1. COMPASSION FATIGUE: ARE YOU AT RISK? Deborah Boyle MSN, RN, AOCNS, FAAN, Oncology Clinical Nurse Specialist/Palliative Care Nurse Lead, University of California Irvine Health (UCI) & Nancy Jo Bush MN, RN, MA, AOCN, FAAN, Oncology Nurse Practitioner/Clinical Faculty, School of Nursing, University of California Los Angeles (UCLA) Introduction Compassion fatigue (CF) has been inconsistently applied to a wide array of phenomena and is characterized by the absence of a consensus-based working definition (Austin, Goble, Leier & Byrne, 2009). The term was originally created to depict the emotional ‘wear and tear’ or ‘psychic exhaustion’ on trauma workers. Frequently referred to as ‘the cost of caring,’ CF subsequently has been studied in first responders who witness tragedy such as police, firefighters, paramedics and the military. However it is under- recognized, poorly understood and minimally researched in nurses. In fact, no CF measurement instrument has been validated in nurses (Sheppard 2015) and few studies exist of oncology caregivers experience with this phenomenon (Najjar, Davis, Beck-Coon & Doebbeling, 2009). In general, outcomes of CF are negative with multiple manifestations: Indicators of Compassion Fatigue (Boyle 2015)  Physical: chronic fatigue/exhaustion, insomnia, aches/pains, gastrointestinal complaints  Emotional: sadness, apathy, cynicism, oversensitivity, frustration, blaming/judgmental, mood swings, self-medication with alcohol  Social: isolation, loss of enjoyment in activities that previously were desirable  Work: decreased productivity, increased errors, turnover, increased use of sick days, job dissatisfaction, leave nursing  Spiritual: existential questioning Importantly, while compassion fatigue and burnout are often used interchangeably, they are two distinct phenomenon (Boyle 2011):  Burnout evolves from stressors in the work setting (i.e., poor staffing, lack of teamwork, non-supportive manager).  Compassion fatigue emanates from relationships nurses have with patients and their families. Oncology Nurses As ‘First Responders’ Due to the nature of their specialty, oncology nurses are particularly at risk for CF (Perry, Toffner, Merrick & Dalton, 2011; Potter et.al., 2010). Highly empathic and caring individuals, they may absorb the traumatic stress of those they care for (Najjar, Davis, Beck-Coon & Doebbeling, 2009). Unrecognized as ‘first responders’, oncology nurses however are often first on the scene to witness the tragedy of hearing a life limiting diagnosis, news about the futility of prior treatment, responding to a code, being in the room during the dying process, and consoling acutely grieving family members. S ELF A WARENESS Exercises to help personal recognition of the numerous aspects of CF enhance efforts to ameliorate it’s personal and professional consequences … FYI, ask your family Do you notice a difference in me when I come home from work? Am I more cynical and negative lately? A Nurse-Specific Model of CF Nurses’ vulnerability to CF is increased due to three unique variables not shared by others in helping professions:  PROXMITY: nurses cannot leave the scene of the tragedy; they must return to care for the patient/family; they also may have numerous patients concurrently coping with significant loss  EXPOSURE: the affective weariness nurses endure accumulates over time; feeling they know the patient/family best due to their 24/7 care, nurses may also experience moral distress when decision-making is questioned as being in the patient’s best interest  CONCEALMENT: unlike other ‘first responders’, nurses do not have supports in place to assist with the emotional sequela of their work (i.e., counseling, de-briefing, time off); hence they frequently ‘swallow’ their emotional pain Hence, a nursing model of CF must address those characteristics of empathic distress unique to the nurses’ professional role such as:  Unattended sorrow (grief), and  Moral distress Perry, Toffner, Merrick & Dalton (2011) identified other CF corollaries in oncology nurses as:  Competing demands outside of work, and,  Problems with work/life balance that resulted in altered engagement in family activities Additionally, based on our focus group results of >200 oncology nurses on the topic of CF at an ONS Learning Institute (2008), we feel there are two additional aspects of nurses CF that require inclusion:  Unresolved personal losses, and,  Personality style (i.e., namely, those who are idealistic, highly motivated, and committed to nursing and their specialty; also those who have a ‘rescuer’ identify) (Bush 2009). Recommendations for Practice Recommendations for Practice (Bush & Boyle 2012; Aycock & Boyle, 2009) In addition to the need for increased study of this phenomena in oncology nurses, there are three major intervention themes for nurses in clinical care to consider. Suggested Reading  Austin W, Goble E, Leier B & Byrne P (2009). Compassion fatigue: The experience of nurses. Ethics & Social Welfare, 3, 195-214.  Aycock N & Boyle DA (2009). Interventions to manage compassion fatigue in oncology nursing. Clinical Journal of Oncology Nursing, 13, 183-191.  Boyle DA (2015). Compassion fatigue: The cost of caring. Nursing 2015, 45, 48-51.  Boyle DA (2011). Countering compassion fatigue: A requisite nursing agenda. Online Journal of Issues in Nursing (OJIN).16(1):, Manuscript 2.  Bush NJ & Boyle DA (2012). Self-Healing Through Reflection: A Workbook for Nurses, Hygeia Media: Pittsburgh, PA.  Bush NJ (2009). Compassion fatigue: Are you at risk? Oncology Nursing Forum, 36, 24-28.  Najjar N, Davis L, Beck-Coon K & Doebbeling C (2009). A review of the research to date and relevance to cancer care providers. Journal of Health Psychology, 14, 267-277.  Perry B, Toffner G, Merrick T & Dalton J (2009). An exploration of the experience of compassion fatigue in clinical oncology nurses. Canadian Oncology Nursing Journal, 21, 91-97.  Potter P et.al. (2010). Compassion fatigue and burnout: Prevalence among oncology nurses. Clinical Journal of Oncology Nursing, 14, E56-E62.  Sheppard K (2014). Compassion fatigue among registered nurses: Connecting theory and research. Applied Nursing Research, 28, 57-59. The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to walk on water without getting wet. This sort of denial is no small matter. Source: Remen N (2006). Kitchen Table Wisdom: Stories That Heal W ORK S ETTING I NTERVENTIONS Options include …  Counseling: individual, group, healing retreat, peer support  Routine de-briefing: interdisciplinary in nature with a skilled facilitator  Education: topics such as manifestations of CF, communication skill building, adherence to self-care regimens, strenghtening resilience  Complementary approaches: onsite offerings of chair massage, quiet time, mindfulness meditation, journaling, music and aroma therapies S ELF C ARE Identify personal deterrents to self-care; draw a circle and divide it proportionately relative to where you spend your time on a daily basis: work, family, social time, hobbies; what is consuming the bulk of your time and energy?; make a concerted to plan for self care on a daily schedule much like you plan sleep, eating, work; you must take personal responsibility for your self care A central irony in nursing is that the majority of nurses perceive themselves as giving, caring people but find it hard to nurture themselves (Boyle 2011). As a highly proficient yet vulnerable collective of nurturers, we must remember to heal ourselves. (Bush & Boyle, 2012).