Empathy Exhaustion in Nursing  - Psychiatry Advisor

Empathy in Nursing: Why It Is Important

Peplau, a nurse theorist who examined the nurse-patient relationship, defined empathy as the ability "to be able to sit at the bedside of any patient, observe, and gather evidence on the way the patient views the situation confronting him, visualize what is happening inside the patient, as well as observe what is going on between them in the interpersonal relation."2

Davis described an "empathy episode" as comprising of the following2:

• Antecedents to experiencing empathy in the specific situation, such as preexisting factors of the nurse and the patient;
• Processes, including perspective taking; 
• Intrapersonal outcomes, which include emotional and cognitive reactions to another's experience; and 
• Interpersonal outcomes, where the empathizer engages in a particular behavior.

Although the terms empathy and compassion are sometimes used interchangeably, some have proposed that empathy entails being able to feel another person's suffering, while compassion includes both feeling and being willing to alleviate another's suffering.4,5 In addition, some researchers have equated empathy exhaustion with compassion fatigue, while others conceptualize the 2 as related but distinct conditions, with a loss of empathy leading to compassion fatigue.6 Empathy exhaustion can be a contributing factor to burnout, which is chronic stress that can occur in any occupation and is characterized by emotional exhaustion, feelings of depersonalization, and career dissatisfaction.7 

Evidence suggests nurses' empathy can have beneficial effects on their patients, such as improved satisfaction, better adherence to treatment, and better overall health.1,5 Empathy may also improve nurse/patient communication, allowing nurses to better recognize and advocate for their patients' needs.5 Practicing empathy can also help nurses by allowing them to experience less distress and work-related health issues, making them less likely to burn out and better able to provide effective care.1,5

How Empathy Exhaustion Affects Nurses' Mental Health

Empathy exhaustion can occur after prolonged exposure to stressful and taxing patient encounters. Symptoms of empathy exhaustion, include apathy, fatigue, irritability, lack of productivity, poor judgment, callousness, and feeling emotionally overwhelmed and desensitized to the needs of others.8 Symptoms can be categorized as physical, psychological, and behavioral9:

• Physical: Exhaustion, insomnia, somatization, headache, stomachache, fatigue;
• Psychological: Emotional exhaustion, depression, cynicism, fear, anger, irritability, detachment, helplessness, resentment; and
• Behavioral: Increased alcohol and substance use, avoiding patients, impaired clinical decision making. 

Some researchers consider emotional exhaustion to be a form of secondary traumatic stress resulting from repeated exposure to patients' injury and trauma, with symptoms similar to those of posttraumatic stress disorder, such as intrusive thoughts, irritability, and avoidance.8,9

Empathy Exhaustion in Critical Care Nursing 

While empathy exhaustion among nurses can occur across multiple specialties and settings, it may be more likely in nurses who work in critical care. Nurses working in settings such as oncology or in an intensive care unit (ICU) care for patients with serious illnesses and provide end-of-life care, which can cause distress that leads to emotional exhaustion.

A systematic review and meta-analysis of studies looked at secondary traumatic stress and burnout among oncology nurses, as measured by the self-report Professional Quality of Life Scale (ProQOL).10  Approximately 67% of these nurses experienced secondary traumatic stress.10

Another study used the ProQOL to examine the incidence of secondary traumatic stress and compassion fatigue among 598 health care professionals, including 358 nurses/midwives, who worked in an ICU or other unit that involved treating chronic or serious illnesses.11  Levels of secondary traumatic stress and compassion fatigue were significantly higher in nurses compared to doctors (P =.007) and in those who had previously experienced a traumatic event (P <.004).11 Secondary traumatic stress and compassion fatigue were correlated with increased levels of burnout.11

Addressing Empathy Exhaustion in Nursing

Strategies nurses can use to prevent or alleviate the effects of empathy exhaustion often focus on being aware of the condition and practicing self-care.9 Nurses can begin by learning about emotional exhaustion, its symptoms, and its consequences, and assessing themselves for symptoms using a tool such as the ProQOL.12 Commonly suggested interventions include the following9:

• Exercising
• Eating a healthy diet;
• Maintaining strong social networks; and 
• Participating in activities that promote relaxation, such as art, spirituality, yoga, and meditation.

Other possibilities include taking adequate time for breaks during and between shifts, and maintaining a balance between work and time off.12 In some cases, a nurse experiencing empathy exhaustion may benefit from psychotherapy. Health care organizations can support nurses by providing educational programs about empathy exhaustion, resiliency training, and employee assistance programs. Interventions that offer emotional support, such as structured support groups and debriefings about difficult clinical situations led by trained professionals, may also help counteract empathy exhaustion.9 Formal educational interventions that have been used to address empathy exhaustion include the Accelerated Recovery Program, Mindfulness-Based Stress Reduction, the Academy of Traumatology/Green Cross standards of self-care, and the Creative Compassion Model.9