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Resilience and Boundaries to Prevent Compassion Fatigue and Protect Team Health

Posted by Carla Cheatham on Saturday, July 20th, 2019 in Building team resiliance, Spiritual Care Integrity and Excellence, The Power of Presence, Uncategorized

Resilience and Boundaries to Prevent Compassion Fatigue and Protect Team Health (a 4 minute read)

I teach boundaries to caring professionals and volunteers, based on both psychology, research, and my own human goof ups and successes over much of my adult life in social services and healthcare.

For me, the foundation of all healthy boundaries is this:

If I’m empty and need work to fill me up to make me feel okay, then I’ll need something from the interaction with patients and families, which means I’ll make it be about ME rather than what the patient and family need.

But if I’m already full, if I have my own life outside of work where I get acknowledgment and validation and warm fuzzies and love, then I won’t need it from patients and families.

When things don’t go the way I want them to, when symptoms can’t be completely managed. when people make choices that are hard for me to accept, when it isn’t all puppies and ponies, I won’t be as shaken because I don’t NEED things to go a certain way to feel okay.

So instead of giving up my life for this work, I need to first GET a life of my own and then bring the overflow of energy and peace and groundedness to those with whom I work, rather than draining myself to my dregs.

That’s the BEST thing I can do for patients and families, as well as my agency.

Now, I know bosses don’t always agree! We are far too often rewarded for over-functioning and bearing the stress of a system so the system won’t have to. For instance, if the census is too high and the staffing model is off and I work longer hours to compensate, I feel the stress, which means the system does not have to. If the system does not feel stress, it has no motivation to change and grow and become healthier.

We complain about it, but we also contribute by enabling the system, wearing our martyrdom like a badge of honor…to make us feel safe in our position, liked, and “okay”–See the cycle?

Certainly, setting limits and keeping healthy boundaries can be punished in small and large ways. It can feel scary to say, “No” to giving more than we have or more than seems reasonable and far beyond being a “team player”. We may even risk losing our jobs, so please don’t curse my name and ask to come live with me if you try this and it goes amuck!

But another key point of boundaries is this:

We must accept that we are responsible for our choices, even if we do not like our options.

Even if we fear not being able to find another job and not being able to pay our bills and going bankrupt and then being homeless under the bridge, we are still making a choice. Staying with a job that makes us miserable is still what we are choosing rather than facing the risk of life under the bridge.

And being at choice removes our status as a victim; it means we take responsibility for ourselves and let go of blaming everyone else, which feels a LOT better in the short term and is SO much more fun, but it also gives away our power.

We may be powerless to change circumstances or people, but we are not helpless to take action on our own behalf.

Living at choice rather than as a victim can immediately impact our sense of well-being, and greatly alter the lens through which we perceive ourselves and our situations.

So we take responsibility for filling ourselves up, and simply let our work fulfill us. We make good choices on our own behalf and model the good self-care we teach others. We focus on what we can change and how we can be part of a healthy and productive solution.

And we breathe, and we live and, little by little, we will change how healthcare is done by being the change we want to see.

Peace…
Carla

Based on the presentation, “Resilience and Boundaries to Prevent Compassion Fatigue and Protect Team Health” By Carla Cheatham

Rev. Carla Cheatham, MA, MDiv, PhD, TRT has served hospices as a chaplain and bereavement coordinator. She’s the Section Leader for the Spiritual Caregivers Section of the National Hospice and Palliative Care Organization, Chair of NHPCO’s Ethics Advisory Council, and an adjunct professor at the Seminary of the Southwest and an Affiliate Associate Professor at the University of Maryland. Through her Carla Cheatham Consulting Group, Carla provides training and consulting for professional caregivers nationwide. She is the author of Hospice Whispers: Stories of Life and its companion volume, Sharing Our Stories: A Hospice Whispers Grief Support Workbook. Her next book, On Showing Up with Suffering: Others’ and Our Own, is set to publish in 2019.

When They Learn You Work For Hospice

Posted by Carla Cheatham on Tuesday, March 19th, 2019 in Hospice Whispers: Stories of Life, Spiritual Care Integrity and Excellence, The Power of Presence

WHEN THEY LEARN YOU WORK FOR HOSPICE (a 5 1/2 minute read)

“I often joke that if you want to suck all the air out of the room at a dinner party, tell folks you work for hospice…”

I was asked to write more about how to “recover” when we as hospice staff, or any type of caring professionals,
experience various reactions from others when they learn what we do for a living. Whether we’re out socially or
even at the grocery store, we often face *gasps* and looks of sympathy or repulsion or admiration followed by,
“Awww, you work for hospice…?!”.

Below are just a few examples of how others respond to the news and how I work to balance being caring while also caring for myself. Like anything, my strategies are a work in progress, so I look forward to hearing what YOU experience and do, as well.

Taking Time Off…
One self-care ritual I teach to healthcare staff revolves around their name badge. The goal is to avoid thinking
about work until they put their badge on for the day. Then, at the end of their shift, I encourage them to debrief
whatever they need to from their day and then, once their badge comes off, to put their workload and concerns
from their shift down and leave them there.
I have a special place I keep my badge and I leave my work concerns there with it. I do my best to not pick
them back up until I put it on the next time. It seems to help many of us because it’s a tangible boundary we
set for ourselves and a commitment we make to our loved ones to not bring our work, or the energy of it, home
with us.
We need moments when we’re not “on” as a hospice worker, with all the expectations and assumptions that
knowledge can bring up in others. There are times when I literally do tell the friends I go out with, “Tonight, I do
NOT work for hospice. I screw toothpaste caps on toothpaste tubes in the toothpaste factory for a living!”
I honestly do LOVE it when people tell me their stories…most of the time. But there are days I need a break, to
just be Carla and not any of my titles or roles; to not figuratively wear my badge that indicates I’m a helper and
open for business. If I don’t take time off, I become a crispy critter not fit for human consumption. Practicing
what I teach about good self-care is the BEST gift I can give to others, even when they don’t like me having a
boundary, at least not with them.

I do care. I do want to listen. And I also need space to listen to myself, first, so I can hear others from a grounded, centered place from which I can bring my best self, (not a hot-fried mess).

Most often if I or someone else spills the beans about what I do for a living and I see and/or feel people start to
react to the news, I’ll quickly respond as gently as I can, “It’s actually the best gig I’ve ever had, and even the
most fun. But I’m off duty today, so who’s seen the newest Star Wars movie…?” The goal is to politely decline
to go there, to respectfully set a boundary that I’m not up for having that talk today.

Protecting Myself From Being a Pariah…
Holding my boundaries when I’m off duty can also be about refusing to pick up the Grim Reaper scythe,
because the news can be quite a downer for the party’s energy, and it never feels good to be the “buzz kill.”
People sometimes edge away from me and visually scan for the nearest exit or excuse to go talk to someone
else, if they’re uncomfortable with death.
Other times if I face the social obligation of responding to, “What do you do?”, I’ll give the honest answer,
quickly followed by the toothpaste factory line. They usually laugh in relief, as it lets them off the hook from
talking about a squeamish topic and gets me out of having to deal with what I know isn’t rejection of me, but
cumulatively can be wearing.

Putting Down the Halo…
It’s quite an honor to receive persons’ gratitude for this work we do, and to be told so often what “angels” and
“special people” hospice workers are. I never want to verbally or emotionally shove gratitude back at someone
and shut them down. That doesn’t feel good either.
But let’s face it, that freaking halo can get reeaaallly heavy!! Just like we need time to not wear our badges, I
think we also need time to just be human, have a drink, smoke a social cigar, tell an off-color joke, make out on
a date, whatever it is that we would never do in front of patients and families.
The point is to not have to be an “angel” or “special person” all the time. We have to be able to be real and
down to earth and shop for groceries and have a bad day and even have meltdowns and a touch of road rage
without feeling like we’re diving head first off of others’ pedestals.
Besides, we’ve all seen what happens when public figures begin to believe their own press. We don’t want to
fall into the trap of thinking of ourselves as constant heroes or somehow above the rest of humanity and
become pompous arses on one extreme or burned out shells of humans on the other.
So in the face of such admiration, I’ll thank them and then say, “But you know, I missed the first three days of
fractions in 3rd grade and never caught up, so I think it also takes special people to be accountants…” and I
smile. It may take them a moment, but then they get it: We can all do our work in a special way if we just show
up well for others, regardless of what our job title may be.
It levels the playing field and I’ve found it to be an easy and yet connective way to politely decline the invitation
to the top of the medal stand. It helps keep me humble (hopefully), and protects my own neck and back, as
well as my social life, from the weight that comes with special status.

How to Not Listen Without Being an Ogre…
Again, I do love collecting and hearing others’ stories. People fascinate and inspire me. Besides, as an author
I love a good tale. But sometimes people still need a place to process their grief, and when others find out we
regularly play in that sandbox they come running to show us their toys.
Please hear me, I don’t mean to be crass or belittling to those who are in a place of grief and deserve to have
their stories heard again and again as long as they need to tell it. What I do mean to say is that we can softly
decline to be at work when our badge is off.

Cabbies turn off their lights when they aren’t on duty so folks won’t feel abandoned on the side of the street when the yellow car passes them by. We can, too. Just because someone around us has a need, doesn’t mean it is our responsibility to fill it.

We get to have limits. We get to have time off. We get to cry “uncle!” when we’ve had enough. We are not to
be used. We are not here to be taken advantage of, though I am certain that is never the intention of someone
who needs to tell their hospice story.
If I have it to give easily, I will listen to their story and offer words of support. If I don’t have it to give, however, I
owe it to everyone to take care of myself by not trying to give others a drink from my empty well.
So when I do not have it to give, I typically listen for a moment, then place a kind hand on their arm and quietly
say, “I appreciate and want to hear your story, but…(I’m distracted by the gathering, promised my family I
wouldn’t work tonite, am pretty exhausted from my week, etc.). I’d be glad to (have coffee, chat by phone, talk
afterward, find another time) later when I have my full attention to give you.”
That’s just an example of some options. Find what feels genuine and right for you and your personality and
voice. But find something. Make a game plan with a friend before you go out who will agree to come and play
“extract the bereavement counselor/chaplain/CNA/nurse/physician/social worker/staff member/volunteer” and
help you find a way to gracefully exit.
Allowing persons the dignity of finding their own sources of support from loved ones or professionals and not
rescuing them in the moment when they happen to stumble upon a hospice worker does not make you, or me,
a bad guy. We are not abandoning them.
Our title is not an open invitation that means we must listen to anyone, anytime, anywhere anymore than it is
fair or appropriate for me to drag a mechanic out of a cocktail party to change my oil on the spot because I’m
overdue for an oil change.
Again, I don’t mean to be crass about emotional pain, but if I’m cavalier about my own needs, I’ll burn out my
engine and be no good for anyone.

How to Not Take One For the Team…
Other times, a person’s experience with hospice has not been positive. We aren’t perfect. We do make
mistakes and have service failures. Personalities collide, miscommunications happen, values conflict,
expectations go amuck, and grief can get taken out on hospice professionals and agencies. I was verbally attacked by a former friend who had a very negative perception of her experience with hospice surrounding the use of artificial nutrition with her loved one. I don’t know the story. I wasn’t there. But I became a target when I posted an article about end of life choices that hit a tender spot for her, and it was on.
She called my ethics into question and the frustration she felt about her situation came out at me in a flurry. At
first, I listened and tried to be a space of healing for her obviously complicated grief. There came a point,
however, when I had to put down the rope and refuse to play. I simply didn’t have it…and, it wasn’t my job to
fix her experience of pain. I felt for her, but long ago a wise therapist colleague said, “We help no one when we
allow them to be their worst selves, so do not volunteer to be their punching bag.”
Certainly, there are therapeutic exceptions when clinical judgment says we refrain from taking transference
personally and offer others safe space to work through their stuff, but I wasn’t her counselor, nor was I her
chaplain. I wasn’t getting paid and we had negotiated no treatment or care arrangement of any sort. I was not
obligated to hold space for her struggle, because holding such space takes energy that I get to reserve for my
work while using my down time to do just that, let down.
Sometimes, just like listening to others’ grief stories, I’ll listen if I have it easily to give. But if I don’t, I put my own oxygen mask on first before I try to help others breathe.

I don’t know how these will land with you. I’m curious about other scenarios and responses you have found
that work well. I hope you’ll share them, because this work is challenging enough and it helps to know that we
aren’t alone in navigating sometimes choppy waters.

Peace to you…

Building Team Resilience: Increasing Support, Community, & Appreciation

Posted by Carla Cheatham on Tuesday, October 24th, 2017 in Building team resiliance, Spiritual Care Integrity and Excellence, The Power of Presence

Building Team Resilience: Increasing Support, Community & Appreciation (a 3 1/2 minute read)

Leadership experts these days agree that employees are our most important customers, and I believe this to be true.

One of my favorite, and one of the most effective, hospice administrators I’ve known often says, “If we take good care of employees, they’ll take good care of patients and families. If we do that, the money will come.” She was so very right, and our profit margins proved it.

Research shows that employees who feel supported and fairly compensated with good support are less likely to experience burnout.

Resilience literature also tells us that feeling connected increases our ability to not only survive but to actually thrive through challenging times.

Given the uncertainty many healthcare organizations are facing these days, we can’t afford to NOT invest time and energy into creating a culture of support, camaraderie, and cohesion, and community amongst our teams.

One practical way we can do this is to identify what is meaningful to team members; how do they feel most appreciated, cared for, and supported? An easy way to begin this conversation is to ask employees to take a simple on-line quiz.

Many are familiar with the popular book, The 5 Love Languages by Gary Chapman. Before rolling eyes and writing this off as too fuzzy woo woo, managers and leaders would do well to at least consider this option.

The 5 Languages, or things that communicate to someone they are cared for, include:

Gifts
Words of affirmation
Quality time
Acts of service
Touch

You can take the quiz on the love languages website by clicking on the “Learn Your Love Language” tab. The site will ask whether you are taking this for yourself or your child, then whether you are in a relationship or single. It will direct you to the correct version of the test for you to take on-line or to download as a PDF and take and score on your own.

I encourage leaders to identify their own and ask their teams to do so, as well. Take a few moments at your next meeting to discuss this as an agenda item. What were everyone’s results? What surprised them about their scores? What surprised them about others’ results?

Typically, one or two styles will stand out as most important and others will score as less so. The way we most like to receive care will often be the way we express it. That’s fine, if others share our preferences but, if not, a major disconnect can occur.

Buying coffee shop gift cards for employees to whom gifts mean little, but for whom words of affirmation mean the world, misses the mark. For the latter, taking a few extra moments to tell the person how much something they did or how they handled themselves in a situation means to you and thanking them for it may mean so much more.

A literal pat on the back, handshake, or hug (depending on your team culture) may mean far more to someone for whom touch communicates connection than will ordering lunch for the team to share before a meeting (quality time).

Since we tend to express care in the language that is most appreciated by and natural to us, many persons unintentionally botch attempts at extending care because they are speaking in the language that means something to them, rather than the intended recipient. Knowing this can a) help us potentially identify someone’s preferred caring style if we do not have their scores and b) help us see others’ attempts to express care to us in ways we might ordinarily miss.

The simple act of asking team members what helps them feel appreciated can mean the world to some teams. Following through on finding creative ways to match your support with their preferred language can mean even more.

When you ask, be prepared to hear about higher compensation and benefits, but remind them we’re speaking of the so-called intangibles of day to day interactions; the things leaders are more likely to be able to control without top leadership approval.

Certainly, advocate strongly for fair compensation, since a sense of fairness can also prevent dissatisfaction, burnout, and turnover, but we cannot forget the seemingly simple but incredibly important compensation we receive when we feel appreciated and valued in ways that extend beyond the paycheck.

Another intangible benefit workplaces can provide team members is the sense that their work is helping them to be better in other areas of their lives. For instance, in starting the conversation amongst your team members about their Love Languages, persons will not be able to help but immediately consider their significant others, children, and other family and friends and what their love languages may be.

One nurse said, “So when my husband mows the yard and expects me to be all impressed, it may be that his love language is acts of service and he assumes his doing that will mean something to me. It’s meant as an act of love, but I miss it because it’s not my language…OHHHHHhhhhhhh!!!!”

Often, they begin to try to figure out, or they even take the time to ask, what is most important to their kids or co-workers. As light bulbs go off and understanding increases, persons can feel more connected, in their personal and work families; they can ask for what is more likely to speak their language and find ways to give that to others, as well.

Imagine the conversations that can take place as we intentionally consider others’ love

languages and a attempt to match our efforts with their preferred styles. Secret holiday gift-giving in the office will never be the same!

Hopefully, the impact will be seen in employees having an increased sense of truly feeling valued, appreciated, and cared for at work.

For what it’s worth.

Carla

Rev. Carla Cheatham, MA, MDiv, PhD, TRT has served hospices as a chaplain and bereavement coordinator. She’s the Section Leader for the Spiritual Caregivers Section of the National Hospice and Palliative Care Organization and an adjunct professor at the Seminary of the Southwest and an Affiliate Associate Professor at the University of Maryland. Through her Carla Cheatham Consulting Group, Carla provides training and consulting for professional caregivers nationwide. She is the author of Hospice Whispers: Stories of Life and its companion volume, Sharing Our Stories: A Hospice Whispers Grief Support Workbook. Her next book, On Showing Up with Suffering: Others’ and Our Own, is set to publish in 2017.

Retaining Emotional Health in Professional Caregiving—Part IV: More About Symptoms and Risks

Posted by Carla Cheatham on Wednesday, April 26th, 2017 in Spiritual Care Integrity and Excellence, The Power of Presence

Retaining Emotional Health in Professional Caregiving

Part IV: More About Symptoms and Risks

This is an on-going series from my presentations on the use of ethical boundaries and resilience to maintain both healthy professionals and teams as well as prevent compassion fatigue and burnout.

Most of us, if we are honest, have experienced many of these over the course of our lives:

Feeling helpless

Feeling more / less sensitive to patients’ and families’ stories or emotions.

Being or feeling less accomplished and effective

Lowered self-esteem

Harsh or on-going blame and criticism of oneself or others

Attempts to control others or situations

Working more / less

Holding overly ambitious expectations of oneself or others

Persistent feelings of depression of hopelessness

Feeling out of balance

Misplaced anger, irritability, and/or frustration with oneself or others

Depression

Inability or decreased desire to engage in normally enjoyable activities

Chronic lateness

Sleeping more / less

Feeling exhausted even when getting adequate sleep

Gastrointestinal issues

Having an off day or week, getting overwhelmed when life gets all too life-y for a brief period of time, struggling during a full moon or when Mercury is retrograde are all natural responses to life. They are signals to pay attention, increase our self-care, maybe take a day off to re-charge and re-gain our perspective.

When those symptoms intrude on our ability to conduct our lives and/or persist over the course of weeks and months, it is also a natural part of being human, yet one that requires even more focused attention and care. Bad days pass in time. Burnout, compassion fatigue, depression, etc. will too, but usually need and deserve extra support in order to do so.

If this list feels too familiar or describes someone with whom you work or for whom you care, know that all is not lost. There are steps to take that can support us in preventing and even treating compassion fatigue when it does arise, as I’ll begin discussing in the next post. For now, let’s look a bit more at the risk factors involved.

In one study of hospice nurses by Abendroth & Flannery (2006) stress, trauma, anxiety, life demands, and excessive empathy were the key determinants of compassion fatigue (their composite multiple regression model was 91% predictive, P < .001).

A 2008 review by Sabo found similar results, as well as risks for vicarious trauma to include:

*individual characteristics—previous personal trauma, coping strategies, unrealistic self-expectations

*social and community context

*physical, organizational, structural and contextual work environment and

*work-related attitudes—i.e. the “need to fulfill all the needs of the clients”.

Regarding the risk factor of having experienced personal trauma, one young nursing student approached me, after a guest-lecture on the topic, in tears. She told me the 30-second version of her past and then, with a trembling lower lip asked a question stemming from her deepest fears, “Am I doomed to never be able to be a good nurse for patients and families because of all I’ve been through?!”

Her wise instructor smiled in understanding and placed a supportive arm around her shoulders and nodded in affirmation as I responded,

“Oh, honey, no! That’s not it. The fact that you’re asking yourself the question is a good indicator you’re aware enough to be mindful of it when your own stuff gets in the way. Besides, it’s like someone having a predisposition to diabetes—it doesn’t necessarily mean they’ll become diabetic; it just means they have to be a little more careful than the average bear.”

The most important thing for all of us is to be honest with ourselves and each other, to practice being self-aware, and to frequently check in and ask ourselves the right questions. None of us got into this field to be dangerous, so we must be on guard to protect ourselves and those whom we are called to serve in a way that sets none of us up to fail.

Being in intimate space with patients and families may also provide a greater risk for compassion fatigue, along with being a first responder or a sustained responder, experiencing compounded grief, working extended hours, working in intimate space and/or providing intimate care, as well as internalizing patients’ suffering according to a review by Boyle (2011).

As many of these variables are not controllable, but are the very nature of the work we may do, it is important to focus on those areas we are able to change, which will be the focus of most of this series. To place our energy anywhere else is to set ourselves up for losing battle.

As I wrote in the last post issues of work overload, values conflict, lack of reward, lack of fairness, lack of community, and lack of control have been demonstrated as being of particular importance in the development of burnout (Maslach, Schaufeli, & Leiter, 2001), with control being of particular importance.

Maintaining a focus on the variables we can control and caring well for ourselves in the face of the ones we cannot is the greatest piece of advice I could give in this series. When we bang ourselves up pushing against the tide, we serve no one well. When we waste our time blaming and complaining we become part of the problem and avoid spending the energy, instead, finding solutions.

We certainly need space to vent and grieve, and there is nothing wrong with naming what we believe to be unacceptable. We simply must keep such times in check so that we do not continually live there. Again, I’ll say much more about this dynamic in the posts to come.

For now, here is a great website from the Compassion Fatigue Awareness Project with tools for considering one’s own current state. With self-assessments you can take on-line or print, you can score yourself on 3 different measures—the Professional Quality of Life (ProQol) Self-Test, Compassion Fatigue Self-Test: An Assessment, and the Life Stress Self-Test.

As you consider your results, also consider finding safe and supportive colleagues with whom you can discuss your findings. Being vulnerable enough to admit when and where we are struggling is perhaps our greatest tool, since no healing can ever occur if we do not join the rest of the mere mortals on the planet in accepting that we are not, in fact, super human.

For what it’s worth.

Peace,

Carla

REFERENCES:

Abendroth, M. & Flannery, J. (2006). Predicting the Risk of Compassion Fatigue: A Study of Hospice Nurses. Journal of Hospice and Palliative Nursing, 8(6) pp. 346-356.

Boyle, DA (2011). “Countering Compassion Fatigue: A Requisite Nursing Agenda” The Online Journal of Issues in Nursing, Vol 16 (1).

Maslach, C.; Schaufeli, W. B.; Leiter, M. P. (2001). “Job burnout”. In S. T. Fiske, D. L.

Sabo, BM (2008). “Adverse psychosocial consequences: Compassion fatigue, burnout and vicarious traumatization: Are nurses who provide palliative and hematological cancer care vulnerable?” Indian Journal of Palliative Care, Vol 14:1 pp. 23-29.

Rev. Carla Cheatham, MA, MDiv, PhD, TRT has served hospices as a chaplain and bereavement coordinator. She’s the Section Leader for the Spiritual Caregivers Section of the National Hospice and Palliative Care Organization and an adjunct professor at the Seminary of the Southwest and an Affiliate Associate Professor at the University of Maryland. Through her Carla Cheatham Consulting Group, Carla provides training and consulting for professional caregivers nationwide. She is the author of Hospice Whispers: Stories of Life and its companion volume, Sharing Our Stories: A Hospice Whispers Grief Support Workbook. Her next book, On Showing Up with Suffering: Others’ and Our Own, is set to publish in 2017.

Retaining Emotional Health in Professional Caregiving Part III: Risks and Symptoms

Posted by Carla Cheatham on Tuesday, March 28th, 2017 in Spiritual Care Integrity and Excellence, The Power of Presence

Retaining Emotional Health in Professional Caregiving Part III: Risks and Symptoms

This is an on-going series from my presentations on the use of ethical boundaries and resilience to maintain both healthy professionals and teams as well as prevent compassion fatigue and burnout.

Each person will experience and manifest burnout and compassion fatigue in their own way. It is natural to feel irritable, exhausted, less or more sensitive here and there in the natural course of life. These can simply be a signal that we’re due for some time away and a greater infusion of self-care or that a situation in the workplace or with a client has gotten under our skin. In either case, it’s a cue to pay attention.

Often, simply being aware of what’s going on inside of us can be enough to ease the tension. At other times, after a particularly severe and/or long-term situation of strain on our compassion muscles or challenging workplace situation, we must take time repair and steps to heal, just as if a muscle has been overworked or injured.

Suggestions for prevention of and intervention during such times will come later in this series. For now, take note of the risks and symptoms for which to watch. As mentioned previously, there are various forms of burnout, vicarious trauma, etc. with their own distinguishing causes, risks, symptoms, and even diagnostic criteria.

For most of this series, I’ll be using compassion fatigue as the global term for what we can experience as professional caregivers, but I do want to take note of some of the unique risks for burnout and compassion fatigue since differing causes can require differing prevention and intervention techniques.

As mentioned in Part II of this series, burnout was once considered to be about people-oriented jobs, but over time came to be seen by researchers to be more about:

work overload values conflict

lack of reward lack of community

lack of fairness lack of control (with this one being of particular impact)

(Maslach, Schaufeli, & Leiter, 2001)

Compassion fatigue is more about care expenditure surpassing our care intake, to put it simply. When we’re caring for others and the balance between what goes out and what goes in is skewed, we don’t have enough left inside of us to give.

Sometimes, it arises from the gradual residue of caring for dying patients or grieving families, or persons suffering emotionally, mentally, and/or physically day by day and we don’t realize we aren’t taking sufficient time to offload that residue and care for ourselves. Other times, it can be an extreme case, or one that hits our own personal tweak buttons (I’ll talk about those later in the series) so that we feel it more extremely, that drains us in an acute way.

As we think about risks and symptoms, there are some distinctions that are important to consider between burnout and compassion fatigue, especially given the current state and culture of professional caregiving as having more stress and less support. Both can involve feelings of helplessness and control, conflict and frustration, emotional distress, decreased effectiveness on the job, etc.

With burnout, however, you may be more likely to see helplessness and frustration that is related to feeling put-upon, overworked, or otherwise misused in a workplace situation that seems unethical and/or unfair with inadequate compensation, recognition, connection, support, or options for making things better. The frustration here, then, is more about the dynamics of the business, leadership, and colleagues.

One may feel similarly frustrated, out of control, helpless, and as if things are unfair when a child is dying and nothing can be done to stop the progression of an illness, for instance. Here, the risk is more likely for compassion fatigue and moral distress rather than burnout, though they can arise simultaneously.

Burnout will likely involve more anger toward the workplace while compassion fatigue and moral distress may involve more existential angst with life and frustration or guilt about not being able to make things be different. With burnout, folks may be inclined to try less because of the helplessness and frustration with a system that just won’t seem to change. With compassion fatigue and moral distress, they may push harder to try to make things better for a patient.

I’ve often been asked to come into a team to help them with their compassion fatigue only to find out they are actually dealing with burnout. It’s not the patients and families with whom they work that’s pulling down morale, it’s the dynamics with colleagues and leadership and the system of their workplace.

Sometimes it’s both!

That is why, when leading trainings about burnout, compassion fatigue, and team morale, I speak about how to handle both the things we can change as well as take care of ourselves in the face of what we cannot. I’ll cover those in this series because it is a vital distinction that can either help us find freedom or drive us under even further into feeling victimized and helpless, which isn’t good territory for anyone!

These dynamics also exist for family caregivers, not just professionals. When caring for a loved one, if a person feels put upon and unfairly used or unsupported, they are more likely to suffer deleterious effects on their health. So they may feel compassion fatigue from day in and day out care, but also may experience caregiver burnout from lacking support, reward, lack of community and connection and so on. It’s a rather universal phenomenon.

I’ll discuss more about the risks and symptoms in the next post, bringing in some of the research that tells us about what seems the most likely predictors of our distress. There ARE things we can do to care well for ourselves, no matter what our situation or which combination of the above we are facing. We can prevent and intervene when we find ourselves in a not good place.

For now, please hang in there knowing that you are not weak, you are not crazy, and you are not alone. Your colleagues across the country in all forms of professional caregiving industries are facing similar circumstances, similar struggles, and similar feelings. You will find your way through this and, while you do, there is support available to take care of you for a change. We’ll pick up with more of it next week.

For what it’s worth.

Peace,

Carla

Rev. Carla Cheatham, MA, MDiv, PhD, TRT has served hospices as a chaplain and bereavement coordinator. She’s the Section Leader for the Spiritual Caregivers Section of the National Hospice and Palliative Care Organization and an adjunct professor at the Seminary of the Southwest. Through her Carla Cheatham Consulting Group, Carla provides training and consulting for professional caregivers nationwide. She is the author of Hospice Whispers: Stories of Life and its companion volume, Sharing Our Stories: A Hospice Whispers Grief Support Workbook. Her next book, On Showing Up with Suffering: Others’ and Our Own, is set to publish in 2017.

Retaining Emotional Health in Professional Caregiving Part II: History of Compassion Fatigue

Posted by Carla Cheatham on Tuesday, March 21st, 2017 in The Power of Presence

This is an on-going series from my presentations on the use of ethical boundaries and resilience to maintain both healthy professionals and teams as well as prevent compassion fatigue and burnout.

Professionals in caregiving fields are hungry for information to help them maintain a healthy balance in their work. Managers are desperate to know how to support functional teams. We’re all seeking solutions.

In 2013, the National Hospice and Palliative Care Organization’s Spiritual Caregiver Section performed a survey of SCCs and their managers from member agencies across the U.S. See the writeup on pp 16-27 in NHPCO’s January 2014 NewsLine.

Over 1,000 respondents chose their top 5 picks for continuing education. The second most requested was “Preventing and responding to compassion fatigue for hospice staff (and self)” (43% Total; 44% SCCs; 39% Managers).

While there may be no quick and easy fix to one of the primary hazards of professional caregiving, there are steps we can take to support ourselves, and each other, and prevent compassion fatigue. First, it’s helpful to know what it even is and a bit about the history of our understanding.

History of Our Growing Understanding

The term burnout was perhaps first heard in the 1960 Graham Green novel, A Burnt-Out Case. In the 1970s, clinical psychologist, Herbert Freudenberger, first discussed the phenomenon of burnout (Freudenberger, 1974).

Early researchers, Maslach and Jackson, postulated it arose from a 12-phase process that included excessive ambition, self-neglect, denial, withdrawal, depression and more until it resulted in full-on burnout. To assess for this, they developed the Maslach Burnout Inventory (Maslach, Jackson, & Leiter 1996).

It was once considered to be about “people jobs”, but over time research found it was more about work overload, values conflict, and a lack of reward, community, fairness, and control, with this last one being of particular impact (Maslach, Schaufeli, & Leiter, 2001).

According to Maslach, burnout involves exhaustion, cynicism, and inefficacy in our work. Feeling out of control of one’s situation only magnifies the impact we feel.

Related to Maslach’s findings about the impact of values conflict, Andrew Jameton explored “moral distress”, which arises when one knows the right action but is in some way constrained from taking it (Jameton, 1984).

Other terms arose during these years of early exploration, such as post-traumatic stress disorder and secondary traumatic stress disorder. Finally, Charles Figley introduced compassion fatigue (1995).

Compassion Fatigue as an Overarching Framework

There are distinguishing factors, clinically, amongst these various terms, but for the sake of brevity, I speak of each in the following general terms—burnout is about exhaustion and a feeling of disillusionment and helplessness, moral distress is about wanting to help but not being able to, compassion fatigue is about wanting to help but having inadequate energy left to do so, and the more vicarious traumas are about feeling the pain with patients and families.

With all of them we may see fatigue, depression, anger; feelings of ineffectiveness, apathy, and/or detachment; physiological symptoms such as headaches, insomnia, and gastrointestinal distress. Surprisingly, nurses appear to be amongst those most likely to miss physical symptoms as being a sign of their own stress.

Increasingly, compassion fatigue has become the generalized, overarching term seen in the literature to describe what it is so many of us can experience in various forms over the course of our lives and careers. For ease of discussion, I will also use this term rather globally throughout the series.

What is Compassion Fatigue?

According to one well-respected expert on compassion fatigue, it is:

“a progressive state of emotional unease. It evolves from compassion discomfort, to compassion stress, and finally to compassion fatigue, a state where the compassion energy that is expended by nurses surpasses their ability to recover from this energy expenditure, resulting in significant negative psychological and physical consequences.” (Boyle, 2011)

It is a deterioration in empathy and sensitivity to suffering that can arise at home and/or at work or it can even present as an over-reaction to suffering. In whichever extreme it manifests, it can lead to poor performance at work, anger and resentment over seemingly trivial matters, and a distrust of and struggles with the perceived system, such as management, leading to the suffering.

Most often, compassion fatigue is a gradual, progressive process that stems from exposure to on-going job strain which can lead to an erosion of idealism and a view that one is not achieving one’s professional achievements. Figley, another prominent expert on the topic, called it a “state of exhaustion and dysfunction biologically, psychologically, and socially—as a result of prolonged exposure to stress.” (1995, p. 253).

It can seem overwhelming and hopeless when one is feeling their compassion muscles have worn out or been dealt a blow or when we are working with others who are experiencing such fatigue. However, with an understanding of the factors that put us most at risk and the symptoms that alert us that compassion fatigue is present, we can prevent and intervene before the impact becomes long-lasting or detrimental.

In next week’s post, I’ll discuss the risks and symptoms and, as the series continues in the following weeks, lay out a way of being that can provide protection and healing for us all. For now, please be gentle with yourselves, and each other.

For what it’s worth.

Peace,

Carla

Boyle, DA (2011). “Countering Compassion Fatigue: A Requisite Nursing Agenda” The Online Journal of Issues in Nursing, Vol 16 (1).

Figley, C. (1995). Compassion Fatigue: Coping with Secondary Traumatic Stress in Those Who Treat the Traumatized, Brunner-Routledge, London.

Freudenberger, H. J. (1974). Staff burnout. Journal of Social Issues, 30(1), 159-165.

Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice-Hall.

Maslach, C., Jackson, S.E, & Leiter, M.P. MBI: The Maslach Burnout Inventory: Manual. Palo Alto: Consulting Psychologists Press, 1996.

Maslach, C.; Schaufeli, W. B.; Leiter, M. P. (2001). “Job burnout”. In S. T. Fiske, D. L.

Rev. Carla Cheatham, MA, MDiv, PhD, TRT has served hospices as a chaplain and bereavement coordinator. She’s the Section Leader for the Spiritual Caregivers Section of the National Hospice and Palliative Care Organization and an adjunct professor at the Seminary of the Southwest. Through her Carla Cheatham Consulting Group, Carla provides training and consulting for professional caregivers nationwide. She is the author of Hospice Whispers: Stories of Life and its companion volume, Sharing Our Stories: A Hospice Whispers Grief Support Workbook. Her next book, On Showing Up with Suffering: Others’ and Our Own, is set to publish in 2017.