Compassion fatigue is ‘an extreme state of tension and preoccupation with the suffering of those being helped, to a degree that means it is traumatising for the helper’ (Figley, 1995; 2002).
The term was initially coined by Joinson (1992), in an article written for Nursing. The concept was developed further by Figley (1995).
‘Losing your ability to show care and compassion because you're just so overwhelmed with the amount of support you've been giving to people – patients, relatives, colleagues.’
Nurse interviewee
Typically, there are four responses to someone else's suffering:
- Sympathy: I care about your suffering
- Cognitive empathy: I know that you are suffering
- Emotional empathy: I feel your suffering
- Compassion: I want to relieve your suffering.
These responses are normal and healthy, until they breach one's own emotional and physical boundaries. The theme of emotional empathy is particularly relevant here, and will be dicussed in more detail.
Figley more recently referred to compassion fatigue as the healer's burden, a natural consequence of providing care to sick and needy patients (Figley, 2011). This suggests it is likely to be commonplace among those who work in the caring professions.
Effects on work and personal life
Compassion Fatigue drags people away from effective caring in one of two directions. Some become toughened. They withdraw from the pain they witness. They become numb. They lose their empathy. Others head in the opposite direction. They take on the burden of suffering. They become unable to differentiate their own pain from that of their patients. They lose themselves.
Every individual will respond in their own way, showing some of the many changes that can occur to emotions, thoughts and behaviours in relation to compassion fatigue.
Emotional signs include reduced empathy for others and themselves, irritability, anger, annoyance, intolerance, anxiety and resentfulness.
Intrusive thoughts include ruminating over the day or past experiences, self-criticism and harsh self-judgements, and an overall sense that they are falling short in some real or imagined way. Disturbed thinking can also affect decision-making ability.
Changes in behaviour include withdrawing from time spent in direct contact with patients or colleagues, taking time off work, or, conversely, working longer hours trying to keep up.
The sense that someone is not doing a good enough job can also be compounded by the effect known as moral distress. This is where the environment prevents an individual from helping someone as much as they think they should. It was first described by philosopher Andrew Jameton in 1984 as the psychological unease ‘of being in a situation in which one is constrained from acting on what one knows to be right’.
Moral distress is accompanied by additional self-criticism and self-judgement for not being able to do their job to the expected standard (British Medical Association [BMA], 2021). As one interviewee from the authors' own research put it:
‘You feel really guilty because you're not giving people the care that they fundamentally need.’
Nurse interviewee
Ultimately, compassion fatigue can have serious negative consequences both for nurses and those in their care, ‘…people with compassion fatigue may eventually find professional life unfulfilling. No longer enjoying work, and disappointed, disheartened and disillusioned,’ (Stoewen, 2020).
Who is susceptible
Professional helping roles attract people who are naturally caring and empathetic. When it comes to being at risk of compassion fatigue, community nurses face particular dangers. First, people who want to help are attracted to the job; and secondly, the job itself often makes impossible demands to help with insufficient resources. Additionally, the nature of the work can draw nurses into helping beyond the boundaries of their role. Individual susceptibility to compassion fatigue is influenced by several factors.
Empathy in overdrive
Emotional empathy is essential for giving good care; it is how people relate to someone else's suffering through their own human experience of suffering. However, empathy in overdrive can cause someone to be vulnerable to compassion fatigue.
People whose empathy is in overdrive do not just have a radar to detect the pain around them, it is as if that radar is boosted and the signal is unbearably intense. This goes beyond the working environment; every conversation is targeted at drawing out other people's needs. ‘It is as if their empathy circuit is in a constant state of hyperarousal,’ (Baron-Cohen, 2003). Empathy, when regulated, is fundamental to good caregiving, but when it flips into overdrive mode there is too much focus on the other and insufficient focus on the self–the needs of the caregiver.
Professor Vicki Helgeson refers to this ‘unmitigated communion’ to describe people who ‘focus on others to the exclusion of the self’ (Helgeson and Fritz, 1998). She specifically refers to people who ‘carry helping behaviour to an extreme’. Research has found that people who placed others' needs before their own were more prone to various forms of distress, including anxiety and depression. They were also more likely to neglect their needs in several health-related behaviours such as diet, smoking, exercise and relaxation (Helgeson, 2015).
Helper's belief system
To understand why some people are susceptible to compassion fatigue, it is useful to explore the beliefs that drive their helping in the first place. Taken from the authors' own research on super-helper syndrome (Baker and Vincent, 2022), two specific irrational beliefs are particularly relevant here.
The good person belief, ‘I must help others to prove I'm a good person’, relates to the individual's own sense of self-worth. This belief drives the compulsion to help, even when the individual is struggling personally. This belief can develop where someone is heavily socialised to help as a child. They learn to see themselves as a valuable person when they provide help, so helping becomes part of their identity.
‘I got noticed when I was a good girl. Praise made me feel like I was good enough. Thirty-seven years of autopilot is hard to break.’
Community practitioner, questionnaire respondent
The they-couldn't-survive-without-me belief, is another thought process that compels an individual to help, even when they are suffering themselves. A community nurse can feel that they are indispensable to the patient, that the patient has total dependency on them and that they as the nurse have no choice but to help.
Hardiness
There are clear individual differences in what we perceive as traumatic. What one person can handle with ease would keep another awake at night.
The idea of ‘hardiness’ was developed by psychologists Suzanne Kobasa and her supervisor Salvatore Maddi, in the 1970s. They studied how 12 000 people reacted to losing their job. Kobasa and Maddi found that two-thirds of them ‘fell apart’ as a result of this life upheaval, experiencing depression, drug dependency, divorces, heart attacks, strokes, cancers and suicide. But they also found that others thrived, experiencing more fulfilment than they had before. This led Maddi to propose that how people interpreted the stressful events in their lives mattered more than the severity of the adverse experiences they faced:
‘… hardiness gives you the courage to face stresses, turn them to your advantage, and grow in the process,’
Salvatore Maddi
Hardy people still experience the stress but handle it better. In the literature on hardiness they are defined by three characteristics: they have a strong sense of purpose in life, they respond to challenges as opportunities to grow and they believe they have control over their own destinies (Maddi, 2012).
Following this line of enquiry has resulted in longitudinal studies with hundreds of nurses, showing that those who were lower in hardiness tended to experience more fatigue, anxiety and depression (Saksvik-Lehouillier et al, 2016), and those who were hardier had lower incidences of stress-related illnesses such as hypertension (Chtibi et al, 2018).
Hardiness is a third factor that influences susceptibility to compassion fatigue. Trauma expert and psychologist, Beth Hudnall Stamm, reported that hardiness plays an important role for those who work with traumatised patients in the community. She found that compassion fatigue was more likely to occur when individuals felt they could not influence the outcome and when they felt less equipped to cope with the patient's trauma (Stamm, 2002).
What can be done?
Ask for help
This can be especially difficult for those who place others' needs before their own, or see themselves as the provider of help, not the recipient (Baker and Vincent, 2022). It is essential to acknowledge the fact that you are struggling before you reach the point of compassion fatigue. Remember: you do not need to feel guilty for burdening others with your problems, people who like and respect you tend to be eager to help.
Develop hardiness
Some beliefs can cause us harm, other beliefs can help us thrive. Adopting the belief that stress is enhancing is not an easy task, but it can help to protect you from compassion fatigue.
Begin with this prompt, to affirm this new way of thinking: ‘I've dealt with stress in the past and it's made me stronger’. Remind yourself of personal examples and recall how you dealt with stress at the time. The knowledge that you have overcome difficult times in the past can support you when you face future challenges (McGonigal, 2015).
Set healthy helping boundaries
Remind yourself of the limits of your responsibility. If you are a community nurse, you do not have to take on the role of helper in all the other aspects of your life. Helping family, friends, neighbours and volunteering in your spare time alongside a caring profession may not be sustainable. Review who, how and when you help others. Ensure that your needs are met too.
‘I feel as though my responsibility to that patient goes beyond my contract,’
Nurse interviewee
Try adopting beliefs that will support you, such as, ‘I know and respect the limits of my capacity to help’. If you do breach your own boundaries, be aware that there might be consequences for you, for your patients and even your colleagues.
Have the courage to talk to the people you work with and clarify what you can expect from them and what they can expect from you. It is not always easy to say what you want or need, but standing up for yourself is a fundamental right.
Be kinder to yourself
Self-compassion fosters wellbeing, while also strengthening compassion for others. There are many quick and effective tools that can cultivate self-compassion, some can even be used during the act of care. For a range of useful exercises see, for example, Chapter 5 of The Super-Helper Syndrome (Baker and Vincent, 2022). For a broader exploration of self-compassion see Kristen Neff 's book listed under Further Reading. You deserve to turn the tender, soothing, reassuring qualities that you freely share with others towards yourself.
Conclusion
Community nurses are susceptible to compassion fatigue because their role attracts people who have a strong desire to help others, and because their work is emotionally challenging. Community nurses have a duty to care for themselves to protect themselves from the variety of harms that come with compassion fatigue. This can be possible if they watch for signs of emotional exhaustion, develop hardiness, set stronger boundaries and give themselves the same level of care that they show their patients.
Key points
- Community nurses are susceptible to compassion fatigue because their role attracts people who have a strong desire to help others.
- Compassion fatigue can affect individuals in many ways, altering their emotions, behaviours and thoughts.
- Individual susceptibility to compassion fatigue is influenced by levels of empathy and hardiness, and the helper's belief system.
- The article points to specific interventions that could help community nurses protect themselves from developing compassion fatigue.
CPD reflective questions
- How easy do you find it to ask for help?
- Do you see yourself as a hardy person?
- How confident are you at setting healthy helping boundaries, choosing who, how and when you help?
- How good are you at meeting your own needs?
- What else could you do to practice being kinder to yourself?