I had worked with Jane for several months during her frequent hospitalizations. She was just 40 years old and had widely metastatic vulvar cancer. Her pain was severe and difficult to control, despite epidurals and nerve blocks. The slightest movement was excruciating, yet she insisted on getting up to walk to the bathroom rather than suffer the indignity of a catheter. She had exhausted all treatment options, and her oncologist recommended hospice care. Desperate to live, Jane left the hospital and, with her husband Zach, drove several hours to get a second opinion at the Mayo Clinic. As they entered the hospital lobby to register, Jane had a stroke. She returned to our unit awake and alert but aphasic and paralyzed on her left side. Her death was imminent.
I sat by Jane’s bed as her husband arrived. He held her hand. She opened one eye and started to try to speak, her speech garbled. Zach said helplessly, “I can’t understand you, honey.” Desperate to communicate, Jane began to repeatedly hit her chest with her fist and then point to Zach. She was becoming more agitated as we looked on helplessly, struggling to understand what she was trying to say. And then I finally got it. “Jane, are you telling Zach you love him?” She nodded vehemently, relieved to have finally gotten her message across. Zach, who was typically stoic, broke down in tears. I left the room to give them privacy in this devastatingly sad moment, and also because I could not maintain my composure any longer. Watching Jane and her husband suffer through this long and painful journey, culminating in this final insult, had left a lasting mark on me.
DEFINITIONS AND DISTINCTIONS
Oncology nurses witness their patients’ physical, emotional, spiritual, and existential suffering every day that they go to work. This repeated exposure to trauma can be a regular stressor for the caregiver. Although experienced oncology nurses may have learned how to deal more effectively with exposure to so much pain and suffering, tenure is no guarantee that a nurse will not suffer the physical and emotional symptoms that are commonly associated with compassion fatigue (CF), also known as secondary traumatic stress (STS). Understanding CF/STS, being able to recognize the symptoms of CF/STS, and knowing how to manage and prevent the negative consequences of this occupational hazard can be critical to the personal and professional health of the nurse.
Nurses drawn to the specialty of oncology are generally compassionate people. Radley and Figley define compassion as a “deep sense or quality of knowing or an awareness [among helping professionals] of the suffering of another coupled with the wish to relieve it.”1 This empathic engagement is what contributes to job satisfaction, but it can also manifest as blurring of the boundaries between provider and patient and can leave the oncology nurse at risk for negative emotional and physical outcomes.
Compassion fatigue and secondary traumatic stress are used interchangeably and are defined by Charles Figley, PhD, a pioneer in the field of traumatology, as “the natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other—the stress resulting from helping or wanting to help a traumatized or suffering person.”2 Figley refers to compassion fatigue as “the cost of caring for others in emotional pain” and “an extreme state of tension and preoccupation with the suffering of those being helped to the degree that it is traumatizing for the helper.”3 The symptoms of CF/STS, as listed in Table 1, are almost identical to the symptoms of posttraumatic stress disorder (PTSD). In PTSD, however, the person experiencing the symptoms is the same person who experienced the original trauma; whereas in CF/STS, the symptoms result from awareness of events happening to someone else.
An indirect connection to trauma is common to those who work in the field of oncology and who are regularly exposed to death and dying, grieving families, traumatic stories, severe physical pain, and strong emotional states, such as anger and depression in patients and family members. Being a witness to these situations may subsequently result in personal grief—and emotional and physical exhaustion in the nurse.
Other terms in the literature that may be familiar are burnout, vicarious traumatization, and countertransference. Research has demonstrated that although these constructs overlap, important differences exist in the etiology, prevalence, and symptoms related to each, and they are clearly distinguishable from CF/STS.4
Burnout usually develops gradually and intensifies over time, culminating in emotional exhaustion and demoralization. In contrast, CF/STS can develop acutely. Burnout is a defensive response to chronic dissatisfaction with work-related issues of inadequate support, short staffing, high workload, inadequate resources, and frustration with system issues. These demands and stressors eventually lead to feelings of hopelessness and powerlessness to make a difference in the lives of those being served. Burnout may be a precursor to CF/STS.4,5
Countertransference is the nurse’s emotional reaction to the patient as the provider sees himself or herself in the patient and begins to overly identify with the patient. The risk in countertransference is that the nurse will attempt to express or meet his/her own personal needs through the client.2 For example, a young oncology nurse whose father died of leukemia when she was in high school may struggle to work with patients of the same age and with the same diagnosis as her father. The professional role and the personal experience become blurred.