Everyone is Affected

A few weeks ago I set out to answer some questions I have about the impact caring for others takes on caregivers, more specifically nurses. I am satisfied with the answers I have found for the first question (What is this I'm feeling?) so for the last few weeks I have attempted to find out as much as possible to answer the next one.  How many nurses are impacted?

The truth is every nurse in the world is affected by those they care for to some degree.  Whether they have made you smile, broken your heart, or just pissed you off your patients have impacted you; but is it to the point of compassion fatigue?  Maybe not everytime but from reading and talking to others I realize every nurse is bothered by symptoms associated with compassion fatigue at some point in their career, some more often or to a greater degree than their counterparts.  But why?

As children, growing up we think of nurses in white dresses and little oddly shaped hats that work in the doctor’s offices and hospitals.  The truth is nurses go beyond the hospitals and doctor’s offices to flight lines, law offices, rehab facilities, government agencies and much more.  There are unlimited nursing specialties each as individual as the nurses practicing them.  As with any career field there are some specialties considered more stressful than others.  Recently I read “Nurses and Compassion Fatigue” by Laurie Barkin RN, MS in which I believe she summed it up nicely,

"It is difficult to assess how many nurses develop compassion fatigue. In a recent review of seven studies of secondary traumatic stress among nurses working in forensics, pediatrics, emergency medicine, hospice, ICU, and oncology, rates of secondary stress symptoms ranged from 25% to 78%.  A study of emergency nurses, found that nearly 86% had moderate to high levels of compassion fatigue."

All of this has led me to add more question to the list. Which nursing specialties pose the greatest risk for experiencing compassion fatigue, or worse, burnout? Is there a "safe" area of nursing?  That's where I leave you today as I begin seaking the answers to my newest questions.   I can't wait to share what I find.

Shit Happens

After multiple days off, I got to my floor and begin doing "turnover." Amy, the day shift nurse,  put down her pen and stared at me, waited for me to look up and make eye contact.  When she was satisfied she had my full attention she proceeded to inform me Mrs. Smith, the new post surgical patient is a little constapated, making those finger quotation marks around "a little constapated."   Being constipated is nothing new for post surgical patients.  The anesthesia and all the pain meds tend to slow your systems down.  They usually get some colace and a lot of fluid, not a big deal.  By the slightly amused smirk on her face, I could tell there was more to it.  I stared back at her waited for her to get to the point. 

"By a little constipated I mean, she actually needs an enema.  The doctor JUST wrote the order for it so that means you're going to have to do it.  I have to pick up my kids from school," and just like that she handed me the keys, the enema, and the order and walked away. 

I don't have a weak stomach and I have no issue with blood, mucous, vomit, and even urine but not feces.  Luckily, as if answering my prayers, the nurse working the other side had overheard everything and grabbed my hand and the box.  She started pulling me toward Mrs. Smith's room and assured me she'd handle most of it as she can't handle vomit and would rather do this torturous deed than actually clean up my lunch. 

We get in the room.  Tracy, the other nurse, quickly goes to work as I remain at the patients head offering unconvincing words of support.  Tracy's face goes blank on the other side of the bed.  I assume it must be a ton coming out.  I mouth the words "thank you" but she shakes her head and waves me into the bathroom.  Confused, I follow. 

"Nothing's going in...." it took a moment for the words to fully make sense.  Then it hit me!

"Oh shit!"  Not realizing how true those words could be.  My patient was impacted.  That's right, the nurse that can't handle feces has to now go in a break up a large impaction. (A large, hard lump of dry stool blocking the rectum.)  The treatment for this is to go in manually, that's right with your hands, and break up the lump so that it can come out and clear the way for everything else.  I started to gag thinking about it and I realized I was giving Tracy the puppy dog eyes silently begging her to do it. 

"No, absolutely not.  NOT going to happen.  I love you but I can't.  That's where I draw the line.  I'll get sick!" she proclaimed as I followed her out of the room.  For the second time that day, my prayer was answered.  The shift RN overheard us from around the corner and came to my rescue. 

I entered the patient's room with my two heroes trailing behind.  The RN, Steph, took her place at the right side of the bed.  With the patient still lying on her left side from earlier, I grabbed her right knee, the one on top, and pulled it toward her chest.  Tracy took her place to my left toward the foot of the bed ready to assist.  With her fingers well lubricated, Steph went in.  Instantly, the smell consumed the room, tears filled my eyes my gag reflexes kicked in.  Steph handed Tracy a large chunk of something that looks like a melted ball of snickers.  Tracy's composure went out the window the second it touched her gloved hand and immediately she was tearing up holding back her own vomit.  Steph continued the process, in and out, in and out,  but begins laughing so hard at the two of us her eyes filled with tears too.  The whole time in the room I was thinking this is one of those things that make me want to quit.  The debacle continued for what seemed like a lifetime. In all actualitly we were only in there for maybe five minutes before we got the "all clear." 

The other two nurses went on to do their own work and I returned to Mrs. Smith's bedside to give her something for the discomfort and make sure she wouldn't get backed up again any time soon.  Upon entering her room I found her sitting up watching America's Funniest Home Videos and laughing hysterically, a start contrast to the woman crying in agony less than half an hour earlier.    I apologized for the travisty and handed her the medications.  She set up strait, turned the T.V. down and took her the little cup.  After getting all the pills down she smiled at me and said, "No need to apologize, shit happens," with the largest smile I've seen in a long time.   I couldn't help but laugh. 

Coming Full Circle

I've read back over my previous post and I see I'm putting a lot of emphasis on the negative impacts.  While I don't want to shy away from the negatives, I want to show the positive as well.  I've gained a lot from nursing and from each and every person I've had to privilage of caring for; however, I think in order for others to understand exactly what those of us who do this job take away from it you have to ask, "why did you choose this career?"

I began asking some coworkers and other friends in the field.  Suprisingly, 12 of the 15 I asked gave similar answers.  They had lost someone they cared about.  I personally had many reasons for choosing this path (my mother's a nurse, I love knowing I made a difference...blah blah blah) but the main reason, the one that keeps me going back is the same I heard from so many of those I asked.  I was 21 when I recieved the phone call informing me my 39 year old father had lost the battle.  He died in 2009 from non-diabetic kidney failure, leaving behind three children.  Two of which were still in high school and depending on him as their only parent. 

Now this wasn't a sudden death, but it was a suprise.  He had been ill for a few years at this point.  In and out of the hospital, dialysis two then three times a week, special diets, countless drugs, tests, and procedures. It all became a normal part of our life.  It was his routine.  The fluid would build up, he would go to the hospital for a few days, feel "all better" and go home.  Then repeat the process two or three months later.  At first the dialysis slowed the cycle but in the end kidney failure leads to heart failure and no matter how strong your spirits you can't beat nature.  I watched him taking in every minute I could as this horrible, painful process continued.  One of the things I noticed was my father's mood.  Whether it was his dialysis nurses or the nurses in the hospital during one of his many stays, his mood fluctuated depending on who his caregivers were that day.

I knew through phone calls accross the country who his favorites were and who he despised.  I could hear in his voice whether today was a good day or bad day.  During the last four years of my father's life I had been serving overseas for two of them.  My father wasn't married and my siblings were busy with their high school lives (my father insisted they try to live normally, regardless of his condition); it was the caregivers by his side more than anyone else.  It amazed me.  These people, who were just doing their jobs, had such an influence on my father.

Standing at the graveside on my 22nd birthday, watching as they lowered the casket into the ground, I realized life really is short and you have to make it mean something.  Shortly after returning from Texas I started nursing school.  I feared the moment I would be assigned a dialysis patient.  I am very self aware.  I know what I am capable of as well as what my limits are.  Taking care of a patient dealing with that horrible condition was not something I could EVER do. 

Then it came.  I was assigned a man in stage 3 renal failure; he had just had surgery placing the dialysis shunt (the port under the skin that the dialysis machine hooks up to).  It was challenging not to burst into tears everytime I walked into the room, but I did it.  After he was discharged I recieved a letter from his daughter.  She thanked me for my compassion and empathy and told me her father had compared every nurse he's had since then to me - TO ME! It was the most humbling yet amazing feeling I've ever had.  It was like everything had come full circle.  I couldn't do anything to make my father live longer, but I could honor him and his struggle by providing the best care possible to those who need it. 

I know I emphasize the negative impacts but no matter how much negative there is, it will NEVER out weigh the positives I get from what I do.  I have days where I am tired and just know I can't go on. I have nights I want to crawl under a rock and bawl.  I get angry with God for taking those from their families.  I have shifts that make me swear I am going to quit but no matter what, I wake up the next day smiling, excited to go back. 

There Are Others Out There

I've been searching the endless sea of digital information we know as the internet non stop looking for sources to further my knowledge on the nursing field and it's impact on those who choose this career.  Amongst it all, I've found some really great blogs by other nurses.  My favorites include some that are serious and some that are humorous, but they are all informative.  I read the entry on Code Blog from January 19th.  In the first post I read this nurse discusses the impact of losing not a patient but one of her mentors.  It made me realize I have put a lot of focus on the impact caring for patients has had on me as a nurse.  I plan on reading more from this blogger, perhaps even using her as one of the resources for a paper I have to do this semester.  A second blog I've really enjoyed is Madness: Tales of an ER Nurse.   This blogging nurse tells it like it is and mixes the serious side with humor.   There are of course other blogs I have read but in this community, it's difficult to tell who's the real deal and who's sitting at home watching Grey's Anatomy.  I'll continue reading and sharing anything I feel might actually be worth it. It's just nice to know there are others (nurses, new and old) out there.

What is "This" I'm Feeling?

I began this journey as most researchers do, with a question.  Being a new nurse feeling the impact of caring for others I set out to find out if I am the only one effected by this.  The answer is obviously no but it has led me to further questions such as: What is "this" I'm feeling?  How many nurses are impacted?  To what extent are others effected?  What are the signs?  What can be done to prevent burnout or compassion fatigue? I'm determined to continue until I find the answers to these questions and probably more and as long as I'm searching, I'll keep sharing. 

I have found a study summary from Medscape.Com I'd like to share.  This not  offers clarity but also some very interesting insight.  "The purpose of this study was to describe the prevalence of compassion fatigue among a broad spectrum of nurses and to investigate the situations that lead to compassion fatigue and nurses' methods of coping."  (Edmunds, 2010).

Previously I related burnout and compassion fatigue and used them interchangeably but this study differentiates between the two. "Compassion fatigue is often linked to burnout, a related but different concept in which the nurse experiences slowly developing frustration, a loss of control, and generally low morale."  (Edmunds, 2010).   The author further defines compassion fatigue as the "term used to describe the emotional effect of being indirectly traumatized by helping someone who has experienced primary traumatic stress." Having the two separate definitions will aid us as we continue learning about both. 

Reflecting on the last year, I now realize what I was (and still do feel from time to time) is compassion fatigue.  Reading over the study summary, it tells us this fatigue is often triggered by certain situations nurses may find themselves in.  It gives the following examples:

• Believed that their actions would "not make a difference" or "never seemed to be enough";
• Experienced problems with the system (high patient census, heavy patient assignments, high acuity, overtime, and extra workdays);
• Had personal issues, such as inexperience or inadequate energy;
• Identified with the patients; or
• Overlooked serious patient symptoms.

All of which I know I've experienced or done at some point since starting out.  It's terrifying.  I leave work some nights with a knot in the back of my throat.  I go to dinner with my significant other, begin thinking to my self about work, and end up snap at him for asking if I want dessert.  Really?  Pie is usually not something to yell over but when I'm lost in negative thoughts about what more I could've done or what tell tale sign I MUST'VE missed, it bleeds over into my personal life.  I've also taken extra shifts, not for the money, but because I refuse to let my floor be short handed.  The extra shifts have turned into "doubles" (16-20 hour shifts) causing me to be sleep deprived, miss homework deadlines, or class all together.  Needless to say, that's not having a positive effect on my GPA.

I have found some reassurance in learning that others experience the same issues, however.  The next step is deciding which coping skills are effective to prevent the new nurse (i.e. myself) from progressing from compassion fatigue to full out burnout.  I know it will be different for each person so I'd like to explore as many options as possible over the next few months; trying as many out as possible and reporting back the effectiveness.  As with Ms. Cindy's advice (see It's All About Balance) I'd appreciate any input or suggestions from those of you who've been in similar stressful situations.

Resources:
Edmunds, M. (2010, November 15). Caring Too Much: Compassion Fatigue in Nurses. Medscape: Medscape Access. Retrieved February 7, 2012, from http://www.medscape.com/viewarticle/732211

It's All About Balance

As I delve further into the subject of the emotional impact on nurses, I find there are others out experiencing the same impact from their profession.  I am not saying I am anywhere near the point of "burnout" or want to change my career path but it is an eye opener to see where these feeling can lead if not managed. 

Depending on which article you're reading, it's called anything from burnout to depression to compassion fatigue.  For every name you can find, there's atleast five different causes.  Regardless of the name or what you choose to blame, caring for the ill, injured, or worse takes a toll on nurses around the world.  For the purpose of this entry, we're going to use the term "Compassion Fatigue" to describe the "deep physical, emotional and spiritual exhaustion accompanied by acute emotional pain" (Pfifferling & Gilley, 2000) often experienced by nurses.One of the articles I've read discusses compassion fatigue which the author calls an "occupational hazard of providing empathetic, relationship-based care to patients and families." (Lombardo & Eyre, 2011). 

As previously mentioned, there are many causes that lead to compassion fatigue but more than likely it isn't just one cause.  Fatigue, whether physical or emotional often results from a combination of factors, "develops over time and diminishes your energy and mental capacity." (Mayo Clinic, 2010).  It may not be the first person you lose that bothers you.  You may be able to push those feeling to the back of your mind and drive on but for how long?  Eventually your emotional resevoir reaches it's limits. 

Whether a new nurse on a floor or a well seasoned veteran, you can develop fatigue.  Managing the stressers you are sure to face is key.  I could spend thirty minutes of your time listing what some articles say are the "best" stress managers but I won't.  I went to the experts myself,  the senior nurses on my floor.  In one interview I asked Ms. Cindy, a nurse with over 40 years experience, how she manages life on the floor.  Her response was simple.  "It's all about balance.You must keep the good and bad in balance."  That evening, as I held her hand, I watched as one of my patients took her last breath. I remembered Ms. Cindy's advice.  I was sad for the patient and her family but I recalled the patient that had been discharged earlier that day just in time to walk his daughter down the aisle the following weekend.  I remembered reading his chart and learning of the motor vehicle accident he was in.  It crushed his femor.  After multiple surgeries the doctors doubted he'd ever walk again.  I was the one fortunate enought to hold his hand as he took his first step just months later. 

I now know I am not the only one impacted by those I care for; however, I have also learned there are some impacted far more than I.  Compassion fatigue, regardless of what we wish to call it, is a serious condition facing nurses around the world.  We have to learn to manage our stressers so we can continue to provide care for those who need it most. 

References:
Fatigue - MayoClinic.com. (2010, August 14). Mayo Clinic. Retrieved February 2, 2012, from http://www.mayoclinic.com/health/fatigue

Gilley, K., & Pfifferling, J. (2000, April 7). Overcoming Compassion Fatigue - Apr 2000 - Family Practice Management. Home Page -- American Academy of Family Physicians. Retrieved February 2, 2012, from http://www.aafp.org/fpm/2000/0400/p39.html

Lombardo, B., & Eyre, C. (2011, January 31). Compassion Fatigue: A Nurse's Primer - OJIN: The Online Journal of Issues in Nursing. American Nurses Association. Retrieved February 1, 2012, from http://nursingworld.org/MainMenuCategories