workers serve not as priests to be adored, but rather as warriors to be honored. They serve as soldiers, not saviors. In fact, during the current COVID crisis, nurses have been described as “heroes” and “front lines workers”- terms borrowed from battlefields. Sickness crashes through the door of our illusionary world wherein we worship health and well-being. Suffering reminds us all of our frailty and ultimate mortality. Good chaplains stand ready to support and encourage those workers in the midst of this conflict. They bring a reassuring presence to the battlefield of health care.

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Suffering remains as much (if not more so) a theological problem as a medical struggle. The chaplain has a clarion voice as they stand among staff and family who grapple with the deepest issues of life and eternity. Although only given a name recently, CF has traumatized care givers for millennia. Like chaplains and health care workers of today, the prophets of old struggled with their own form of compassion fatigue. When enemy armies destroyed Jerusalem in 586 B.C., the prophet/pastor Jeremiah wrote what he saw before his eyes, “…with their own hands, compassionate women have cooked their own children who became their food.” (Lamentations 4: 10). Let that image of a helpless and seemingly hopeless prophet settle in your mind.

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Overwhelmed by the moans, the prophet/pastor cried, “Cursed be the day I was born” (Jeremiah 20:14); and later, “My heart is broken within me, all my bones tremble” (Jeremiah 23:9). This prophet is credited with also writing the Biblical book of Lamentations, which by its very name gives voice to the sufferings of people through all ages. The book of Psalms includes dozens of laments. But, unlike the care aid Ellen, the prophets could not go home or change jobs. The agony continued to come. Another prophet/pastor, Habakkuk, also questioned God when he demanded, “Your eyes are too pure to look on evil, you cannot tolerate wrongdoing” (Habakkuk 1:13).

 

The prophets of old and the chaplains of today grapple with the perpetual anguish of suffering, the tragic result of the Fall. However, chaplains (and pastors) offer a comforting perspective infused with hope. Do what is achievable within human resources and leave the remainder to God. As one care aid reflected, “I take pride in knowing that I helped where I could and comforted where I could do little else.”

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Chaplains know that, like the prophet Elijah of old, weary health care workers sometimes isolate themselves and withdraw into their own emotional dark caves. However, even in the dark caves of depression and exhaustion, God comes to restore with rest, food and renewed relationships as He did with the prophet Elijah. Here are some suggestions for chaplains and pastors who invest their time in health care settings. I call this “Triple A Support”.

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• Be Available to others on the team, especially at shift changes, break times, in the church front lobby and other settings when the medical personnel are available to talk. Listen and be supportive for them, thank them for being at work. Provide brief materials on CF that can educate them. Through an informal “appreciative inquiry” kind of probing, collect positive stories from those who have shown resiliency in the workplace and share these with others. One nurse shared, “ I have a life outside of work that includes hiking and being with friends.” Another offered, “My toddler son gives me such joy!” And yet another added, “The people with whom I work make it all doable. We laugh and cry together.”

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• Be Aware of the issue and take note of those team members who may be susceptible to CF. These include a new nurse or care aid who is “learning the ropes”, or a staff member who has a difficult workload, or an R.N. who has numerous traumas on a recent shift. One day, I overheard a care aid trying to help a resident with dementia who was very distressed; and, it was not going well! Later I smiled and thanked the care aid for her calmness. We live in a death-defying culture where medical care is assumed to keep death away from the doors of our lives. Yet medical staff deal with its reality every shift. Effective health care workers have somehow come to grips with their own mortality and frailty.

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• Be Active in Offering Practical Help: Encourage health care workers to use the Professional Quality of Life Scale (PROQOL) a self-administered survey that provides insights into how the respondent is handling workplace stress. It can be found at https://proqol.org/proqol-measure. Although the survey does not represent a formal diagnosis or assessment, the personally identified results give indications of the overall emotional health of the person.

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• Encourage them to limit the extra shifts they accept.

• Thank team members whenever you see them doing something special

• To avoid isolation, encourage a sense of community and team work on the floor. Bring food!

• Encourage staff to pursue outside interests that help them keep a work/life balance. Ask about their families and hobbies.

• Have fun (lots of it!) and provide practical goodies like chocolate.

• Collaborate with the other administrators to provide resources for the staff.

• Pray with staff, when appropriate.

• Celebrate the small wins on the shifts.

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 “The naïve expectation that we can go to work where aging and suffering surround us without its impact upon us personally-is as unrealistic as assuming we can walk through water and not become wet” .        Dr. Naomi Rachel Remen