COMMON STRESS-RELATED CONDITIONS

Work-related stress in the healthcare profession commonly manifests in one of several distinct, identifiable conditions. These include:

  • Burnout: A syndrome that results from unmanaged chronic workplace stress (WHO, 2019)
  • Compassion fatigue (or empathy distress fatigue): A state of declining empathetic ability due to repeated exposure to the suffering of others (Peters, 2018)
  • Vicarious trauma: An ongoing process of change over time that is due to witnessing or hearing about the pain and suffering of other people (Trish, 2021)

Within both healthcare literature and common usage, these terms are sometimes used interchangeably. In general conversation, this may not be an issue, especially if the intent is to share personal experiences or to express concern or empathy. But healthcare providers are more likely to be seeking to understand their reactions or to formulate personal care or prevention plans. In this case, understanding the similarities and differences between these stress reactions is important.

Burnout

According to the World Health Organization (WHO, 2019) in the International Classification of Diseases, 11th revision (ICD-11), burnout is defined as:

A syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: 1) feelings of energy depletion or exhaustion; 2) increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and 3) a sense of ineffectiveness and lack of accomplishment. Burnout refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.

STAGES OF BURNOUT

Burnout has been described as having five stages:

  1. Honeymoon phase
  2. Onset of stress
  3. Chronic stress
  4. Burnout
  5. Habitual burnout
    (Calmer, 2020; De Hert, 2020)
Stage 1: Honeymoon Phase

This phase is characterized by high job satisfaction. The employee is committed to the job, energetic, and creative. Although employees may believe that this stage will last indefinitely, job stress is inevitable. Employees should anticipate eventual job stress during the honeymoon phase. Coping strategies should be established in order to support personal and professional well-being.

Characteristics of this phase include:

  • Job satisfaction
  • Happily accepting responsibility
  • High energy levels
  • Optimism
  • Commitment to the job
  • Desire to prove oneself
  • Creativity
  • High productivity
    (Calm, 2020; De Hert, 2020)
Stage 2: Onset of Stress

The second stage of burnout is characterized by an awareness that the employee is experiencing some difficult days at work. Optimism starts to decrease, and symptoms of stress begin to appear, including:

  • Irritability
  • Sleep disturbances
  • Trouble focusing
  • Reduced social interaction
  • Anxiety
  • Headaches
  • Heart palpitations
  • Fatigue
  • Changes in appetite
  • Forgetfulness
    (Calm, 2020; De Hert, 2020)
Stage 3: Chronic Stress

In the third stage of burnout, chronic stress develops. Symptoms from stage two become more intense, and additional symptoms develop, including:

  • Persistent fatigue
  • Missed work deadlines
  • Procrastination at work as well as at home
  • Resentfulness
  • Physical illness
  • Social withdrawal
  • Anger
  • Apathy
  • Cynicism
  • Decreased libido
  • Feeling out of control
  • Increased alcohol, drug, and/or caffeine intake
    (Calm, 2020; De Hert, 2020)
Stage 4: Burnout

Stage four is actual burnout. Symptoms become critical, and one’s ability to cope is crumbling. Professional mental health counseling is essential at this stage. People in stage four may exhibit:

  • Obsession over problems at work and/or in life
  • Self-doubt
  • Physical symptoms increasing in intensity
  • Social isolation
  • Chronic headaches
  • Chronic gastrointestinal problems
  • Neglect of personal needs
  • Desire to move away from work or friends and family
  • Desire to escape from society
    (Calm, 2020; De Hert, 2020)
Stage 5: Habitual Burnout

The final stage, habitual burnout, is characterized by the ongoing mental and/or physical problems described above. Addition symptoms include:

  • Chronic sadness
  • Depression
  • Chronic mental and physical fatigue
    (Calm, 2020; De Heret, 2020)
CASE

About a year ago Dan Ramirez, RN, got his first job as a nurse working in a long-term care facility. Dan’s many responsibilities include administering medications, providing wound care, writing care plans, maintaining patient records, and supervising patient care assistants. When Dan began in the job, he felt challenged and proud of his ability to manage so many duties. After a few weeks, when one staff member went on sick leave and another quit, Dan sympathized with his supervisor’s difficulty finding qualified help. He enthusiastically assumed additional duties because of insufficient staffing, expecting the situation would last only a few weeks (“honeymoon phase”).

But soon Dan found himself working overtime almost every day and felt obliged to “do it all.” He began having trouble sleeping, became irritable and anxious, and complained of frequent headaches (onset of stress). The additional work hours began to cause trouble at home, with his wife and children saying that they never see him, and when they do, complaining that he is irritable and impatient.

As the weeks went on, Dan started to feel fatigued almost all day, every day. He discussed his concerns with his supervisor, who told him he was doing a good job and to just “hang in there” until more staff members were hired. Dan resented having to do so much additional work, with no end in sight. He started self-medicating by drinking a couple of glasses of wine before bed and began to feel apathetic toward his job and his colleagues. Dan felt that he no longer had control over his work or personal life (chronic stress).

Then, one day, Dan made a medication error. Fortunately, the patient was not harmed, but the physician scolded Dan loudly in front of other staff members. He was humiliated and began to doubt his abilities and to think of himself as a professional failure, an imposter. He even began to question his decision to become a nurse. As his self-confidence decreased, Dan’s self-doubt and detachment increased, and he began distancing himself from his coworkers, family, and friends. He frequently felt nauseous, and his headaches became chronic. He felt that his marriage was also coming under significant strain (burnout).

As the situation continued, Dan became more and more irritable, cynical, and callous. He now felt sad and depressed most of the time. One afternoon he hurt his back lifting a patient and went out on sick leave. After months of physical therapy, surgery, and then more physical therapy, Dan went back to work part-time, but he just couldn’t keep up the pace. He felt like a failure, unable to carry on. On the verge of collapse, he quit his job, disillusioned with the nursing profession and the entire healthcare system (habitual burnout).

Discussion

Dan’s case illustrates the five stages of burnout. By assuming the duties of the absent attendants rather than assertively addressing the issue of inadequate staffing with his supervisor, Dan became physically and emotionally exhausted. The resulting impacts on his job performance soon caused him feelings of cynicism and self-doubt. This in turn caused him to become cynical and callous, finally leading to a sense of failure and quitting his job entirely.

RISK FACTORS FOR BURNOUT

Job burnout is caused by many interactive factors; some are due to the personality and lifestyle of workers, and some are due to the work environment.

Individual Risk Factors

Individual risk factors for burnout mirror many of the individual risk factors noted in other sections of this course. Work-related risk factors for burnout include:

  • Lacking control over one’s schedule, assignments, and workload
  • Having unclear expectations about one’s job
  • Working long hours (e.g., 12-hour shifts, overtime, being called in when staffing is short, finding it difficult to leave work when the shift is over, being on call)
  • Working in busy, high-stress environments
  • Lacking the skills needed to do the job
  • Lacking social support (isolation)
  • Having a work-life imbalance
    (Erickson, 2018; Cleveland Clinic, 2021; Mayo Clinic, 2021)

Individual personality traits also play a role in the development of burnout. These may include:

  • Putting others first. When caring for patients, dealing with family responsibilities, and working long hours, it is easy to fail to meet one’s own needs. When this continues unabated, burnout is likely to be a consequence.
  • Having perfectionist tendencies. Most healthcare professionals strive to do their best to provide excellent patient care. Perfectionists, however, criticize themselves mercilessly if everything is not perfect. Sometimes perfectionists avoid certain responsibilities because they are so afraid of failing, of not being perfect.
  • Being pessimistic. Pessimists tend to see the world as threatening. They worry about things going wrong, expect bad things to occur more often than good things, and place unnecessary stress on themselves by anticipating the worst in most circumstances.
  • Being excitable. People who are more excitable than others have a greater response to stress and experience stress more easily.
  • Having a type A personality. Some characteristics of a type A personality are associated with increased levels of stress and susceptibility to burnout, including lack of patience and free-floating hostility.
    (Ericksen, 2018; Scott, 2018)
Organizational Risk Factors

Increasing attention is being paid to the organizational environment and the development of burnout. Researchers have identified the following organizational risk factors for burnout among healthcare professionals:

  • Work process inefficiencies (e.g., computerized order entry and documentation)
  • Excessive workloads/caseloads
  • Inadequate staffing
  • Long working hours
  • Shift rotation
  • Unrealistic goals for employees
  • Dysfunctional workplace dynamics
  • Unclear job expectations
  • Organizational climates characterized by high levels of role overload (when an individual is called upon to fulfill multiple roles simultaneously but does not have the resources to do so) and role conflict
  • Lack of opportunities for professional growth
    (Calmer, 2020; Dyrbye et al., 2017; Mayo Clinic, 2021)
PATIENT SAFETY AND BURNOUT

Promotion of patient safety is one of the most important goals in healthcare. Research shows that compromised patient safety is an organizational factor that contributes to burnout and stress. What is described as a “better” work environment is associated with enhanced patient safety. Factors that contribute to such an environment include lowered patient loads, ability to complete tasks safely, and reduced burnout. Thus, increasing staffing levels and providing adequate support for caregivers to spend more time on direct patient care increases the safety of the organization and contributes to a lowered incidence of burnout (Liu et al, 2018).

GENDER BIAS AND STRESS

Women may face barriers to communication with an organization’s management because of workplace cultures that often exclude women from leadership positions and/or covertly support an atmosphere that views women as secondary to their male colleagues. Male leaders may believe that women do not succeed or attain managerial and executive positions because they are not qualified or capable of fulfilling the responsibilities associated with leadership positions or even of effective communication.

Most workplaces were created by men, for men, and are run by men. Hiring women to increase the number of females in leadership roles without changing a male hierarchy–focused culture is futile. The most powerful people in the workplace set the standards of behaviors and communication. Without respect and equality in the workplace, adverse working conditions related to gender bias will continue to increase both stress and burnout (King, 2020).

Compassion Fatigue / Empathy Distress Fatigue

The ability to feel what someone else is experiencing or to “put oneself in another person’s shoes” is generally considered to be an essential characteristic of healthcare professionals. However, feeling what patients are feeling can lead to overidentying with a patient’s sufferings and stressors, which can then cause healthcare professionals themselves to experience undue stress (Cleveland Clinic, 2021; Dowling, 2018; Amplion Clinical Communications, 2019).

Compassion fatigue is described as a state of deep emotional exhaustion resulting from repeated exposures to traumatic situations or stories. This type of exhaustion reduces the healthcare professional’s ability to feel empathy for their patients, family, and coworkers. People who are very empathic are at increased risk for developing compassion fatigue. They associate themselves with traumatic situations and stories more definitively than other persons (Intraconnections Counseling, 2019).

A considerable part of compassion fatigue involves becoming emotionally distraught when exposed to another’s traumatic experiences and/or someone else’s suffering. These distraught feelings are also referred to as secondary traumatic stress (Sheppard, 2016).

The term compassion fatigue was first coined by Charles Figley in the 1980s. Since its inception, the concept of compassion fatigue has been widely embraced by the psychological community. Despite this acceptance, however, it has never merited its own diagnostic category by any edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (Boyle, 2015).

Empathic distress, which is another term for this phenomenon, “refers to a strong aversive and self-oriented response to the suffering of others, accompanied by the desire to withdraw from a situation, disconnect from those who are suffering, and adopt depersonalizing behaviors in order to protect oneself from excessive negative feelings” (Singer & Klimecki, 2014). In healthcare, empathy distress fatigue is the emotional and physical exhaustion that occurs when healthcare professionals care for people day after day under extremely stressful conditions (Cleveland Clinic, 2021).

COMPASSION FATIGUE OR EMPATHY DISTRESS FATIGUE?

The term compassion fatigue is used most often to describe the phenomena discussed above. However, some experts in psychology and neuroscience now question this term and believe that this form of fatigue is caused not by compassion but by empathizing with patients.

Compassion is the ability to understanding and show concern for the suffering of others while using emotion regulation skills so as not to actually feeling their suffering oneself. Empathy more commonly refers to sharing the feelings of others, including their fears and stressors, blurring the “self-other” distinction and absorbing another’s suffering as one’s own.

Thus, these experts recommend using the newer term empathy distress fatigue rather than compassion fatigue. To date, however, most of the literature continues to use the older term (Cleveland Clinic, 2021; Dowling, 2018; Hofmeyer et al., 2020).

RISK FACTORS FOR COMPASSION FATIGUE

Both individual and organizational issues contribute to compassion fatigue. Some of these overlap with the risk factors for burnout described earlier in this course.

Individual Risk Factors

Healthcare professionals at greater risk for compassion fatigue include those who:

  • Are in situations where they fear for their safety or the safety of their patients
  • Have a lack of or are separated from personal support systems
  • Perform physically difficult or exhausting tasks
  • Have a heavy workload
  • Do not get enough sleep
  • Have substance use issues
  • Are exposed to anger or lack of gratitude
  • Have excessive empathy
  • Feel helpless to deal with work circumstances
    (Local Public Health Institute of Massachusetts, 2021)

Others at high risk for compassion fatigue are healthcare professionals who form close, personal relationships with patients and/or families, especially when personal boundaries are crossed (Sheppard, 2016). Sometimes, in an effort to be supportive and empathetic, healthcare professionals begin to slowly cross professional boundaries without actually being aware of what they are doing. Every relationship between a patient and a healthcare professional must be based on the premise of professional behavior.

CROSSING PROFESSIONAL BOUNDARIES

The National Council of State Boards of Nursing (NCSBN, 2018) cautions that inappropriate behavior can be subtle at first. However, healthcare professionals should be aware of the following “red flags” that warn of the dangers of crossing professional boundaries, which may occur when a professional:

  • Discusses their own intimate or personal issues with a patient
  • Engages in actions that could be interpreted as flirting
  • Keeps secrets with patients or family members
  • Believes that they are the only one who understands or can help the patient or family members
  • Spends more time than is necessary with certain patients
  • Speaks poorly about colleagues or employers with patients or families
  • Shows favoritism toward certain patients or family members
  • Meets with patients in settings besides those needed to provide direct patient care
Organizational Risk Factors

Anyone who works in a difficult work environment is at risk for stress-related conditions, including compassion fatigue. Organizational factors that contribute to a difficult work environment include:

  • Rotating shifts
  • Changing job assignments
  • Long working hours
  • Asking employees to do more with less
    (McHolm, 2018)

Researchers investigating compassion fatigue among critical care nurses have identified several other organizational factors that increase this form of job-related stress:

  • Lack of support (organizational, leadership) when nurses deal with difficult situations
  • Failure to receive acknowledgment/accolades for their work
  • Not having their input considered regarding removing or modifying system-based obstacles
    (Arnetz, 2020; Shreffler et al., 2020)

SIGNS AND SYMPTOMS OF COMPASSION FATIGUE

Symptoms associated with compassion fatigue include:

  • Feeling bored with work
  • Feeling exhausted most of the time
  • Self-medicating with drugs or alcohol
  • Feeling detached and distant from patients and colleagues
  • Conflicts in interpersonal relationships
  • Being irritable and short-tempered
  • Difficulty sleeping
  • When off duty, worrying about things that may have been forgotten at work or thinking about disturbing events that took place at work
  • Mental and physical exhaustion
  • Headaches and/or backaches
  • Nausea, especially when going to work
    (Cleveland Clinic, 2021; Sheppard, 2016)
COMPARING COMPASSION FATIGUE AND BURNOUT

The most important step in combatting compassion fatigue is recognizing it. First and foremost, compassion fatigue must be distinguished from burnout. While healthcare professionals can experience both, these are two distinct issues. Burnout is associated with workplace stressors such as manager unresponsiveness, lack of camaraderie and teamwork, staffing shortages, working long hours, intense workloads, conflicts with other nurses and healthcare providers, and time pressures. Compassion fatigue, on the other hand, emanates from the stress healthcare professionals experience from their relationships with patients and families (Boyle, 2015).

Vicarious Trauma

Vicarious trauma, also referred to as trauma by proxy, occurs when healthcare professionals experience secondary traumatic stress reactions triggered by helping, or wanting to help, traumatized patients and families. Vicarious trauma refers to negative changes in the healthcare professional’s view of self, others, and the world that occur as a result of repeated empathetic involvement with patients’ traumas. Healthcare professionals may develop symptoms of posttraumatic stress disorder (PTSD) as a result of caring for these patients and families (Quitangon, 2019). Vicarious trauma tends to make it difficult to focus and perform duties as assigned.

RISK FACTORS FOR VICARIOUS TRAUMA

Individual Risk Factors

Vicarious trauma is influenced by individuals’ personal experiences with traumatic events that have impacted them, their family members, and/or close friends. Such personal experiences can make someone more vulnerable to vicarious trauma. People are also at risk for vicarious trauma if others who work with them are experiencing the phenomenon, thereby becoming a negative influence on those around them. That is, vicarious trauma can “spread” from one person to another (NCADV, 2018).

Persons who work in helping professions are especially vulnerable to vicarious trauma as well as compassion fatigue. Those at high risk for developing either vicarious trauma or compassion fatigue are persons who:

  • Have a personal history of trauma
  • Care for patients who have suffered trauma
  • Are repeatedly exposed to patients’ narratives of trauma
  • Are preoccupied with the traumatic stories of the people they care for and work with
  • Display emotional symptoms of anger, grief, mood swings, anxiety, or depression (which may also indicate that the person is already experiencing vicarious trauma)
  • Have physical issues related to stress (e.g., headaches, fatigue, gastrointestinal problems) (which may indicate that the person is already experiencing vicarious trauma)
  • Have feelings of powerlessness, hopelessness, and disillusionment
    (Quitangon, 2019; Salazar, 2016)
Organizational Risk Factors

A workplace that fails to support its employees increases the risk for vicarious trauma. Specific organizational factors that increase the risk of vicarious trauma in the workplace include:

  • Failing to acknowledge the problem and develop a strategy for reducing it
  • Failing to provide support services (e.g., mental health resources) to staff who are experiencing patient/family trauma
  • Failing to create an environment where persons experiencing vicarious trauma can acknowledge it without fear of ridicule or job compromise
  • Failing to know what vicarious trauma is, what strategies can prevent it, and what actions are needed to help those experiencing it
  • Failing to acknowledge that managers and supervisors also experience vicarious trauma and require appropriate support
    (NCADV, 2018)

SIGNS AND SYMPTOMS OF VICARIOUS TRAUMA

Among the physical manifestations of vicarious trauma are anorexia and direct gastrointestinal (GI) symptoms such as nausea, stomach pain, and diarrhea. If the person reacts to this GI upset by not eating or eating less than usual, fatigue and reduced energy can result. Paradoxically, both insomnia and hyperactivity are also possible. Headache and chest pain may present (Joyful Heart Foundation, 2018).

Psychological signs may present as exaggerated forms of a person’s usual behavior or as reactions not usually seen, at least in the workplace. As the situation continues, these responses may become more frequent and/or stronger and/or require less and less to trigger them.

Among the common presentations of vicarious trauma are the following:

  • Irritability, anger, resentment, and/or cynicism
  • Feeling that no matter how much you try or give, it is never enough
  • Feelings of hopelessness and helplessness
  • Feeling disconnected from emotions
  • Difficulty in seeing multiple points of view or new solutions to problems
  • Having intrusive thoughts and/or images related to the traumatic events you have seen or heard about
  • Absenteeism from work
  • Avoidance of work, responsibilities, or engaging in interpersonal relationships
  • Dread of activities that used to be positive
  • Lacking a personal life outside of work
  • Extreme concern about the safety of loved ones
    (Joyful Heart Foundation, 2018; Quitangon, 2019)
CASE

Sara, a respiratory therapist, and Josie, an emergency department (ED) nurse, are both involved in caring for multiple critically ill patients who have COVID-19.

Sara has found herself strongly shaken by the sight of so many of her patients struggling to breathe and the large numbers of patients on ventilators. Sara has also been struggling to deal with the many fatalities due to COVID-19. Despite postincident counseling, continuing her meditation practice, and taking time off with her family, Sara has not yet worked through her feelings. She is also finding herself unable to concentrate and experiencing images of her younger brother, who has severe asthma, struggling to breathe as he battles COVID-19. She has also had dreams in which her elderly grandfather is on a ventilator at the point of death.

Josie is frequently on duty in the ED when critically ill COVID-19 patients arrive. In addition to being an ED team leader, she provides patient care, often holding patients’ hands as they are intubated or as they die. Caring for so many critically ill patients hour after hour, day after day, has begun to take a toll on Josie. She is unable to recharge and has begun feeling detached from her patients, a loss of interest in ordinary activities, and insomnia.

Discussion

Sara is experiencing vicarious trauma as the result of both her ongoing exposure to traumatized, critically ill patients and their families. A unique symptom to this form of job-related stress is Sara’s recurring, intrusive images of her vulnerable relatives struggling to survive COVID-19.

Josie is displaying symptoms more characteristic of compassion fatigue brought about by her constant exposure to suffering patients and characterized by her feeling of detachment from her patients.

Both women need help to address their stress-related issues due to the ongoing pandemic, especially since the circumstances surrounding patient care may not improve anytime in the near future.