Opening Case Study

Monica, a radiation technician, was preparing Ryan, a young man who was recently diagnosed with cancer, for his first radiation treatment.  Ryan became upset before she began, and Monica took some time to talk with him about his fears, and to reassure him that the radiation machine was modern and well-maintained.  Ryan told Monica about the active life he had been leading and the shock of discovering that he had cancer.

After she was finished with Ryan, Monica stepped into the break room and sat at the table.  She rested her head on her hands and fought back tears.

 

Keep in Mind: Healthcare professionals often listen to patients tell stories and talk about their feelings of sadness and helplessness.  Have you ever been involved in helping someone else deal with their sadness and felt like you might not have the emotional energy to listen anymore?

 

Sean, an MRI technician, stopped in for his morning coffee break.  He stood at the door and observed Monica.  He knew that a lot of scared patients passed through the radiation department and that Monica always took time to be as comforting and reassuring as possible as she prepared them for their treatment.  From his own experience, Sean also knew that this could be emotional draining for healthcare professionals who were consistently in these situations with patients.

“Hey Monica,” Sean sad as he sat across from her.

“Hi Sean,” Monica answered.

“Having a rough day?” he asked.

Monica didn’t answer but nodded her head.

 

Keep in Mind: If you walked into the break room and saw Monica sitting at the table, would you say anything to her?  Would you be concerned about getting involved where you may not be wanted or needed or would you want to try and reach out to her?

 

Introduction

How are YOU feeling?

Previous chapters in this book have been focused on understanding and reaching out to newly-diagnosed patients, offering them emotional support, guidance, information, and helping them to maintain ongoing compliance with treatment and lifestyle management recommendations.  In turn, this will deepen the level of therapeutic communications between the patient and the healthcare professional and potentially enhance quality of care and patient outcomes.  However, maintaining a deeper level of involvement with the patient requires a great deal of emotional and physical energy, as well as compassion.  While this can be gratifying for healthcare professionals, it can also be emotionally and physically draining.

The issue of stress and compassion fatigue is often discussed in relation to the helping professions, both mental health and healthcare.  Stress can result from many aspects of the healthcare professional’s job, including handling multiple emergencies and dealing with difficult patients, including patients facing the crisis of a diagnosis.  Ongoing stress, that is not relieved in any way, can lead to compassion fatigue, in which healthcare professionals feel they really have nothing emotionally to give to the patient.  Indeed, many examples exist of professionals who, after working with patients in extremely emotional situations, felt so exhausted that they needed to take a break from this role, if they were able to continue at all.

Healthcare professionals assisting newly-diagnosed patients are especially vulnerable in this regard because they are hearing the stories and the reactions of patients at a time when their emotions are especially raw.  As discussed in previous chapters, healthcare professionals have their own emotional reactions to their patients and the stories they tell.  Repeated experiencing what newly-diagnosed patients are experiencing, and the helplessness that this may cause, can leave healthcare professionals feeling depleted and less able to be effective.

Healthcare professionals can prevent their own stress and compassion fatigue by being proactive in self-care and supportive of other healthcare professionals, based on the suggestions and guidelines in this chapter.

 

Self-Care for Healthcare Professionals

Recognize Symptoms of Stress and Compassion Fatigue

Healthcare professionals are trained to look for symptoms in their patients, including symptoms of stress.  Ironically, they may not recognize, or acknowledge, these symptoms in themselves.  Yet, professionals exhibit symptoms of stress that are very similar to those of patients, including:

• Feeling sad, sometimes to the point of overwhelming depression
• Feeling you aren’t accomplishing anything or adding any value
• Getting impatient or angry easily, with patients, your friends and family, and other professionals
• Physical symptoms, including fatigue, sleep disturbances, and changes in appetite
• Changes in work habits, including sloppiness and being late for work
• Being too objective or too empathetic with patients
• Constantly feeling helpless, and that nothing is in your control

 

Healthcare professionals are advised to monitor their own symptoms of stress, and compassion fatigue, on an ongoing basis.  However, it is human nature to assume that stress is temporary, or will dissipate on its own over time, or that stress is unacceptable and should be hidden from others.  The consequence for healthcare professionals is that they may ignore symptoms in themselves that they would consider to be ‘red flags’ for stress in their patients.  Being on the watch for these symptoms in other professionals, and lending a helping hand or a listening ear, as described below, can be a positive step forward in promoting self-care on the healthcare team.

 

Keep in Mind: What are your personal signs that you are experiencing stress?  It can be helpful to be aware of how you experience stress so that, in the event you experience compassion fatigue, you will be better able to monitor your own symptoms and reach out for help.

 

Know Your Strengths and Your Limits

Each individual brings their own personal qualities to their professions.  Some healthcare professionals are natural comfortable with interacting with patients in a way that demonstrates good listening skills and an ability to show empathy, while maintaining objectivity and professional boundaries.  While these skills can be learned to a great extent, not all professionals are as comfortable as others with patients who are experiencing strong emotions, and may therefore not be as effective.  In a similar vein, a healthcare professional who is experienced in working with patients newly-diagnosed with cancer, for example, or HIV, or diabetes, might have more to offer to a patient with one of these conditions than one who is less familiar.

Effectiveness may vary from day to today.  Everyone has days when they are feeling less able to be emotionally available to patients and consequently need another professional to act as a backup.  Furthermore, patients may feel more comfortable talking about emotional topics with members of the healthcare team whom they feel are similar to them in some way, e.g. the same gender, similar age or background.

 

Maintain Objectivity

People often describe being upset by a book or a movie that reminds them of their own life, or hearing about a friend’s problem and remembering how they felt in a similar experience.  When someone else’s situation brings up feelings in ourselves, we may find it hard to think about it if the feelings that come up are too painful, or we may feel so strongly about their situation that we want to get involved to the extent that we try to solve if for them.  Healthcare professionals may have the same experiences with newly-diagnosed patients.  It is referred to as lacking objectivity.

Objectivity means being able to view a situation without personal prejudices, without judgment, and instead to focus on factual information.  Being objective does not imply that essential elements in communicating with newly-diagnosed patients, including empathy and compassion, are missing.  However, it’s important for healthcare professionals to be able to balance their rational and emotional sides – just as is recommended for patients – so that they can make realistic assessments and appropriate recommendations that are based on their training and their responsibilities, as well as the emotional needs of the patient.

 

Set Boundaries with Patients

As discussed in previous chapters, as much as healthcare professionals may want to be emotionally available to patients, and to help them as much as possible, when professional boundaries are crossed, neither healthcare professionals nor patients benefit.  One of the results of not maintaining objectivity is a blurring of boundaries between the professional and the patient.

Being too available to patients is one example of crossing professional boundaries.  When encountering a newly-diagnosed patient, healthcare professional sees someone who is in emotional pain, most likely uninformed about the medical condition, possibly lacking adequate support from family or friends, and who has major decisions to make as well as what may be lengthy or ongoing treatment challenges.  Healthcare professionals have chosen this field because they are motivated to help people and, depending on the medical condition, newly-diagnosed patients may have so many needs that it is a natural reaction to want to ‘go the extra mile’ with them, e.g. to be available after work hours, to assist with tasks that outside of the healthcare professional’s responsibilities, or to give advice.

Helping newly-diagnosed patients can be emotionally draining.  Offering additional assistance to multiple patients, on an ongoing basis, can result in stress and compassion fatigue.  Furthermore, if patients become too dependent on one staff member, this may encourage dependency at a time when patients need to learn to become more empowered, and it may prevent other members of the healthcare team from carrying out their duties and responsibilities.  Certainly, giving advice to patients that is outside of the scope of professional responsibility can have ethical and legal implications.  Hospitals, clinics, and practice settings generally have guidelines regarding the roles and interactions between healthcare professionals and patients, and these guidelines are based not only on best practices and ethics, but also developed as a means of preventing staff fatigue.  Suggestions for setting boundaries with patients were provided in Chapter Eight.

It’s important to keep in mind that one aspect of setting boundaries is to let patients know that other members of the team are also available to support them.  Following this, reach out to co-workers who can become involved.  Your organization may also offer the services of an Employee Assistance Program (EAP) as a benefit to employees.  If so, you can contact and potentially be connected with a certain number of sessions with a mental health professional.

 

Follow the Guidelines for a Healthy Life

When human beings are not at their best physically, they are also less like to function as well mentally or emotionally.  Healthcare professionals give their patients advice about maintaining a healthy lifestyle, including adequate rest, a healthy diet, and regular exercise but they do not always follow this advice in their own lives.  Taking care of yourself physically will assure that you are better able to meet the demands of caring for patients, and for patients who are making adjustments in their own lifestyles, their healthcare team can set an example for them to follow.  Other aspects of a healthy life include avoiding over-work and taking breaks during the day, as needed, to recharge.

 

Recognize Your Own Contribution

Being a healthcare professional can sometimes feel like a ‘thankless job’ when the day to day challenges of caring for patients who may not always show their appreciation, family members who make unfair demands or take their own stress out members of the healthcare team, as well as co-workers who may, out of their own fatigue and stress, not always be easy to work with.  Newly-diagnosed patients present additional challenges because they are at a time in their lives when they are especially needy, and require additional emotional support, information and guidance.

It is human nature to want to feel acknowledged by recipients of this attention, the patients, as well as co-workers and management.  Sometimes this acknowledgement is freely given and sometimes it isn’t.  Professionals learn to reward themselves with the knowledge that they are doing the best they can for patients who are facing a crisis, through positive self-talk, described in the ‘self-talk’ section in this chapter, as well as through their own self-care, e.g. taking rest breaks and finding moments outside of work to rest and enjoy life.  Sitting down with a good listener can also help.

 

Find a Safe Place to Express YOUR Feelings

As healthcare professionals, we encourage newly-diagnosed patients to sit with someone who is willing and able listener – who doesn’t, out of their own helplessness, attempt to dictate what they should do – and talk about their emotions, even the feelings that are less ‘acceptable,’ such as anger and frustration.  Healthcare professionals can benefit from taking their own advice by calling up a co-worker, family member, friend, clergy person, or a mental health professional who can be an objective listener.  Having a safe place to express feelings, and even to ventilate as needed, can be a way of preventing stress from building up to the point where it results in, for example, difficulty being empathic or overreacting emotionally.  (As a word of caution, always keep in mind that HIPAA guidelines restrict healthcare professionals from giving out the names of patients in conversations with individuals outside of the healthcare team.)

 

Keep in Mind: Who are the members of your own support system that you might rely upon in the event that you experienced compassion fatigue?  Keep your support system handy, and offer to be ‘on call’ for a colleague.

 

SIDE: BODY LANGUAGE

Just as we are patients’ state of mind is evident in body language, state of mind is also evident in our own body language, which we can monitor in ourselves as well as in co-workers.  Signs of stress and compassion fatigue include:

• ‘Avoidance’ posture, e.g. arms folded, disinterested expression
• ‘Fatigue’ posture, e.g. leaning against a wall, expression shows tiredness
• ‘Tension’ posture, feet apart, broad gestures, angry expression

 

SIDEBAR: SELF-TALK

Negative self-talk expressed by healthcare professionals may include:

Doesn’t anybody know how hard I am working? 

There is no way I can give these patients the emotional support they really need. 

I have to be a rock here or the patient is not going to have anybody. 

I know I’m a terrible person but I can’t listen to another sad story today. 

I don’t think I can go on any longer before I am completely emotionally drained. 

 

Antidotes to negative self-talk included:

I know I’m going above and beyond the call of duty today.  I don’t have to always be told by others what a good job I’m doing.

I’m only human, too, and I don’t have to always know the right thing to say or do. 

I can be here for patients but also pay attention to my own need to pace myself. 

Patients have me to rely on, but they also have my co-workers, and other resources, available to them. 

 

SIDEBAR: EDUCATIONAL MOMENT: Self-Care for Healthcare Professionals

We often try to hide how we are really feeling, out of a sense that we can’t be ourselves.  While we need to maintain professionalism with patients, we can also be on the lookout for signs of stress and compassion fatigue in ourselves and our co-workers.  As these moments arise, reminding ourselves that we are doing the best we can, and offering support to co-workers, can help keep everyone on the team feel supported.

 

Rx: Conducting a Conversation About Compassion Fatigue

Sean had experienced stress and compassion fatigue at various times during his career, and other healthcare professionals had reached out to him to offer support, and so he reached out to Monica.

 

Sean: Is there anything I can help you with?

Monica sits up and look at Sean.

Monica: I am just having a bad day, you know.

Sean: We all have them.  I’m here to listen.

Monica: My patients are facing one of the most difficult times in their lives, if not the most difficult.  They’re living their lives and then all of a sudden they’re going through our clinic, telling me what happened and, sometimes I think, hoping I can tell them they are going to be okay.

Sean: I know what you mean, Monica.  You hear a lot of sad stories…

Monica: Yes, and sometimes you wonder if you won’t be able to listen to any more at some point.  I mean, you want to help patients any way you can but you also wonder if you can possibly give them the help they need.

Sean: It can be overwhelming, right?

Monica: Absolutely.  At least it feels overwhelming today.

Sean: Can I give you some feedback?

Monica: Sure.

Sean: We’re only human, Monica.  After hearing how helpless our patients feel, and how scared they are, it is only natural that we would feel helpless after awhile too.  And it takes a lot of emotional energy to be with so many sad and scared people, to listen to them, and to show them that we care.  Sometimes we get tired out.

Monica: Exactly.

Sean: What I do is remind myself of what I just told you.  I tell myself that I am human and that I am doing the best I can.  But I also make sure I take care of myself.  After a hard day, I make sure I do something I enjoy in the evening, even if it is only to listen to some music that I enjoy while I make dinner.  Maybe I’ll call a friend and talk about my day, you know, blow off some steam.  And make sure I get a good night’s sleep.  Are you taking care of yourself?

Monica: Kind of… but maybe not enough.

Sean: And another thing.  I don’t take on all of the responsibility for helping patients with their emotions.  We’re not counselors, after all.  I listen.  That’s the best thing I can do for them at that time.  And I answer their questions.  But I also remind them the clinic nurses can refer them to a counselor, and I tell them how valuable it might be for them to get some additional emotional support during this time.

Monica: That’s a good idea.  I have to admit that, with some patients, I wonder if anyone other than me is taking the time to really listen to them.  It’s like they have never talked to anyone else about how they feel.  That’s a big job for me.

Sean: And they probably haven’t talked to anyone.  It’s a gift to be a good listener, and to show someone that you care.  I don’t want to not do that for patients.  But I also want to make sure they get the professional support that they need, and that’s where our resource file comes in handy.

Monica: That’s a great idea.

 

Figure 14-__

As in previous chapters, an illustration of stair steps, labeled according to the sub-heads below, including Listen, Normalize, Encourage self-care, Encourage referrals.

 

Guidelines for Conducting a Conversation About Compassion Fatigue

The following are guidelines for conducting a conversation with another healthcare professional about compassion fatigue.

 

Offer to Listen

Like our patients, healthcare professionals experiencing compassion fatigue first of all need to be able to express how they feel.  In other words, what they need most is someone who is ready to listen.  Sean began the conversation by offering to listen to Monica.   Notice that he used a tentative approach and gave her the option to open up if she chose to.

 

Normalize Feelings

Monica was initially expressing some guilty feelings about feeling compassion fatigue, and wondering if she was adequate to the challenge of being emotionally available to patients.  As Sean reminded Monica, it is normal to feel emotionally drained when working with patients who are struggling with newly-diagnosed patients.  He offered additional reassurance by telling her that he had had similar experiences.

 

Encourage Self-Care

Healthcare professionals can’t be present for patients if they aren’t taking care of themselves.  Sean recommended that Monica build some relaxation into her day, do things that she enjoys, and call on friends who can offer emotional support.  Again, he used his own experience as an example.

 

Encourage the Use of Referrals

Healthcare professionals are part of a team, and that team includes mental health professionals who can be called upon to assist patients emotionally.  Sean reminded Monica that their clinic has mental health resources that patients can be referred to.

 

Summary

Healthcare professionals are asked to be present with patients during a very emotional time of their lives, and the level of empathic listening and emotional support that they offer to patients can be physically and emotionally draining.  Caring for the caregiver is something that healthcare professionals can do for themselves and for others.