As previously discussed, the action of providing nursing care can result in significant stress. The stress response is exacerbated when experiencing extreme or repeated stressors, such as client deaths. In some health care settings, nurses do not have time to resolve grief from one loss before another death occurs. This lack of time to resolve grief has been exacerbated during the COVID-19 pandemic where many units continually filled with clients requiring high levels of skilled nursing care. Additionally, some patients with COVID died without the face-to-face support of friends and family due to visitor restrictions. This resulted in the end-of-life transition supported solely by the health care staff. Many nurses felt additional stress due to supporting both the client and the client’s family during this challenging time.

Compassion fatigue and burnout occur frequently with nurses and other health care professionals who experience cumulative deaths that are not addressed therapeutically. Compassion fatigue is a state of chronic and continuous self-sacrifice and/or prolonged exposure to difficult situations that affect a health care professional’s physical, emotional, and spiritual well-being. This can lead to a person being unable to care for or empathize with someone’s suffering. Additionally, many individuals who experience compassion fatigue may become detached from the emotions associated with the care experience or client needs. These individuals can often appear numb to the severity of the circumstance of the events that are occurring. Burnout can be manifested physically and psychologically with a loss of motivation. It can be triggered by workplace demands, lack of resources to perform work professionally and safely, interpersonal relationship stressors, or work policies that can lead to diminished caring and cynicism.^[1] See Figure 12.4^[2] for an image depicting a nurse at home experiencing burnout due to exposure to multiple competing demands of work, school, and family responsibilities.

With the significant dangers of burnout and compassion fatigue within the nursing profession, it is important to acknowledge actions and strategies to facilitate self-care. Self-care can occur in many actions that individuals take to maintain self-health and is critically important for preventing compassion fatigue and burnout.

To facilitate self-care, nurses must recognize the need to take time off, seek out individual healthy coping mechanisms, and voice concerns within their workplace. Prayer, meditation, exercise, art, and music are examples of healthy coping mechanisms that nurses can use for self-care. Nurses should reflect on what actions bring them personal satisfaction and rejuvenation. These strategies should then be purposefully included to help reduce the influence of work-related stressors. For example, perhaps you are a nurse working in a busy Level 1 trauma center and emergency department. You are nearing the end of your third 12-hour shift and have the following day off. The unit manager approaches you and states that there has been an ill call for tomorrow’s evening shift. You are offered premium pay to come in and work. Although there is a part of you that is interested in receiving the premium pay, you also take a moment to think about your current situation. You are tired from working three 12-hour shifts the last three days and had plans to go to your child’s baseball game tomorrow evening. Taking stock of these reflective thoughts, you politely decline the additional shift. Acknowledging your fatigue and the satisfaction that you will feel in attending your child’s game are important parts of facilitating self-care. Although you could have chosen to work the shift, taking time to look inwardly on what will bring about the greatest rejuvenation and avoid burnout will help cultivate professional engagement.

Additionally, nurses must recognize when outside resources are needed to mitigate stress and facilitate self-care. Many organizations sponsor employee assistance programs that provide counseling services. These programs can be of great value and benefit in allowing individuals to share both individual and employment stressors. For example, employee assistance programs can address employment-related stressors, such as cumulative client deaths, as well as personal challenges impacting one’s work role, such as a family illness. The support of an impartial, trained professional can be very helpful as individuals navigate through stressful stimuli.

There are specific stress stimuli that may require specialized intervention. For example, after a client death resulting from trauma, many organizations hold debriefing sessions to allow individuals who participated in care to come together to verbalize their feelings. These sessions are often held with the support of chaplains to facilitate individual coping and verbalization of feelings. Debriefing sessions can be very helpful as individuals experience collegial support in working through traumatic stress stimuli.

Strategies for Self-Care

By becoming self-aware regarding signs of stress, you can implement self-care strategies to prevent compassion fatigue and burnout. Use the following “A’s” to assist in building resilience, connection, and compassion:

• Attention: Become aware of your physical, psychological, social, and spiritual health. For what are you grateful? What are your areas of improvement? This protects you from drifting through life on autopilot.
• Acknowledgement: Honestly look at all you have witnessed as a health care professional. What insight have you experienced? Acknowledging the pain of loss you have witnessed protects you from invalidating the experiences.
• Affection: Choose to look at yourself with kindness and warmth. Affection prevents you from becoming bitter and “being too hard” on yourself.
• Acceptance: Choose to be at peace and welcome all aspects of yourself. By accepting both your talents and imperfections, you can protect yourself from impatience, victim mentality, and blame.^[4]

Cultivating Care of Self

Taking care of oneself can feel as if it goes against the nature of the nursing role, but it is a vital component for professional success. Provision 5 of the American Nurses Association Code of Ethics states, “The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.”^[5] In a profession where one spends most of their time thinking about the needs of others, it can be difficult to recognize when special care and attention is needed for one’s own health. However, there are many strategies that nurses can use to help them navigate stress and prioritize their own health and wellness. Although not every strategy may be “right” for every nurse, it is critical for nurses to find actionable interventions to help them address their own stress.

Here are some examples of stress management strategies:

• Meditation. Meditation can induce feelings of calm and clear-headedness, improving concentration and attention. Research has shown that meditation increases the brain’s gray matter density, which can reduce sensitivity to pain, enhance the immune system, help regulate difficult emotions, and relieve stress. Mindfulness meditation in particular has been proven helpful for people with depression and anxiety, cancer, fibromyalgia, chronic pain, rheumatoid arthritis, type 2 diabetes, chronic fatigue syndrome, and cardiovascular disease.^[6] See Figure 12.5^[7] for an image of an individual participating in meditation.

• Yoga. Yoga is a centuries-old spiritual practice that creates a sense of union within the practitioner through physical postures, ethical behaviors, and breath expansion. The systematic practice of yoga has been found to reduce inflammation and stress, decrease depression and anxiety, lower blood pressure, and increase feelings of well-being.^[8] See Figure 12.6^[9] for an image of an individual participating in yoga.

• Journaling. Journaling can help a person become more aware of their inner life and feel more connected to experiences. Studies show that writing during difficult times may help a person find meaning in life’s challenges and become more resilient in the face of obstacles. When journaling, it can be helpful to focus on three basic questions: What experiences give me energy? What experiences drain my energy? Were there any experiences today where I felt alive and experienced “flow”? Allow yourself to write freely, without stopping to edit or worry about spelling and grammar.^[10]
• Prayer. Prayer can elicit the relaxation response, along with feelings of hope, gratitude, and compassion, all of which have a positive effect on overall well-being. There are several types of prayer rooted in the belief that there is a higher power that has some level of influence over one’s life. This belief can provide a sense of comfort and support in difficult times. A recent study found that clinically depressed adults who believed their prayers were heard by a concerned presence responded much better to treatment than those who did not believe.^[11]
• Spiritual community. Join a spiritual group, such as a church, synagogue, temple, mosque, meditation center, yoga class, or other local group that meets to discuss spiritual issues. The benefits of social support are well-documented, and having a spiritual community to turn to for fellowship can provide a sense of belonging and support.^[12]
• Nurturing relationships. Relationships with family, significant others, and friends aren’t static – they are living, dynamic aspects of our lives that require attention and care. To benefit from strong connections with others, you should take charge of your relationships and put in the time and energy you would any other aspect of your well-being. It can be helpful to create rituals together. With busy schedules and the presence of online social media that offer the façade of real contact, it’s very easy to drift from friends. Research has found that people who deliberately make time for gatherings or trips enjoy stronger relationships and more positive energy. An easy way to do this is to create a standing ritual that you can share and that doesn’t create more stress, such as talking on the telephone on Fridays or sharing a walk during lunch breaks.^[13]
• Mindfulness. Mindfulness has been defined as, “Awareness that arises through paying attention, on purpose, in the present moment, and nonjudgmentally.” Mindfulness has also been described as, “Non-elaborative, nonjudgmental, present-centered awareness in which each thought, feeling, and sensation that arises is acknowledged and accepted as it is.” Mindfulness helps us be present in our lives and gives us some control over our reactions and repetitive thought patterns. It helps us pause, get a clearer picture of a situation, and respond more skillfully. Compare your default state to mindfulness when studying for an exam in a difficult course or preparing for a clinical experience. What do you do? Do you tell yourself, “I am not good at this” or “I am going to look stupid”? Does this distract you from paying attention to studying or preparing? How might it be different if you had an open attitude with no concern or judgment about your performance? What if you directly experienced the process as it unfolded, including the challenges, anxieties, insights, and accomplishments, while acknowledging each thought or feeling and accepting it without needing to figure it out or explore it further? If practiced regularly, mindfulness helps a person start to see the habitual patterns that lead to automatic negative reactions that create stress. By observing these thoughts and emotions instead of reacting to them, a person can develop a broader perspective and can choose a more effective response.^[14]
• Nature. Spending time in nature is cited by many individuals as a spiritual practice that contributes to their mental health.^[15]
• Physical activity. Regular physical activity, such as brisk walking, can relieve stress and tension. ^[16]