Chapter 4: Results

Introduction

The purpose of this study was to determine the essence of resiliency to CF among nurses. It used paradigms from empathy, emotional contagion, resiliency, and CF theory. The primary research question was: What is the collective essence of healthcare professionals‘ experience of resiliency to compassion fatigue? The secondary questions were: Research question 2: What distinctions and similarities do healthcare professionals experience between burnout, CF, and vicarious trauma? And research question 3: What qualities and characteristics do health care professionals experience as supportive to being empathic and yet resilient to CF? This chapter presents the setting for the study, the demographics of the participants, the data collection process, and data analysis. I then discuss the verifiability and trustworthiness of the study. The remainder of the chapter presents results for each of the research questions, and additional information gathered in the interviews. The sequence of presentation follows the semi-structured interview questions, which are subquestions of the research questions (see Appendix E).

Setting

Data for this study was collected primarily at a teaching hospital in a northwestern city in the United States. Four other local hospitals were also represented: two participants worked at both the primary hospital and two other hospitals, and two worked solely at other hospitals (see Table 4 below). The interviews were conducted in places of the participants‘ choosing, and lasted an average of 47.5 minutes (see Table 5): Four

participants individually came to my home; two were interviewed in their offices; and one, the first participant, was interviewed by phone.

Personal or Organizational Conditions

The hospitals and departments represented by the participants did not place any organizational conditions on the interviews. The personal conditions which existed, however, need to be taken into account: I was taking opiates to combat severe pain, and I had low energy. If I had been in full health, it is possible deeper and richer material could have been elicited.

Demographics

Demographics were minimally of interest in this study. The participants‘ gender, age, ethnicity, and other biosocial characteristics were not relevant to this study, only their length of experience, and type of nursing placement. Characteristics Relevant to Study The seven participants were nurses with a range of from 25 to 40 years (M = 31.6) in nursing, working at least the past five years in their present departments. No gender-based differences were seen between the responses of the six women and the one man, who had retired the past year. Four of the nurses had worked primarily in Labor and Delivery. As this was the majority of participants, the study results should not be generalized beyond these participants. Their information, however, underscored how much that area of a hospital is at risk for the development of CF. Table 4 presents the code name for each participant, and the hospital area in which that person worked. H1 refers to the teaching hospital, the primary source of data

collection. One person worked primarily at this hospital, but also worked some of the week at a second hospital (H2). Another participant worked primarily at a third hospital (H3), and some of the week at the teaching hospital. Two participants did not work at the teaching hospital, but at two different hospitals (H4 and H5). Table 4

Demographics of Participants

__________________________________________________________________ Participant Gender Primary Secondary Area Years in Hospital Hospital Nursing __________________________________________________________________ L2 F H1 - Labor & Delivery 30 L3 F H3 H1 Labor & Delivery 35 L4 F H1 - Labor & Delivery 25 P5 M retired H5 Psychiatry 30 A6 F H1 - Admin 36 A7 F H1 H2 Oncology 25 O8 F H4 - Operating Room 40 Avg 31.6 __________________________________________________________________

Data Collection

Data was collected in several ways. The primary source was from semi-structured interviews, using the questions in Appendix E as a guideline. Seven nurses from various departments at several hospitals participated, as shown above in Table 4,. Additional data was collected through my observations and notes in a field journal, and through the participants‘ memberchecks of the transcribed interviews.

Locations and Durations

Table 5 presents the locations and durations of the interviews. Each participant had a single interview. Table 5 Location and Description of Interviews __________________________________________________________________ Participant Date of Location Duration Quality of Interview Interview __________________________________________________________________ L2 9/24/12 phone 40.25 medium* L3 10/11/12 my home 45.75 excellent L4 11/3/12 my home 51.25 excellent P5 11/23/12 my home 49.00 very good A6 12/7/12 P‘s office 55.33 excellent A7 11/20/12 P‘s worksite 48.00 excellent O8 12/8/12 my home 43.00 emotional; good

Avg 47.50 __________________________________________________________________ *The quality of the recording was not good. The interview was not as deep as the in person interviews, however the transcription was enhanced later by the participant during memberchecking.

Recording of Data

In every case the participants agreed to have their interviews audio recorded. In addition I took notes in my field journal. The first interview, conducted by phone, was recorded by putting the phone on speaker phone and recording by digital recorder. As indicated above in Figure 5, the quality of the recording was not good, and the depth of the responses and interaction were less than when the interview was conducted in person. The participant provided more information during the memberchecking phase of data collection. The six other interviews were audio recorded by placing a digital recorder on a surface between the participant and me. When these recordings were transcribed, the typist indicated where she could not decipher what was being said by placing brackets around what she thought may have been the words. During the membercheck phase, participants corrected these areas where necessary. Variations from Proposal The proposed study would have involved 9 to 12 participants in different types, levels, and areas of healthcare. Instead, only seven nurses were participants. The nursing research coordinator placed a limitation on participation of nine nurses, with no other

type of healthcare professional included. After interviewing the seventh nurse, I recognized I had reached data saturation, as I was not receiving significant new information. A second variation from the proposed study occurred in the transcription of the interviews. After struggling to transcribe the first interview, I realized I would not be able to capture accurately what had been said. A trusted friend is a professional transcriptionist. She signed a form assuring confidentiality and nondisclosure, and transcribed the seven interviews, plus an interview with one of the experts who had guided my research. She checked each transcription against the digital recording for verification. I also checked her transcriptions against the recordings.

Unusual Circumstances

The day before my first scheduled interview I fell on my back, leading to a concussion and spinal injury. My doctors were concerned that I would develop paralysis from the waist down, and told me I needed to avoid twisting, lifting, or bending. Under their orders, I was home-bound for two months. During that time I was on opiates, making it difficult to think clearly, or to imprint short term memory. Because of being home-bound, after the effects of the concussion were behind me, I made an appointment for a phone interview with the first participant. The quality of the digital recording was very poor, and the interaction did not have the depth it might have if the interview had been person to person. I discussed the situation with my chairman, and with the head of nursing research at the primary hospital. It was decided that if the participants wanted to come to my home as their choice of location, I could

proceed. Four of the participants did make this choice. The quality of their interviews was very good, and provided rich amounts of data.

Process

After the participants had checked their individual transcripts and returned them, I digitally transferred them into case nodes in NVivo10. As I listened again to the recordings, and reread the transcripts, I annotated them with my field note observations, and coded them into a hierarchical set of nodes based on the interview questions. The process of coding, writing memos and annotations was tracked in NVivo10. I also kept an audit trail of my process in my field journal as new themes emerged. Included in the responses was information outside of my research questions, but supportive to the answers: personal history, the pros and cons of nursing, changes in nursing, the role of spirituality in their lives, and other themes. Each of these themes became a free node. Because my own words in the interviews frequently represented my own biases, I coded them into an epoché file (summarized in Appendix H). After the initial coding into hierarchical nodes, I explored the nodes for word frequency, but did not find this useful for identifying themes. In reviewing the hierarchical coding of the interview transcripts, I realized I needed to refine the nodal distinctions. Where pertinent, I subdivided the nodes into child nodes (see Appendix I). Iteration of the reading and coding led to an identification of additional themes, and relationships between the themes. Rereading the transcripts, and using NVivo10 to add

notes to the coded material, I was able to distinguish subthemes, which I listed in various tables. In forming the tables, I was able to organize the results into meaningful units. The analysis process described above was repeated several times. At the same time I made notes relative to the structural description of the participants‘ experiences, following Moustakas‘s guidelines (1994), determining what were the conditions which existed underlying the participants‘ accounts. While rereading the transcripts I noted any differences between nursing departments, or between male and female nurses, but found nothing of significance. I also compared the individual transcripts for differences in language, using word analysis for positivity or negativity, presentation style, and emotion. While doing this, I followed van Manen‘s guidelines: (a) reflect on essential themes, the essence of the lived experience; (b) maintain a strong, oriented focus; and (c) balance the research context by considering both components and whole ([van Manen, 1990, pp. 30-34](/dissertation/references)). Each pass through the data gave me more insight and depth about how the participants experienced resiliency to CF, and what they considered supportive. After compiling the results from the transcripts which provided the phenomenon from the participants‘ point of view, I used imaginative variation as described by Moustakas (1994, pp. 97-98) to develop mental images of what might have happened beyong what the participants told me. The purpose of this was to develop structural descriptions, and precipitating factors which could have accounted for the participants‘ experiences. This was useful in creating a structural composite model of the phenomenon, and how resiliency interacted with the development of CF (see Figure 2).

Discrepant Cases

One of the seven participants was included specifically because, before her interview, she had indicated she was experiencing either burnout or CF. As might be expected, her interview used negative language, and was emotional. In the interview she said: [The operating room is] all I‘ve ever done. And it‘s a lot of changes now, and – basically I‘m burned out. I was burned out, which was why I went back to school, but I think now I‘m beyond burned out. There‘s just nothing about it that I want to do any more. I mean, I like when I‘m there, taking care of the patients, but all the other stuff that gets in the way . . . ([O8, December 8, 2012](/dissertation/references)) Most of her other information overlapped with what the rest of the participants had provided about resiliency and compassion fatigue. Her description of experiencing burnout provided an important contrast to the phenomenon of compassion fatigue: she still had compassion for her patients.

Evidence of Quality and Trustworthiness

Following the recommendations of Creswell (2007), the standards of trustworthiness and quality of the study are based on: (a) the depth of my understanding of the principles of phenomenology philosophically and in research; (b) the clarity of the phenomenon of CF resiliency, and the presentation of this in an articulate and concise manner; (c) the use of trustworthy process based on recognized phenomenologists, Moustakas and van Manen; (d) the presentation of the ―overall essence of the experience of the participants;‖ and (e) my reflexive attention throughout the study ([Creswll, 2007,

pp. 215-216](/dissertation/references)). The structural model of resiliency to CF (see Figure 2) is similar to resiliency in other areas, discussed in the literature review. The results and implications of this study are limited in transferability due to the small number of participants and range of medical departments represented. The structural description of the phenomenon and detail of process flow used in this study should strengthen the possibility of replicability with other populations experiencing CF. The validation strategies used for this study included: 1. Prolonged engagement and observation within the nurses‘ working environments. 2. Memberchecking. 3. Clarification of researcher bias by development of an epoché. Over the two years before this study, I observed nurses at work, and talked casually with them about the problem of CF. This led to the decisions shaping the study. During the study, I continued to observe and talk with nurses, confirming that CF was a definite problem, but that most nurses had built up a resiliency to it, after many years of work in their fields. After the interviews of this study were transcribed, the participants checked their individual transcripts, editing the information and descriptions given. This heightened the validity of the study. Before, during, and after the interviews I took field notes on my own reactions and biases, as well as on the situations of the interviews. This helped me prevent potential bias in leading the participants descriptive answers, as well as introducing bias in reporting their collective responses. Additional credibility occurred

due to the level of nursing represented in the sample: two of the participants were in administrative nursing positions; one was a nurse manager at a secondary hospital. During the study I maintained a balance between reflexivity and subjectivity, and was attentive to the integrity of the data. The interviews, with the exception of the phone interview, quickly established a trust between the participants and me, and the short centering at the beginning of each interview brought our minds more together and focused on the issues. The nurses represented diverse attitudes, experiences, and perspectives although only a view areas of nursing were represented – administration, psychology, labor and delivery, operating room, and oncology. I gathered data I found repeated concepts occurring in the interviews.

Results

The seven participants of this study told me highly evocative stories about their lives in nursing, their experience of CF, and their experience of resiliency to CF. Table 6 presents a summary of the number of participants addressing each of the questions in the interview guidelines (see Appendix E), and the total number of responses. Table 6 Participation Summary per Question and Subquestion __________________________________________________________________ Question # Participants #Responses __________________________________________________________________ Research question 1 7 136 1.1.a Own experience of empathy 5 8

1.1.b Empathy in others 5 8 1.2 Development of CF 4 13 1.3.a Experience of CF in self 7 31 1.3.b Observation of CF in others 6 29 1.4 Resiliency to CF 7 47 RQ 2 7 25 2.1 Comparison of CF to burnout, 7 21 secondary or vicarious trauma 2.2 How empathy relates to CF 3 4 RQ 3 7 73 3.1.a Empathic people who do not get CF 4 7 3.1.b Are you one of these? 2 3 3.2 What helped or hampered resiliency 7 44 3.3 Changes desired in support 5 19 __________________________________________________________________ As an aid in comprehension for both myself and the reader, I have reorganized the results to the interview guideline questions (IGQ) into the following categories: A. Experiences of empathy, CF, and burnout, with discrimination between CF, burnout and vicarious trauma IGQ 1: What is your experience of empathy personally and in coworkers in your workplace? IGQ 2: What happens when a person develops CF?

IGQ 3: What are your experiences or observations of compassion fatigue? IGQ 6: What is your experience of how empathy relates to developing CF? IGQ 5: How is your experience of observation CF different from burnout or vicarious trauma? B. Experiences of resiliency personally and in workplace IGQ 7: Have you experienced people who are empathic but do not develop CF? Are you one of these people? IGQ 4: What is your personal experience of resiliency to CF? IGQ 8: In the workplace, what helped or hindered resiliency to CF? C. Changes desired in the workplace to support resiliency to CF IGQ 9: What would you like to see change in giving support to nurses so they can retain compassion and empathy?

Experience of Resiliency to CF

Empathy in the workplace (1.1). In Figley‘s 2002 model, empathy was the starting point of compassion fatigue. The distinction between empathy and compassion is part of understanding the participant nurses‘ experience of resiliency to CF. Participants (P5, L2, A7) assumed that nurses came into healthcare practice because of their empathy: To me, empathy is to try to look at – listen to the person, try to understand them from where they‘re coming from, try to understand them in their world view and not put any judgment – from the way that I process, or of my world view. Try to put that aside. That‘s empathy.

I see compassion as active . . . Compassion is like not getting angry, not doing something – trying to do something that will help. Trying to not do something that will not help. ([P5, November 23, 2012](/dissertation/references)) Several nurses (A6, P5) discussed their own experience of empathy, and its role in compassion: I see empathy . . . when I try and understand where that person‘s coming from, from their perspective. . . A lot of times I don‘t know, so I have to ask questions. . . It‘s like, ―How are you feeling about that?‖ And, ―Tell me more about that?‖ . . . When you‘re not assuming how someone‘s feeling, and you‘re busy focusing on trying to actually learn it, you‘re not necessarily experiencing it yourself. You‘re truly understanding what that person‘s experiencing – if that makes sense? Not taking it on yourself. ([A6, December 7, 2012](/dissertation/references)) All participants provided examples of compassion within their work. One scenario occurred in labor and delivery: It was a woman who had traveled up from Montana because of some abnormalities with her baby. And the baby . . . would be taken directly to Children‘s. [The mother] had a C-section that afternoon. Anyway, they‘d had a call to say this baby wasn‘t going to make it, and it may not live an hour. So usually we would discharge the mother. There is no facility to take a mother to another hospital – but she‘s fresh C-section, had duramorph on board, which meant she had to be observed closely for 24 hours as she was at risk for a respiratory arrest.

There‘s no way we could [discharge her], but the charge nurse, the doctors – everybody in the facility said, ―We have to get this woman to her baby.‖ She had not held her baby. She hadn‘t seen her baby. This is not in the rules, it‘s not in the budget but we have to make it happen. So I was asked if I would go – because there were a couple of people that were a little nervous about that. So I said, ―Yeah, sure.‖ So did all the phone calls and pharmacy pulled out the stops to do what – an hour‘s work in ten minutes because AMR was on the way, and hand delivered some drugs to me, and I signed them out and so-on. So I went over, spent a couple hours. When we got there the baby was already being operated on and had a tamponade. They cracked its chest in NICU. So it lived for her to see. She got to spend about an hour and a half with the baby . . . They [Childrens] gave me a little waiting room that I reorganized [as an adult patient room]– all the furniture, the fish. The family on one side and her stretcher that AMR had left me. . . . It was interesting to spend time with that family – very close, very supportive family. And [the mother] got to spend some time –they all went in one by one and spent time with [the baby]. And I . . . got her back to [the primary hospital] at about two o‘clock in the morning, passed her over to an ante-partum nurse to look after. ([L3, October 11, 2012](/dissertation/references)) The nurse then went immediately to take care for another patient who had just been triaged in the emergency room, another case requiring a great deal of empathy and compassion.

In contrast to empathic healthcare professionals, one nurse described people who seemed to have little empathy: I‘ve definitely seen some people come into the field that . . . I wouldn‘t necessarily think of . . . as empathic people when they‘re in the [patient‘s] room . . . much more process [-oriented]. I‘ve had a number of co-workers that have come into nursing as a second career, and they‘ve started out in the business field. And to me that just seems – you have to have a different type of personality. . . I also know that they must be sharing something with their patients they‘re not sharing with us, because the patients that – when they would come in they would ask if that nurse was on, and wanted to have them caring for them, so – . ([A7, November 20, 2012](/dissertation/references)) L2 described a coworker who was very unkind to her patients: With no thought of how the teenage new mother would feel, the coworker went into the new mother‘s room and asked, ―Is your husband coming?‖ And of course, the patient was not married, and felt badly about that. I think this woman – I think she has a lot of pain in her life. You know, when you talk to her, she screams out about – it‘s almost like . . . she embodies pain that she hasn‘t dealt with. So for instance, she immigrated to the U.S. . . and she‘s been bitter about being here. She‘s married to somebody who‘s a researcher, and has kids and – You know, I just picked up the feeling that she feels like her husband doesn‘t attend to her needs, and she should have never come to the U.S. And her life has been wasted here, and now to go back – everything will be different. So

it‘s like she is unkind to her patients in the same way life or family has been unkind to her. She seems to live the unexamined life...and replicate her traumas on others. ([L2, September 24, 2012](/dissertation/references)) Another nurse described coworkers who seemed to have empathy, but were not able to pull away when they should have. L3 said she had seen people who had so much empathy they were crippled by it: ―It‘s sympathy [really], and it cripples them in their life‖ (L3, 10 November 2012). Healthy empathy. The participants‘ sense of healthy empathy coincided with mine: ―One of the definitions of empathy that I really like that it‘s an ability to see the other person‘s reality – and feel it – but also to know the difference between that person and yourself‖ ([personal communication with L4, 3 November 2012](/dissertation/references)). This was seconded by A7: ―You not only experience the other person‘s reality, but you realize it‘s the other person‘s reality.‖ In order to have healthy empathy, ―you have to be very reflective about your own life before you can have empathy for somebody else‖ ([personal communication with L2, 24 September 2012](/dissertation/references)). I think we all bring our experiences into that, though. I mean, if you‘ve personally lost a baby . . . it‘s harder to be healthily empathetic with someone. You know, . . . because my mom died ten years ago, . . . I‘m better able to help people understand what their mom‘s death means to them. I‘m never afraid to ask the questions because I know, really, people do want to talk about it. [It‘s just that] people are . . . afraid to ask them. So I do – and often we have good conversations

about that. But when I was so close to my own mom‘s death I couldn‘t separate– Talking with someone about it, I could just feel myself getting, just right down there in that [hard place]. ([A6, December 7, 2012](/dissertation/references)) Being empathetic is a good thing, she continued, even when it led to her own tears. The key part of showing emotion while in the presence of a patient is somehow to let the other person know ―you don‘t have to take care of me because I‘m crying‖ ([personal communication with A6, December 7, 2012](/dissertation/references)). It is a mix, and it‘s being able to be confident that you can go back and forth between being able to disassociate - that boundary is still there, intact. By distancing – I mean, integrating – it seems to me a tremendous boon. In other words, it‘s healthy empathy, as opposed to – it could be negative. ([L4, November 3, 2012](/dissertation/references)) How empathy relates to CF (2.2). Three participants (L2, L4, O8) described their perceptions of how empathy is part of compassion, and therefore part of CF, but not part of burnout, except that burnout can heighten the risk for CF: I think that in addition to having empathy and compassion for my patients, which I do, part of doing a really good job of taking care of them when they‘re in probably one of their most vulnerable states . . . A big part of that is also having empathy and compassion for co-workers and that gets harder for me, being burned out. ([O8, December 8, 2012](/dissertation/references)) Another participant discussed the relationship between empathy and CF by comparing the differences in empathy levels between homogenous and xenophobic communities:

Sometimes when we take care of everybody except for ourselves, we tend to be a little bit – I think we get lost in that community; we owe the community, or we do for the community. . . . It‘s much easier for a homogenous community, because everybody else is like us. If you put difference in the community, so some people are – whatever – striped, and some people are dotted, we‘re not going to like the people who are different than us. This is how ―Othering‖ occurs and when we ―Other‖ people, if we are fearful, we strike out at the ―Other‖ out of fear obviously, then not compassion. ([L2, September 24, 2012](/dissertation/references)) The participants, in general, believed nurses were empathic, and this was why the profession of nursing had such a risk for CF.

Experience of CF (1.3). Six of the seven participants had experienced CF at

some point in their careers. The participant who never had CF had avoided it early in her career by understanding which nursing areas would create problems for her: ―When I was deciding on what career to go in , I don‘t think I could have been effective when I had a three-year-old at home – working a pediatric unit with a three-year old. It‘s like, I knew better than that‖ ([A6, December 7, 2012](/dissertation/references)). She also ruled out nursing in a burn unit: Patients stay in the burn unit for – I honestly don‘t know. I haven‘t worked there. . . . It‘s so –you‘re causing pain to patients as you‘re caring for them. It‘s often a unit that people don’t go home from healthier than when they came in, necessarily. There‘s a lot of patients die there. It‘s not death that‘s the issue [for nurses]. It‘s the difficulty of causing pain. And that‘s just a unit where I don‘t think that I could be very effective in. ([A6, December 7, 2012](/dissertation/references))

Observations of CF. The participants provided rich descriptions of their observations of CF in others, summarized in Table 7. None believed that CF was gender- specific, but that it could occur more frequently in certain areas of nursing, and to specific types of personalities. The development of CF was outlined: The daily routine and stress leads gradually to exhaustion; the nurse will not admit anything is wrong; and the nurse disassociates from situations at work. Then a triggering event creates a problem (A6); the nurse is called before the board (A6, A7); the nurse may request a change of area, or leave nursing (A6, O8). Or worse. One nurse (who asked not to be identified, even by code) had considered jumping off a bridge. Her supervisor interceded, told her she was needed at work, and she simply had to toughen up. She complied, as best she could. Table 7 Observation of CF in Others ____________________________________________________________________ Characteristic Participants who mentioned this ____________________________________________________________________ CF is not gender-specific P5, A6, A7 Certain areas are at risk for CF L3, A6 Certain personalities are at risk L2, A6 Gradual depletion and increase of fatigue P5, A6 Lack of self-awareness regarding CF L4, A7 Disassociation from situations at work L2, A7

Emotions are completely frozen P5 Emotions are labile, feeling crazy L2, L3, L4, O8 Difficulty interacting with people at work, L4, O8 at home, and patients ____________________________________________________________________ Changes in what is expected of nurses, as well as new attitudes about nursing from the new generation, may effect risk of CF: I think that . . . just trying to stay human in a very dehumanizing environment – If I could say one thing about compassion fatigue, for me, it‘s just all the forces that are causing [nursing] to be less human, are causing a huge toll on nurses to still be the nurse they want to be, and give the care they want to give. ([L4, November 3, 2012](/dissertation/references)) Expectations which the nurses have may also effect risk of CF. The types of patients the nurse expected to work with may be different. For instance, coming into labor and delivery, one expects joy and celebration; one does not expect to face grief and loss: The reality in an academic medical center is not – I mean, we move most of our normal births up to [another] Hospital. So our nurses here really went into Labor and Delivery to help moms do normal deliveries. . . . Nine out of ten of their births are, the babies – 28 weeks and go into the Neo-natal Intensive Care Unit or, ―We‘re so sorry but we – you have a choice about terminating your pregnancy, and how are we going to work that through with you?‖ or, you know, that‘s the kinds of things that they‘re working with. And, yes, it‘s a very different – So

that‘s another thing I think about compassion fatigue is – depending upon what your expectations are, when you‘re not doing something you expected to be doing, or your family isn‘t [the kind you expected to be working with]. It‘s more a unit by unit situation. And compassion fatigue, as you know, isn‘t just about people dying. ... I think any loss is – You can go through all the same things Kubler-Ross tells you all about: denial, grief, and all that stuff. So it‘s – the areas that I work in are rehab – those patients aren‘t dying but they are suddenly having an incredible change in their state. They‘re paralyzed, they‘re – even what you yourself [referring to the interviewer] have gone through. . . I see nurses totally lose themselves in their patients when they work on the rehab units. Psych, the same way. And the – well, just having a baby who now has Down‘s Syndrome, or now has – is going to have learning disability because they were born 27 weeks premature and lost their eyesight, with retina [hard to hear] premature – any of those kinds of losses. Or – even just loss of what your expectations were, for what they care about and love. Yes, so I think that those are all other ways that – And when people are tired, themselves, I think that they‘re – I think having that balance. I see most of it in night nurses. ([A6, December 7, 2012](/dissertation/references)) Participants commented about certain personality types who seemed more at risk for developing CF. People who were unable to view themselves realistically were described:

One of my co-workers was – she would come into work and it was almost not pleasant to be around her. And she – and most of it was not because she was being catty, or being negative. It was more just that – again, you‘d just look at her and feel like she was just at the bottom of barrel. You would talk to her and, ―No, no, no. I‘m fine. I‘m fine.‖ . . . People who invest all of their time in their job and in their patients, and go home at the end of the day and don‘t have anything to take their focus off of that – are probably more the problematic people. ([A7, November 20, 2012](/dissertation/references)) People who frequently blur boundaries were another group at risk: I don‘t think they realized they‘re not being the kind of nurse they should be. . . . The person who has trouble keeping and maintaining their own boundaries has difficulty in not getting compassion. It doesn‘t have anything to do with resiliency. It‘s a question of setting up what they consider a screen so they won‘t get compassion fatigue, but it‘s really artificial. There‘s really not a heck of a lot they can do except change the way they attach to people. ([L2, September 24, 2012](/dissertation/references)) The risk for CF increased for people having problems and trauma elsewhere in the nurses‘ lives: And these single moms – if they have a lot of trauma in their lives already, it‘s difficult for them to even notice they‘re having problems, and then find anybody else to help them or get what they need. . . . So then they bring it to work, and then they want to find it either in the patient, which is not great, the family or their

co-workers, or all of the above. So that‘s the enmeshment. I see more of that [at another hospital] because it‘s a little community, and everybody knows everybody. It‘s a lot different than town where you sort of get along and move on. You know, you need to – if you can‘t cut it you‘re out the door, basically. There‘s not a lot of – It‘s not that we don‘t care for each other, but it‘s much more – You‘ve got to be on top of your game. We say, ―Hi. How are you doing?‖ and we really are moving on. We‘re not stopping to find out for sure. ([L4, November 3, 2012](/dissertation/references))

Development of CF (1.2): Daily exposure ―to loss – loss of expectations, loss of

life and limb, whatever‖ contributes to the development of compassion fatigue ([A6, December 7, 2012](/dissertation/references)). Compassion fatigue comes from ―having to face situations in which compassion is required, as a professional, every day, hour after hour, minute after minute, every single day. And after so much time, you‘re going to become fatigued‖ (P5, 23 November 2012). Situations rise which demand compassion, not judgment, and can cause mental conflict between the rules, ethics, and humane action: I think it‘s getting to the heart of what that patient‘s asking and needing you for, and it may have nothing to do with why they‘re there. It may have everything to do with who they are and how they got to where – how they got that way. This woman, she just wanted her darn arm-board released so she could get her baby up and kiss him. And nobody would help her, and she was beside herself.

She was so primal at that point, and I just said, ―It doesn‘t matter if you might hemorrhage – because your placenta‘s still in. It doesn‘t matter that you‘ve been incontinent all over the bed. It doesn‘t matter that we need to go to the OR and help get this placenta out. It matters to you that you kiss your baby, so we‘re going to take the arm-board off.‖ And that nurse was so traumatized by the whole scene that was presented in the hallway that . . . she just couldn‘t do anything. And at that point she needed to be removed from the care because she wasn‘t helping at all. ([L4, November 3, 2012](/dissertation/references)) The high risk areas of nursing, such as psychiatry, can be ―a pressure cooker situation . . . and sometimes [staff] don‘t really handle the pressure well, . . . they start fighting with each other . . . rather than trying to deal with what‘s going on here‖ ([P5, November 23, 2012](/dissertation/references)). Negative interactions among the staff can increase the stress of nursing (P5, O8). If a nurse decided to be in direct service work, but the pressure from other staff on the team became too high: [Many] would leave the field . . . or take administrative jobs . . . or secretarial stuff. . . .People don‘t like to admit that they‘re compassion-fatigued, or whatever they choose to call it. It‘s not an easy thing for people to admit . . . or accept. . . .In medicine generally there‘s always the, like, ̳Let‘s get it done‘ – right?‖ ([R 5, November 23, 2012](/dissertation/references)) The development of CF is gradual until a triggering event occurs:

. . . Like give an overdose of a drug, or whatever . . . that‘s often when they make that decision, . . . ―I just can‘t go on like this.‖ . . . [The] triggering event . . . could be something personal. . . . But when you have an event that just stops you in your tracks and suddenly you‘re before the nursing board because you‘ve administered the incorrect dose of a drug or someone has died because of it, or you had the wrong instruments and something happened – any of those things that can happen to people, especially when they‘re tired, that‘s more of where I see it. We talk about crashing, but you know, you don‘t crash. . . . I think fatigue builds and you don‘t even realize [it]. . . . [You think] you build up resistance to it and you can deal with more and more of it. ([A6, December 7, 2012](/dissertation/references)) Personal experience of CF (1.3). The poignant description by six of the seven participants who had experienced CF personally (L2, L3, L4, P5, A7, O8) emphasized the enormity of developing CF. A6, who never developed CF, thought she had narrowly avoided it during her first year of nursing. Some nurses who had also experienced burnout (P5, A7, O8), made a distinction between how CF and burnout felt. The symptoms of CF which have been catalogued in the literature were also presented by individual participants in this study, as seen in Table 8. Many of the characteristics presented in their observations of others were echoes of their own experiences.

Table 8 Personal Experience of CF _______________________________________________________________________ Characteristic Participants who mentioned this _______________________________________________________________________ Physical: Exhaustion physically and mentally L4, P5, A7 Burned out, in addition to CF A7, O8 Behavior: Being inattentive O8 No longer being humane L4, P5, O8 Showing artificial compassion L2 Emotion: Boredom with work P5 Desire to pull away from dealing with people P5, A7, O8 Raw emotion and frequent crying L2, L3, L4 Depression and numbness P5 Self-judgment: Feeling stigmatized by admitting weakness P5 Having difficulty admitting the condition of CF P5, A7 Feeling incompetent in providing care L2, L3, O8 Feeling of failure O8

Feeling trapped P5 Wanting to quit L2, L3, L4, P5, O8 _______________________________________________________________________ ―To me compassion fatigue is a point where it becomes cumbersome to be empathic, and you start feeling yourself pull away. . . . You just can‘t make those connections anymore‖ ([A7, November 20, 2012](/dissertation/references)). The physical aspects of CF presented were: feeling dragged out, impossibly exhausted, and unable to cope with the physical requirements of the job. No one mentioned lowered immune systems, although the literature suggested this was a characteristic of CF. Differences between CF, burnout, and vicarious trauma (2.1). Several participants used the terms, burnout and CF, interchangeably at the beginning of the interviews, but then gradually made distinctions. For example, O8, who identified herself as having burnout, then later as having CF, said, ―I think with burnout, that when I would have a break or a vacation, that would renew me and refresh me. And now nothing does.‖ ―And that‘s why you say you think you have compassion fatigue, because it‘s a continual –?‖ ―Continual. I don‘t want to go to work. And I‘ve just had 12 weeks off and I thought going back would be okay. And I‘ve been there two weeks and I‘m –,‖ she sobbed. Only one participant, L4, knew the term, vicarious trauma: ―Yes, I‘ve seen that. . . . It‘s more common [in the northwest island community hospital]. It‘s more visible.‖ At the primary hospital ―they put the mask on a little more.‖ She did not, however, draw any

distinctions between CF and vicarious trauma. Another participant said she tried not to put labels on anything like burnout, CF, or vicarious trauma. Several participants presented a clear separation between burnout and CF: I think burnout can be boredom, it can be . . . many different factors, right. You just – you‘re running all the time. You‘re exhausted. You‘ve worked ten days in a row. I mean, you‘re just feeling numb. And then you shut down and you‘re unable to – So I think of burnout more that way. Where as compassion fatigue is truly much more on a relationship level, and personal energy, that you just feel like you don‘t have – You see people put a lot of energy, but I still think they‘re carrying CF. They‘re still [making the motions] . . . . And they sometimes feel like they cannot – Well, again, I‘ll use what is most familiar to me – the Labor and Delivery or the NICU is, you just – You can‘t take care of one more baby that‘s going to die on that shift. You know? It‘s not that you‘re not coming to work. (A6) A7 had experienced both burnout and CF, and made a clear separation between the conditions, as well as where they overlap. From her point of view, burnout was more serious than CF, and required a complete change. The similarity between CF and burnout was the need to draw away from work and personal connections. As with others I interviewed, the period where she experienced either burnout or CF was about a year and a half after she began nursing in oncology, in a step-down bone marrow transplant oncology unit.

To me the compassion fatigue is, if you identify it – If you‘ve identified that you‘re getting to that point, it‘s – the compassion fatigue is when you feel yourself starting to draw away. You‘re not getting the reward in your work anymore. You‘re getting – it‘s fatiguing to be there, and you‘re feeling like you‘re just having – You‘re getting up in the morning and starting to go through the motions, but you‘re recognizing that that‘s happening. As opposed to many times – The one time I‘ve been burned out – has really been where I just – I don‘t even recognize that I‘m there. I‘m really kind of – I‘m going to work, I‘m going through all the motions but, you know, my co-workers are noting that I‘m not involved any more, and that I‘m just kind of there. So they could be just different ends of the same spectrum, but it‘s – the compassion fatigue piece I have seen more as, I have an ability to maybe draw myself out of it. Whereas once you hit that burnout you‘re kind of – you need to make a change. And that‘s actually what I did when I hit that stage. I went and traveled for five months and worked on a surgical unit to see if I maybe should be working in a different field. (A7) L2 said, ―I think of burnout as little bit more . . . political. It‘s like being tired of having – I‘m tired of not being able to effect any change efficiently, or having very little authority to effect change. Burnout is like dealing with the system. . . . You know, I have a lot of responsibility but very little authority to change anything. Whereas, I think compassion fatigue is like, you just get tired of caring, or taking of people.‖ L4 considered burnout to be ―when you‘re so desperate, it‘s almost too late at that point.‖ CF, on the other hand, was ―all the forces that are causing [a person] to be less

human, [and] causing a huge toll on nurses to still be the nurse [sic] they want to be, and give the care they want to give.‖ Empathic people who do not develop CF (3.1). A6 discussed the reasons behind the many people she knew who were empathic, yet did not develop CF: ―A couple of them, probably including myself, have a very strong spiritual foundation, or background.‖ Having a strong family background, and following ―your heart‖ you‘re your choice of professional area were two other reasons she gave. A7 also knew people who did not develop CF, although they were empathic: I could generalize and say maybe they‘re people who come in and do their job, and then go home. And it‘s not like they‘re not empathic, but they are people who are able to – There are people that are able to turn off work when they go home, and whether it be from the time that they walk out the door, or from the time they walk in the door at home -- I asked where these people learned how to make this separation, and A7 responded: I don‘t know. I guess – One of my co-workers was talking about a book she was reading . . . just recently that was talking about differences between men and women. And her – what she was relating – and it was how women become successful in a male-dominated field. And they said some of the characteristics of women who were in top CEO positions in business areas are very similar to men in that they don‘t have – They have work relationships with their co-workers, and they go home and they have their family life. And when they are at work they

don‘t talk about home, and when they‘re at home they don‘t talk about work. [laughs] And it actually amused me because I had gone home and had a conversation with my husband about something that had happened at work, and he looked at me like, ―What the heck?‖ And I realized that I can tell when he‘s having a bad time at work, but he never talks about it when he comes home. And it‘s the exact – I think there‘s something that is just in us that allows us to turn off those switches. The comparison between generations, those in the ―sandwich‖ generation who are part of ―an aging work force . . . [who] are struggling. And they‘re just physically having a harder time, and just getting tired of the twelve-hour shifts, and taking care of [patients] that have way more complex issues‖ (L4), in contrast to a new generation of nurses who who seem to have a less compassionate demeanor at work. Five of the participants (L4, P5, A6, A7, and O8) spoke about this new generation. ―They know it‘s going to be a good wage,‖ said O8. ―It‘s going to be something they can do, not because they really wanted to take care of patients. So they‘re missing that caring or compassionate part.‖ Only one (A6) of the participants identified herself as an empathic nurse who had not developed CF. Experience of resiliency to CF. The participants discussed resiliency in general, as well as resiliency to CF. Table 9 presents a summary of attitudes, behaviors, and self- judgments considered important to resiliency. Aspects at work which reinforce or hinder compassionate care and resiliency are summarized in Table 10.

Characteristics which supported resiliency. Self-awareness, or mindfulness, was considered a key component of resiliency. This self-awareness, however, needed to be realistic and healthy, with the ability to separate self from other when necessary, and balance care of other with self-care. Being aware of the choice involved in attitudes and decisions was stressed. Table 9 Characteristics supporting resiliency __________________________________________________________________ Characteristic Participants __________________________________________________________________ Attitude: Love your work, find joy in it L4, A6, A7 Know how to live a meaningful life P5 Learn how to cope with own pain L2, L3 Change point of view regarding perfectionism L3, A7 Prioritize and place values on actions; identify what you L2, L3, L4, A7 cannot change, and what you can Be persistent in getting through stress L2, A7 Be accountable A7 Keep a sense of control of making choices; carry resignation L4 letter with you Self-judgment:

Self-monitor; integrate conscious and unconscious L4, P5 Recognize separation of ego and other A7 Transfer feelings of worth to abstract; not get emotionally L4, P5, A6, A7 attached to patients Do not seek strokes from patients L4 Behavior: Use physical exercise as a way to cope with stress L4 Do something else, or focus elsewhere A7 Balance self-care with care of others; balance time L2, O8 Meditate P5, O8 Touch into spiritual energy L2, L4, O8 Learn from more experienced colleagues P5 Find your niche at work P5 Try to separate work stress and personal life L3 Find support for work stress in personal life L4 Develop a strong support group L4 Get therapy L4 Limit exposure to stressful situations L4 __________________________________________________________________ Development of resiliency in early life. Familial support early in one‘s life, as well as in the present, was an important part of the development of a resilient nature, according to one participant:

So I don‘t know if it‘s necessarily a personality thing as much as it is maybe an accountability. And that could go back to the familial support or – Is it the familial support or is it the teaching of morality and ethics, and the understanding of – I am accountable for my own actions. (L4) A traumatic upbringing can also help a person develop resiliency, although this possibility may have something to do with genetics. In response to my asking why some people do not get CF, L4 said: I think a lot has to do with genetics, and your upbringing, and what you bring to the field of nursing. . . . I just have had so much exposure to so many things like this. And I was raised in a kind of traumatic family myself. We had ten kids and an alcoholic father, and that tells you a lot right there. And I think of all the ten kids, I was seen as more able to hang on, to be there for everybody, not to enable or enmesh but just to kind of survive it, but help them get through. . . .I tried not to take that on, but I‘m still the organixer – kind of the same role I do in my jobs. (L4) A combination of persistence, spiritual energy, and knowledge of effective coping strategies for dealing with one‘s own pain strengthened one participant‘s resiliency: You have to be very, very persistent. You have to know what your values are, if you‘re going to be resilient. You know, this is odd but – for me, one of the things that happened is having a spiritual experience as a child and knowing there‘s a spirit greater than myself. And that experience, although I knew it would never mean anything to anybody else and probably nobody would believe me, that got

me through some very difficult situations and I always, always knew that there was something greater than I. I don‘t subscribe to any religion, but . . . that experience was more real to me than my own hand! (L2) Cultural support can be another factor in resiliency, not only in support of spirituality, but through a focus on community rather than an individual. Families stay together, and [there‘s] a lot of socialization and community, and the kids all know [each other and the adults], . . . and everybody‘s just there together. . . . People have fulfilling lives. They feel supported. They feel like people know who they are personally. They‘re not using their work or their relationship with their patients to have [who they are] expressed.(A6). Attitude. Mindfulness, being self-aware, and knowledge of how to live a meaningful life were traits most of the participants (with the exception of O8) thought important. Loving your work, or at least finding joy in it, was part of the equation, one that could be strengthened over time: Who knows, maybe I‘ve gotten better at avoiding compassion fatigue because I‘m putting less of myself out there, because I‘ve found a different way of rewarding myself. You know, maybe I don‘t need that relationship with my patient any more. Maybe I just need to know that I did my job well. And is that something that‘s grown over the years? Absolutely. . . . But I think that might be identifying what is valuable for you in your job, and then taking pride in that. . . . Maybe this is a characteristic of resiliency, of being able to recognize – and being able to

separate yourself from how you do it. What is a job well done? And that it‘s not about you. (A7) The joy of knowing you have done the best you can cannot be present without changing your criteria for being perfect, and placing your values carefully (A7). Identifying what can be changed within a situation, and what cannot, reinforces a sense of control, a necessary part of resiliency (L3, L4, A7): If I go to work intending to do everything I can, I should be able to do basic safe care for somebody. I can‘t change anybody‘s life, you know, and I‘m there for that particular shift. I can let that go. But when I know that people aren‘t getting safe care, I can‘t turn around. So I actually – in that case I did channel [that attention] into something else. (L3) One participant said she was able to maintain a sense of control by keeping a letter of resignation in her pocket. (L4) Another suggested using the serenity prayer: The stuff that comes out of work that makes us want to give up – It‘s not worth our attention. . . . God grant me the serenity to know the things that I cannot change. That‘s not worth your attention. Just keep going on. Don‘t let it hurt you, you know? [We have to figure out ways to cope] with our own pain so that we don‘t replicate it in our patients. ([L2, September 24, 2012](/dissertation/references)) Self-judgment. Self-awareness, as in mindfulness, helped six of the seven participants in strengthening the separation of self and other, and in not seeking positive strokes from patients. Part of training in nursing is learning not to get emotionally attached to patients, yet be able to be compassionate (L4, P5, A6, A7). Self-monitoring is

a skill which can be taught, and was helpful after people had developed CF to avoid developing it again (L4, P5). This integration of the conscious and unconscious senses of where your body, mind, and spirit are was part of resiliency not only to CF, but to all stress in one‘s life. If you can be more conscious . . . you can actually be more compassionate. . . . The main focus of my meditation would be to let stuff waft up from my unconscious – because I know whatever I‘m thinking about, it‘s being worked on even though I‘m not conscious of it, in my mind. So I try to let these things waft up and say, ―Oh, wow! I really think that, huh?‖ [Laughter.] But at least, then, you know it. Then you can do something about it. (P5) Placing judgments of self-worth on something more abstract also helped be resilient, rather than seeking positive reactions from people in the workplace: Mostly, I found for me it was like, taking the time to quiet my mind, to meditate, to re-affirm the task I chose to do, and to stay . . . positive about it, find value where I could. And then I realized that – really, what‘s happening here is that maybe what‘s so – maybe what‘s really important is not how a person reacts to me but how I react to the person. So I started looking at it that way for several years. (P5) Behavior. Being self-aware of behaviors is another way to strengthen resiliency. Catching yourself paying more attention to something or someone in distress, and then refocusing is a cognitive behavior which helped all the participants. This could occur

during meditation (P5, O8), touching into spiritual energy (L2, L4, O8), or simply doing something else, if possible: When it happened again, I could feel myself dragging as I was coming into work. It‘s like, ―Okay, I need some time off. I need to find a way to refocus.‖ Normally what I‘ve done – I‘ve had probably about eight different roles or job types in nursing since I started, and I usually at that point in time get involved in something else, so it takes me outside of my job. And most of the time it‘s fairly – it‘s professional involvement. But at one point in time I got more involved in our local oncology nursing society chapter, and started working on education. At another point, ―Oh, I want some more education – I‘m going to go back to school.‖ Or, I got more involved in our national chapter. Or, I also volunteered for Campfire and I started teaching CPR classes for them. So it was giving me some sort of ability to utilize my professional skills without having to pour more into work, so it then made a – I think what I was finding was that I was trying to get something else from work that I wasn‘t able to get at that point in time so I had to go find it somewhere else. And by separating things, then I was able to just say, ―Okay, I‘ll figure out where to go and can kind of rest through it.‖ Balancing time spent giving care to others and giving care to one‘s self was a critical part of resiliency (L2, A7, O8). Outside of work, using physical exercise or getting out into the natural world was very helpful in coping with stress: That‘s how I cope – through physical outlets. . . . And fatigue – just from tiredness, from shifts, even – You know, doing the night shift, too. If you wake up

and have to think, oh my God, I‘m going to have to work tonight, and how am I going to cope? Instead of getting up and going out and actually walking around Green Lake – and the endorphins will keep you going. You know, because you‘ve done something for yourself, in the sunlight. And then there‘s all the sad stuff and everything else. You can go on. (L3) Limiting exposure to stressful situations was another behavior adopted by a participant (L4). Another participant decided, in order to cope with too much stress in the overall workplace, it was important to find a niche: For me, when after I got burnt out, my niche was to work on the night shift for several years, because it was less – you know, there was less pressure from administration and from protocol and all that – and politics. . . . Just as much pressure from the patients, yes – but less administration around. (P5) Developing a personal support group was another behavior suggested. This might include a therapist, but should definitely include friends and family (L4). The separation of stress in personal life from the stress in the workplace could be another way to strengthen resiliency (L3). Workplace factors. In the vivid descriptions of the nursing workplace which all of the participants provided, positive factors reinforced resiliency to CF, while negative factors lowered it, as seen in Table 10. Finding joy in the work of nursing was one of the positives mentioned (L4, A6, A7), but sometimes, when interactions with colleagues in that area were negative, this was not sufficient reason to stay in that particular area of nursing (O8).

Working at a highly rated hospital where research and teaching are cutting-edge may have both positive and negative results for nurses. The expansion of knowledge and breadth of experience strengthen one‘s resolve to stay and find a resiliency which helps get through the stressful situations. The negative side of this, however, can be an emphasis on process, rather than on compassion (L3, O8). In general, in-service training as well, as learning from others‘ experience, have helped support resiliency: We actually did have several courses . . . [but] that was a long time ago, . . . much closer to when I entered nursing – in how do you set boundaries, how do you care for people, how do you care for yourself while you‘re doing that. And recognize when you‘re getting into trouble with [boundary setting]. (A6) Table 10 Elements in Workplace Influencing Resiliency to CF ________________________________________________________________________ Positive Negative ________________________________________________________________________ Learning from more experienced: mentoring (P5) support from manager (O8) Overwork (L3, L4, O8): No time for interaction with colleagues Emphasis on use of time: ―doing people rather than being‖ (L3) Training in communication skills between Bad communication between nurses,

nurses, managers, and doctors (L3) managers, and doctors (L3) Training on interaction with patients (A6) Nonsupported situations (A6, A7) In-service training about loss and CF (L3, A7) Barrage of losses (A7) Discharge or death of patients Interaction with colleagues (A7, P5): Supportive advice from colleagues (L4) Interaction with colleagues (A7, O8): Codependency (A7) Erratic knowledge base (L3) Professional practice group (L3) Lack of debriefing after difficult situation or death (O8) Support group for loss and high risk situations (P5, A6) Nonhelpful support group (P5) Support from patient‘s family (P5) Interference from patient‘s family (L3, A6) Being able to leave personal stress at home and focus on others (A6) Personal stress compounded by daily exposure work stress (A6) Breadth of personal experience (A7): Seeing life trajectory Not having a good fit with nursing area (O8) New generation of nurses: Healthier boundaries (A6) New generation of nurses: Lack of accountability (A7) Night shift: Less interruption from families and Night shift: Less support available (A6)

administrators (A6) Dangerous patients (P5) Moral distress (L2, O8): Unaddressed ethical questions (A7) Unreported punitive behavior (L2) Having to give hurtful treatment (A7) Having to treat against patient‘s wish (L4) ________________________________________________________________________ Training in communication skills and interactions between colleagues, managers, and doctors can help strengthen self-confidence and self-care: It‘s down to communication skills. . . . [When] I was a manager for many years, . . . one of the things that I found – when nurses were crashing and burning, when they were having trouble on a unit, or whatever – I think everything comes back to communication skills. . . . [It‘s about] learning to have hard conversations [with] a doctor who‘s just learning his role [and] boundaries [and] how to work with nurses when he perceives he is in charge. . . . It‘s not judgmental coming from you. It‘s because yo‘re the person who‘s at that bedside, and you‘re there reading that patient for 12 hours, and he‘s there 10 minutes an hour, if that. So it‘s about collaboration, as well. (L3) Although training in communications from a book, such as Patricia Benner‘s ―From Novice to Expert‖ was helpful to one participant (L3), she added, ―They‘ll do theory, but

you don‘t learn to communicate well from reading a book. It has to be done by interaction.‖ Training on interaction with patients and their families was considered very helpful in supporting compassionate care, according to A6. Interaction with colleagues at work can be either a positive support or a negative drain. Getting supportive advice from colleagues (L4), as well as simple, casual interchanges helped the participants as a whole: I had a couple of really good friends that I worked with. And . . . the three of us got a lot of grief from some of our coworkers because we spent time together outside of work. So one of my friends was my twelve-hour partner, so she did the day-shift part of my shift, and then another one was somebody that used to work nights with me and then she went on to work days. But the three of us used to bike on our days off. We had similar schedules. (A7) The interchange between these colleagues helped them monitor each other, as well as give support to each other when needed. ―We always love to talk with each other. . . . It makes me yearn for more. It‘s like something quicksilver. . . . You get to the point where you‘re just starting to connect and then . . . somebody‘s pager beeps‖ (L4). In-service training in coping with grief, any type of loss, and CF, when available, was very helpful in strengthening resiliency (L3, A6, A7). In one course offered on CF, the instructor presented a graph of: Here you are, and then here‘s when you start dropping, and you start pulling yourself away. And then here‘s where we‘re at the bottom. . . . You need to make sure that your life is [at least] half full. And . . . if you dip below that half-full, it‘s

going to be a lot harder to fill it up. So taking the time when you‘re starting to dip, to fill up and pull yourself away a little bit. And how do people recognize that it is okay to pull away, it‘s okay to distance yourself? . . . A lot of people think . . . that you‘re not a good nurse unless you‘re a hundred percent invested all the time. And you can‘t be a hundred percent invested in your patient all the time, because you have to keep yourself separate. I think that‘s an important piece for people to understand. (A7) Having a support group which addressed loss and high risk situations while at work provided useful interaction and information (L3, A7). There were, however, difficulties in making this available to all who needed or wanted it (A7). Professional practice groups have also been supportive (L3). In addition to being able to receive support from one‘s nursing manager was not usual, but when available was extremely valuable (O8). In some cases support was provided by a mentor, a more experienced person in the nursing area (P5). Another group who could provided valuable support to a stressed nurse was the patient‘s family: The family would often bring the person in [to the psychiatric unit or emergency department]. So we did a lot of short-term work with families. . . . That helped. When you really get something back, you know? When you really get that – whatever that magic thing is between people – when you get it back, yes that alleviates – so that it takes away some of the fatigue for a little bit. But then the next person comes in. (P5)

Some nurses found working on the night shift helped them cope with the stress, due to less interruption from families and management (A6). At the same time, though, other nurses working the night shift found it a very negative situation, as there was less physical and moral support available, and could lead to tremendous fatigue when attempting to be a mother and wife, or take care of personal life stress during the day (A6). As expected, one of the worst inhibitors of resiliency was feeling overworked, without time to breathe, interact as a humane, compassionate person with patients or colleagues, or de-stress (L3, L4, P5, O8). The whole point . . . is to find out from the patient what‘s really most important to them, and connect with them to make them feel cared for. That‘s quality. . . . But it takes a toll in this environment where you barely have time to tie your shoes or go to the bathroom, far less sit down. It runs contrary to my personal philosophy, as a person, to do health care the way we‘re being asked to do it now with the onset of computerized charting.‖ (L3) This could lead to miscommunication between nurses, managers, and doctors (L3). Too often unsupported situations, due to miscommunication, might occur leading to unsupported patients: It‘s very difficult to be a nurse – to care for a patient, to deliver a baby that [is probably] going to die, or to sit with families while they hold that baby, and that baby dies. . . . When you know that that‘s what the family are there for, there‘s just all the emotions around how do you support this woman through that? (A6)

Another area where support was lacking surrounded the use of digital communication devices. ―With the advent of social media, [a] number of people . . . have friended their patients on Facebook. . . . Because this a newer phenomenon, nobody has really addressed it. There‘s no policies [regarding the ethics of this situation]‖ (A7) Interaction with colleagues could also be very negative and add to the stress (L3, A7, O8). For L3, some people entered Labor and Delivery, having been trained ―on the job, and that‘s as good as wherever you work. So the knowledge base was very erratic. Whereas I had seen in England and Australia, that when people enter with a consistent educational program, that you get more consistent practice.‖ Colleagues who had codependency and boundary issues pulled morale down: The person who has very little ability to set a boundary has a tremendous risk for CF. People who live through other people – it‘s just: help! And unfortunately, there are a lot of people that [sic] go into nursing because that satisfies that need. . . . I‘ve worked with a number of codependent nurses, and it‘s very fatiguing [laughter]. (A7) The new generation of nurses may have brought a healthier attitude regarding boundaries, but many seemed to lack accountability. ―I was taught that sort of accountability, that even if I delegate it, I went back and I checked to make sure it was done right – as opposed to a newer generation of, ―I‘ve delegated – that‘s done, and if it‘s not done right, it‘s not my fault‖ (A7). Subtle interactions between nurses, managers, and physicians can also lower resiliency through lateral violence: ―Sometimes, in verbal ways, sometimes in subtle –

you know, just silence or you feel a vibe or whatever, so that – It makes people very nervous. And there‘s a lot of that in nursing, and there actually are organizations like the Critical Care Nurses Association that has a no-tolerance policy for lateral violence‖ (L3). Lateral, or horizontal, violence refers to ―behavior that humiliates, degrades, or otherwise indicates a lack of respect for the dignity and worth of an individual‖ ([Dumont, Meisinger, Whitacre, & Corbin, 2012, p. 44](/dissertation/references)). Because a hierarchy exists in the medical profession, seen clearly in the operating room (O8), distinctions between positions can amplify the lateral violence. Lateral violence ―is of particular concern in the healthcare setting because it disrupts relationships and causes barriers to communication needed to effectively care for our patients. [Lateral violence] has also been identified as having a negative impact on nurse retention and recruitment‖ ([Dumont et al., 2012, p. 44](/dissertation/references)). Although a breadth of personal experience can be available, including understanding the trajectory of life, the constant barrage of stress and loss are one of the primary reasons resiliency was lowered for the participants. Loss appeared not only through death, but in the discharge of a person after a long-term treatment (A7). When this loss was compounded by lack of debriefing, nurses‘ resiliency was further lowered (O8). For some people, being able to leave stressful situations at home to go to work as a nurse, caring for others, was a positive reinforcement (A6). In more cases, however, the added stress at home led to lowered resiliency when the nurses had to face the daily stresses of work (A6).

Moral distress in the workplace was another significant stressor, leading to CF (L2, L4, A7, O8). This could occur from unaddressed ethical quations (A7), having to treat against a patient‘s wishes (L4), having to give hurtful treatment (A7), or unreported punitive behavior (L2): C-sections are nothing for us, but for a Somali woman, her esteem as a woman is impacted. So, I find the providers don‘t – What I‘m really interested in is, what happens when a patient declines your recommendations? Do you ever – a health care provider, do you experience moral distress, emotional distress, communication problems? Do you just get – I mean, I see punitive behavior by health providers all the time. If you say, ―I don‘t want a C-section,‖ then I have to admit, I see punitive behavior. So a lot of times I work in the Somali community. . . . Biopower [is] when we have power over life. So doctors have power over life, and how we use that power – Especially doctors, not so much nurses, because we don‘t have prescriptive authority. But doctors have this power to say, ―You need a C-section. You need – ‖ I mean, they have incredible power over people. I mean, if you have that power, you really have to be careful that you‘re not using it for your own agenda, but only for the patient‘s agenda. (L2) In addition to the negative pulls on resiliency mentioned by many of the participants, individual nurses had personal barriers to maintaining balance, and managing stress. Although some people had benefited from support groups and inservice training directed at life-skills, CF, and coping with loss, others felt these forms of support were not sufficiently helpful for individuals (P5).

Workplace Support Desired for Giving Compassionate Care and Being Resilient to CF (3.3) Nurses wanted more daily support in their work (L2, L4, A6, A7, and O8). Because the needs differed between individuals, no one suggested a standardized training program for strengthening resiliency to CF. This daily support could take various forms, such as having more time to decompress before going on to another stressful situation, and provision of what is needed physically or logistically for the nurse to be able to give compassionate care. Specific workplace support mentioned was:  Consistent, not absentee, management (O8) who set a positive tone, and provide support, both physical and morale (L4).  Mentors who empower nurses, and help them achieve life balance, as well as learn how to cope with workplace stressors such as lateral violence (L4).  More frequent training sessions offered in coping with loss and high-risk situations (A7).  Training for recognition of CF for both nurses and managers (A6).  A specific support program available for people who are beginning the slide into CF (A6). One nurse would have liked: . . . to be able to go to my manager and say, ―This happened with my patient, and I‘m very distressed about it. I want to be sure that the next time this happens . . . I could have this and this. . . .‖ There was no, ―What else do you need? Is there

anything you need to talk about?‖ There was no time for it, you know? It‘s not considered important. So, if it just legitimizes outcomes, it would become important. . . . If we . . . could measure things in terms of compassion instead of dollars, I think we would do a hell of a lot better. . . . Or at least part of the equation .(L2) A6 said, ―To some nurses, support looks like staffing. We don‘t have enough staffing. If we had more staff . . . I could take my breaks, I could get a lunch, I could go walk out through the stairs, . . . or go to an in-service.‖ Another participant summarized her experience as a nurse: You start off being a nurse thinking it‘s all these technical skills. And when you finally get those technical skills and all the concerns about safety – your patient being safe, and doing the right thing – you realize that – there‘s this humanity about this and there‘s this caring that‘s really difficult to teach. I mean, how on earth do you teach a student nurse to be caring? Especially when they‘re so worried about doing their skills right, or savinig the patient‘s life? I believe, in the end, nursing is so much more about . . . compassion and caring [but] it‘s very difficult to teach or even talk about. (L2)

Summary

The purpose of this study was to determine the essence of resiliency to CF among nurses. This chapter presented the setting for the study, the demographics of the participants, the data collection and analysis processes, and the results of semi-structured interviews with seven nurses.

Summary of Participants’ Experience of Resiliency to CF

The participants believed that nurses were, in general, empathic, and this was the reason their profession was at risk for CF. Six of the seven nurses had experienced CF, and developed resilience to it in the years following that experience. The ability to be resilient, from their point of view, had its basis in positive attitude, realistic self-judgment and self-awareness, and adopting supportive behaviors. Maintaining life-balance, touching into spiritual energy, prioritization on actions, identification of what can be changes, and retaining clear boundaries with patients were considered the primary components of resiliency. Most of the participants believed that the ability to be resilient in the face of daily loss and stress had its foundation in genetics and early family life. The absence of certain negative workplace factors such as lateral violence helped the participants avoid CF. Training in communication skills and interactions between nurses, managers, and physicians also supported their resiliency. Breadth and longevity of experience in the nursing profession was an asset, as well as working with colleagues who were able to be supportive without being codependent.

Summary of Participants’ Distinctions between Burnout and CF

The participants distinguished between empathy and compassion by describing empathy as feeling what another person felt, and compassion as wanting to help the other person. In burnout, neither empathy or compassion for others was necessarily reduced. Instead, workplace factors such as changes in protocol, lack of time to perform at one‘s best, and lateral violence could lead to burnout. An overlap between burnout and CF was possible, as well as having them in sequence – CF leading to burnout, or vice versa.

Summary of Desired Support for Resiliency to CF

The participants considered mindfulness, or self-awareness, a critical part of being resilient to CF. The participants wanted support or training for this. The participants considered learning from various sources important, in-service sessions on coping with loss or high risk situations, and advice from colleagues and mentors. They wanted further training for themselves and their colleagues in how to monitor themselves and each other with regard to CF risks, and a support program for recuperating from any level of CF was requested. The following chapter discusses interpretations of this study‘s results in relationship to the research questions, the paradigms of CF research, empathy, and resilience, and the literature review presented in [chapter 2](/dissertation/chapter-2). Limitations of the study will be presented. Recommendations and the implications for positive social change will complete [chapter 5](/dissertation/chapter-5).