Coping with Caring

A Nurse's Guide to Better Health and Job Satisfaction

Meredith Mealer

• Publisher: Productivity Press
• Year: 2019
• ISBN:
  9780429828706
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Nurses typically go in to the profession of nursing because they want to "care" for patients, not knowing that the inherent stresses of the work environment put them at risk for developing psychological disorders such as burnout syndrome, posttraumatic stress disorder (PTSD), anxiety and depression. Symptoms of these disorders are often debilitating and affect the nurse's functioning on both a personal and professional level. While environmental and/or organizational strategies are important to help combat stress, oftentimes the triggers experienced by nurses are non-modifiable including patient deaths, prolonging life in futile conditions, delivering post-mortem care and the feeling of contributing to a patient's pain and suffering.

It is paramount that nurses enhance their ability to adapt to their work environment. Resilience is a multidimensional psychological characteristic that enables one to thrive in the face of adversity and bounce back from hardships and trauma. Importantly, resilience can be learned. Factors that promote resilience include attention to physical well-being and development of adaptive coping skills.

This book provides the nurse, and the administrators who manage them, with an overview of the psychological disorders that are prevalent in their profession, first-person narratives from nurses who share traumatic and/or stressful situations that have impacted their career and provide detailed descriptions of promising coping strategies that can be used to mitigate symptoms of distress.

Chapter 1

Psychological Distress in Nursing

Working as an acute care nurse is stressful. Let me say that again, working as an acute care nurse is stressful. The reason for the stress is multifactorial, but potential triggers or stressors include, but are not limited to, long 12-h shifts, high patient acuity, high patient mortality, interacting with verbally abusive family members or coworkers, ethical or moral dilemmas, organizational policies, and staffing issues. Oftentimes, it is the combination and cumulative effect of these stressors that causes distress in nurses. There are nurses who are able to cope with the stress of working in the acute care environment, and this will be discussed in greater detail in Chapter 3. However, the prevalence of psychological distress is quite common in acute care nurses, which may lead to maladaptive responses such as sleeping difficulties, relationship issues, substance abuse, and suicide.

The incidence of suicide in physicians is well known because there are mechanisms in place to document death in this manner. It was recently reported that suicide was the leading cause of death in male residents and the second most prevalent cause of death in female residents (Yaghmour et al., 2017). This data is available on residents because the Accreditation Council for Graduate Medical Education (ACGME) maintains information on all U.S. accredited graduate medical education programs and specifically records deaths and cause of deaths in their Accreditation Data System (ADS) records. Approximately 300 U.S. physicians will die by suicide each year, which is available in the Centers for Disease Control and Prevention National Violent Death Reporting System (NVDRS) (Gold et al., 2013). In contrast to statistics on physician suicide, statistics related to nurse suicide in the United States are unavailable. This is unfortunate, as there would likely be resources and funding dedicated to instituting support systems geared toward suicide prevention in nursing. Data in England revealed that between the years 2011 and 2015, the risk of suicide among health professionals was 24% higher than the national average, and this was in large part because of the suicide rate among nurses, which was 23% above the national average (Windsor-Shellard, 2017). Additionally, nurses were four times more likely to commit suicide than people outside of the healthcare field (BBC News, 2000). The most common reason for the increased rate of suicide in both physicians and nurses is depression and other undiagnosed/untreated mental health conditions.

Psychological distress in nurses has also been associated with decreased quality of patient care, increased nosocomial infections, increased medication errors, increase in 30-day mortality rates, and decreased patient satisfaction (Cimiotti et al., 2012; Poghosyan, 2010).

What is meant by psychological distress? There are several concepts in the literature related to the distress experienced by nurses. Compassion fatigue, moral distress, secondary traumatic stress, and vicarious traumatization will be discussed below as symptoms or syndromes and if left untreated can lead to the development of psychological disorders such as anxiety, depression, burnout syndrome, and/or posttraumatic stress disorder (PTSD).

Compassion Fatigue/Secondary Traumatic Stress and Vicarious Traumatization

Compassion fatigue, secondary traumatic stress, and vicarious traumatization will be discussed together as they are often used interchangeably in the literature although each is from different theoretical underpinnings.

Compassion fatigue in nursing was first described over three decades ago and is a phenomenon specific to caregivers who help patients that have been traumatized. Joinson describes compassion fatigue as either a trigger or a consequence of burnout syndrome (1992) with the patient being exposed to the trauma and the nurse or caregiver experiencing the secondary effects of that trauma. Compassion fatigue in other caregiver groups has been described as a concept with a more positive connotation than secondary traumatic stress and vicarious traumatization (Adams, 2006). There is an increased prevalence of compassion fatigue in emergency room nurses, critical care nurses, hospice settings, oncology, mental health, nephrology, medical and surgical units, and pediatrics (Abendroth & Flannery, 2006; Meadors & Lamson, 2008; Robins et al., 2009, Hooper et al., 2010; Potter et al., 2010, Yoder, 2010). Some nurses may decide to leave the profession or change the type of unit they are working in because of compassion fatigue, but many are able to maintain a healthy balance between the positive and negative attributes of caring. On the opposite end of the compassion fatigue spectrum is compassion satisfaction, which is the cumulative effects of the positive feelings a caregiver experiences as a result of helping others (Sacco et al., 2015).

Secondary traumatic stress is a phenomenon similar to compassion fatigue as described above and is caused by a nurse’s interaction with trauma victims, which is also classified as being indirectly traumatized due to witnessing trauma to another individual. It has been described as the development of PTSD in healthcare providers. Interestingly, measures of secondary traumatic stress include the three symptom clusters of PTSD: re-experiencing the event, hyperarousal symptoms, and symptoms of avoidance. The only areas missing for a diagnosis of PTSD are the endorsement of a specific traumatic event, how the event and symptoms affect daily functioning and the length of time the individual has been experiencing the event.

The prevalence of secondary traumatic stress in nurses ranges from 25% to 78% and has been reported in trauma, critical care, oncology, forensic, and hospice nurses.

Vicarious Traumatization was introduced as a concept in 1990 by McCann & Pearlman to describe altered cognitions and memory imagery systems experienced by mental health therapists who experience prolonged exposure to the traumatic experiences of their patients. The underlying mechanism of vicarious traumatization is thought to be countertransference or the therapist’s unresolved conflicts outside of the therapeutic relationship, which interferes with their ability to distinguish their patient’s trauma from their own personal traumas (McCann & Pearlman, 1990). As with secondary traumatic stress, the symptoms of vicarious traumatization include the PTSD symptoms clusters of re-experiencing the event, hyperarousal, and avoidance. Trauma counselors and counselors in sexual abuse and assault experienced changes in their belief system and sense of identity as a result of working with this population of traumatized individuals (Collins & Long, 2003).

Moral Distress

Moral distress is a complex concept, and definitions vary considerably. Jameton’s definition states that moral distress occurs “when the nurse makes a moral judgment about a case in which or he is involved and the institution or coworkers make it difficult or impossible for the nurse to act on that judgment” (Jameton, 1993). Moral distress occurs when there is a need for a morally responsible action, a strategy is determined by the nurse based on individual moral beliefs and the nurse is unable to institute their strategy or action plan due to internal or external constraints. Repeated exposure to ethical dilemmas may illicit more intense symptoms due to recalling earlier stressful situations. The consequences of moral distress include burnout syndrome, depression, anxiety, and ultimately turnover of experienced bedside nurses. Nurses are most at risk for moral distress compared with physicians due to perceptions that they are unable to make decisions during morally complex conversations (Rushton, 2016; Moss et al., 2016; Mealer & Moss, 2016). Up to 80% of nurses experience symptoms of moral distress with the highest prevalence among critical care nurses. Clinical situations that may cause symptoms of moral distress include futile treatments, inappropriate care, inadequate pain relief, incompetent coworkers, hastening the dying process, and providing false hope (Moss et al., 2016).

The next sections will discuss the consequences of moral distress, vicarious traumatization, secondary traumatic stress, and compassion fatigue, which includes burnout syndrome and PTSD.

Burnout Syndrome

Burnout syndrome isn’t new. In fact, the concept has been around for several decades. First described in the late 1970s and early 1980s, burnout syndrome has universally involved a state of fatigue or emotional exhaustion that is caused by prolonged job stress. Depending on the philosophical or existential perspective, burnout syndrome may also include characteristics such as the failure to produce an expected goal, a syndrome that develops from long-term involvement in emotionally demanding situations or a concept that is a direct result of “people work” and, together with emotional exhaustion, results in depersonalization and/or a reduced sense of personal accomplishment (Freudenberg & Richelson, 1980; Pines & Aronson, 1988; Maslach, 1982).

The definition of burnout syndrome was born out of pragmatic concerns instead of theoretical and academic inquiry; the concept was stretched to involve almost all personal problems; and burnout syndrome was largely non-empirical during its early stages of development. These issues have caused confusion and debate in the academic world as the concept of burnout syndrome in healthcare professionals has taken center stage. Professional societies and organizations over the past few years have started to appreciate the pervasive nature of burnout syndrome in the nursing workforce and are trying to understand the impact of burnout syndrome on the individual provider’s mental health, turnover of experienced staff, and patient outcome consequences. The issues being debated include the definition or conceptualization of burnout syndrome, and how burnout syndrome is measured and/or diagnosed in the nursing population, and more broadly the healthcare provider population.

Defining Burnout Syndrome in Nursing

Again, as described above, the concept of burnout syndrome did not arise from a theoretical perspective. Originally, burnout syndrome was defined through a social psychology and psychiatry lens to describe a depletion of emotion and lost motivation and commitment observed in the workplace. The most commonly adopted definition of burnout syndrome in healthcare and nursing is Maslach’s (1982) definition that states “burnout is a syndrome of emotional exhaustion, depersonalization, and a reduced personal accomplishment that can occur among individuals who do ‘people work’ of some kind” (Maslach). In nursing, burnout syndrome has been described as involving common organizational workplace triggers but also trauma and stress triggers, which may overlap with anxiety, depression, and PTSD.

Triggers of Burnout Syndrome in Nursing

In a recent qualitative study that was conducted to design a resilience intervention for critical care nurses to reduce burnout syndrome, nurses from around the United States were asked to provide examples of specific triggers that caused burnout syndrome. The triggers would be used to design didactic content and begin...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface: Coping with Caring
• Author
• 1 Psychological Distress in Nursing
• 2 Triggers and Narratives
• 3 Resilience
• 4 Mindfulness Practices
• 5 Writing for Wellness
• Index