Imagine this: A nurse serves as the primary nurse for a particular patient and family for several months. They form close bonds, becoming friends on social media and having playdates outside of work with the nurse’s children and the patient and siblings. The patient deteriorates and dies from his disease while he is inpatient. The nurse is his nurse that day and is devastated by his death. The nurse goes on to care for more children who are very ill, some of whom die from their disease. The nurse becomes overwhelmed with disenfranchised grief and compassion fatigue, eventually leaving the profession because she “can’t handle it anymore”.
While this exact scenario is fictional, the principles of the story are true. There are nurses out there who befriend current and former patients and family members on social media. Some nurses arrange play dates so their children can get to know the patients. Other nurses become very involved in their patient’s lives, so much so that the grief from the patient’s death is overwhelming. And finally, there are nurses who have left the profession because they cannot find a way to battle the compassion fatigue they feel every day. So what roles do ethics play in these scenarios?
When thinking about the role of ethics in nursing, the American Nurses Association [ANA] Code of Ethics (2015) serves as the guiding principles for the profession. As a nurse, it is hard to balance “the nurse’s primary commitment… to the patient” (ANA, 2015, p. 5) with the provision that “the nurse owes the same duties to self as to others, including the responsibility promote health and safety, [and] preserve wholeness of character and integrity” (ANA, 2015, p. 19). After all, how are we, as nurses, expected to put the patient first while protecting ourselves from the inherent duty to care for our patients?
It is hard to turn off our brains and our hearts when we leave the hospital. It is hard to not think about how our patients are doing when we are not at work. So where do we draw the line?
Nurses have an obligation to advocate for “conditions of employment that are conducive to safe, quality health care” (ANA, 2015, p. 23). This means that nurses have an ethical obligation to advocate for policies that positively impact the nursing profession and aim to decrease or prevent compassion fatigue. These policies, whether they are part of the state legislature, the board of nursing’s definition of scope of practice, or hospital-specific, must be consistent with creating a supportive environment for nurses. By supporting the needs of nurses, policymakers keep good nurses in the field, therefore positively impact patient outcomes.
Nurses must consider the Code of Ethics as well as policies regulating their practice to determine where they must draw professional boundaries. Nurses must look inward at their own psychological well-being to determine where to draw their personal boundaries. By maintaining consistent professional and personal boundaries, nurses can ethically care for patients and prevent compassion fatigue.
Personally, I do not attend the funerals of each one of my patients who passes away from their childhood cancer. I choose to attend some funerals as a way to grieve and honor the patient and family. However, if I was not particularly close with a particular patient, I choose to honor their life from afar rather than at the funeral. The boundaries I have drawn to protect myself and my heart are not necessarily going to work for every nurse, but they are what work for me. By developing these consistent personal and professional boundaries, I choose to create an ethically moral environment to protect myself within my scope of practice as a pediatric oncology nurse.
References
American Nurses Association [ANA]. 2015. Code of ethics for nurses with interpretive statements. Silver Spring, MD: Nursesbooks.org Retrieved from https://www.nursingworld.org/coe-view-only
Nurses and Compassion Fatigue 
Hi Winnie,
I, like yourself, am a hematology/oncology nurse and have been for the last eight years. For the first five years, I worked in a pediatric setting, so I know all too well the stories you speak of. While we are consistently taught to not get too close to families, to have boundaries such as no contact outside of the hospital, the nature of our job makes that nearly impossible. The nurse is often the person bathing the child to avoid the Hickman site and tubes, we administer the medicine so the parents do not have to be the “bad guy”, and we change their diapers throughout the night so that the parents can get just a little sleep. We also are some of the only people who see and understand what the parents are going through and therefore become the only people they talk to about their situation. Whether we try to avoid it or not, in the parents eyes, we become a part of their family. So when that child passes away, we have an impossible decision to make. Attend countless children’s funerals and risk the emotional burden that bears, or disrespect the family that pleads with you to attend.
Whether nurses decide to attend funerals or not is up to them. Every nurse deals with the death of their patients differently and must do what they believe is best to protect their emotional well-being. What is proven, however, to help prevent burnout are interventions provided by hospitals to promote nurse mental and physical health. Henry (2014) notes that interventions such as mindfulness classes, employee assistance programs, mentoring programs, and day long retreats away from the clinical setting help reduce job stress and compassion fatigue. As you note, advocating for policies that positively impact the nursing profession, such as hospital programs mentioned previously, is crucial in preventing nurse turnover. By minimizing compassion fatigue and burnout in nurses, we ensure that hospitals maintain knowledgeable and experienced oncology nurses who will in turn provide the best care to patients and their families, producing better patient outcomes.
References
Henry, B. (2014). Nursing burnout interventions: What is being done? Clinical Journal of Oncology Nursing, 18(2), 211-214. doi: 10.1188/14.CJON.211-214
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In your blog you discussed bedside nurse’s compassion fatigue which develops over time after exposure to childhood disease such as cancer and illustrated that nurses are leaving the bedside due to emotional exhaustion. Likewise you spoke about the practice of some nurses whom chose to go to funerals of patients who die and your personal choice not to in order to save your own sanity.
This cumulative stressful experience you describe is also seen in other professions which endure patient’s personal pain and traumatic experiences. One such example is therapist who listens to patient’s horrific stories of cruelty, molestation and or crimes. Studies have shown some personal attributes of therapist have been found to play an effect whether secondary trauma would likely occur such as; personal identity, worldview and emotional styles (Halevi and Idisis, 2018).
Also, mentioned in your blog was the American Nurses Association code of ethics which discusses a primary responsibility to the patient with shared need to recognize health and wellness within oneself. According to Halevi and Idisis (2018), this phenomenon is also noted in therapist whose work is closely emotionally involved. They state the importance of being empathetic of the patient’s experience but creating a separate distant relationship.
Halevi and Idisis (2018) describe persons who are able to experience intimacy with others and maintain personal boundaries are less likely to develop compassion fatigue. However, persons who empathize to the extent that they take care of others more than themselves are a great risk due to lack of depersonalization.
You also mentioned that nurses must advocate for conditions of safe employment and policies which promote decreased compassion fatigue. What policy did you have in mind that would impact nurses experiencing compassion fatigue? I agree with you that policies which protect employees such as no personal social media contact with previous patients may be necessary to implement in order to place a boundary on nurses who are unable to recognize this need for themselves to do so.
References
Halevi, E. & Idisis, Y. (2017). Who helps the helper? Differentiation of self as an indicator for resisting vicarious traumatization. Psychological Trauma Theory Research Practice and Policy. (10)6. Retrieved at https://search-proquest-com.ezproxy1.lib.asu.edu/docview/1949249640/fulltextPDF/63443142D406455BPQ/1?accountid=4485.
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There are many different interventions that can be utilized to combat compassion fatigue. As far as policy is concerned, I’m going to be looking at statewide policies aimed at providing resources to nurses to decrease compassion fatigue and burnout, such as protected lunch breaks and resources for therapy sessions to address disenfranchised grief.
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