Lying Down in the Ever-Falling Snow: Canadian Health Professionals’ Experience of Compassion Fatigue

By Wendy Austin, E. Sharon Brintnell, Erika Goble and 4 more

8 An Icy Wall (Within and Between): Relations and Compassion Fatigue Health care is a profoundly relational endeavour and the professionals drawn to it often hold a deep dedication to the well-being of others. A sense of purpose and commitment sustain this dedication across the emotional, intellectual, and physical demands of caring work. But in the face of so much human suffering, beneath the weight of heavy caseloads and burdensome bureaucracy, health professionals may experience a cooling or sense of detachment in professional and personal relationships.

• Language: English
• Publisher: Wilfrid Laurier University Press
• Release date: Apr 23, 2013
• ISBN: 9781554588909

Wendy Austin

The authors are Wendy Austin, Canada Research Chair (Relational Ethics), E. Sharon Brintnell, Erika Goble, Leon Kagan, Linda Kreitzer, and Brendan Leier. Scholars and/or clinicians situated primarily at the University of Alberta (Kreitzer, University of Calgary), they form an interdisciplinary group (anthropology, medicine, nursing, occupational therapy, philosophy, psychology, and social work) with a deep interest in ethical, compassionate health care and the well-being of those who provide it.

Book preview

Lying Down in the Ever-Falling Snow

Lying Down in the Ever-Falling Snow

Canadian Health Professionals’ Experience of Compassion Fatigue

Wendy Austin • E. Sharon Brintnell • Erika Goble • Leon Kagan

Linda Kreitzer • Denise J. Larsen • Brendan Leier

This book has been published with the help of a grant from the Canadian Federation for the Humanities and Social Sciences, through the Awards to Scholarly Publications Program, using funds provided by the Social Sciences and Humanities Research Council of Canada. Wilfrid Laurier University Press acknowledges the financial support of the Government of Canada through the Canada Book Fund for our publishing activities.

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Library and Archives Canada Cataloguing in Publication

Lying down in the ever falling snow : Canadian health professionals’ experience of compassion fatigue / Wendy Austin … [et al.].

Includes bibliographical references.

Issued also in electronic formats.

ISBN 978-1-55458-888-6

1. Medical personnel—Mental health—Canada—Case studies. 2. Medical personnel—Job stress—Case studies. 3. Secondary traumatic stress—Canada—Case studies. 4. Secondary traumatic stress. 5. Compassion. I. Austin, Wendy, 1947–

RC451.4.M44L94 2013               616.85’21               C2012-907194-3

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Electronic monographs.

Issued also in print format.

ISBN 978-1-55458-889-3 (PDF).—ISBN 978-1-55458-890-9 (EPUB)

1. Medical personnel—Mental health—Canada—Case studies. 2. Medical personnel—Job stress—Case studies. 3. Secondary traumatic stress—Canada—Case studies. 4. Secondary traumatic stress. 5. Compassion. I. Austin, Wendy, 1947–

RC451.4.M44L94 2013               616.85’21               C2012-907195-1

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Cover design by Blakeley Words+Pictures. Front-cover photograph by Erika Goble. Text design by Janette Thompson (Jansom).

© 2013 Wilfrid Laurier University Press

Waterloo, Ontario, Canada

www.wlupress.wlu.ca

Lyrics from Baby It’s Cold Outside, by Frank Loesser, © 1948 (Renewed) Frank Music Corp., from the motion picture Neptune’s Daughter, are reprinted by permission of Hal Leonard Coporation. All rights reserved. Excerpt from Bloodletting & Miraculous Cures, by Vincent Lam, © 2006 Vincent Lam, is reprinted by permission of Doubleday Canada. The poem Canadian January Night, by Alden Nowlan, from Selected Poems (1971), is reprinted by permission of House of Anansi, http://www.houseofanansi.com. Except from Ethical Openings in Palliative Care Home Practice, by Anna Santos Salas and Brenda L. Cameron, from Nursing Ethics 17, no. 2 (2010), is reproduced by permission of Sage Publications.

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Printed in Canada

Every reasonable effort has been made to acquire permission for copyright material used in this text, and to acknowledge all such indebtedness accurately. Any errors and omissions called to the publisher’s attention will be corrected in future printings.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior written consent of the publisher or a licence from the Canadian Copyright Licensing Agency (Access Copyright). For an Access Copyright licence, visit http://www.accesscopyright.ca or call toll free to 1-800-893-5777.

CONTENTS

The Question of Compassion Fatigue: An Introduction

What Is Compassion?

Differing Understandings of Compassion Fatigue

A New Way of Understanding Compassion Fatigue

The Cold Heart: The Bodily Experience of Compassion Fatigue

The Endless Winter: The Temporal Experience of Compassion Fatigue

Lost and Alone in a Prairie Blizzard: The Experience of Space in Compassion Fatigue

An Icy Wall (Within and Between): Relations and Compassion Fatigue

Bundling Up: Finding Hope in Cold Climes

Survival in Winter Country

Epilogue

Bibliography

Index

THE QUESTION OF COMPASSION FATIGUE:

An Introduction

We see some pretty horrific wounds. Often times, I feel numb. There is so little you can do, other than clean and cover the wounds for the patient. It is difficult because you want to help and yet there is so little that you can do for them…. Once, some maggots crawled out of a man’s wound … you never lose that image…. In my work, you just keep going on to the next patient. There is no time to really catch your breath. A lot of times you are working alone…. You still feel compassion. But it’s almost too much…. You can’t separate your feelings and put that boundary up as easily. So you build walls around you and shut out the caring.

These are the words of Laureen, a registered nurse who, like many other health professionals across Canada and around the world, has found her professional practice and her sense of self affected by something she and other practitioners have begun to call compassion fatigue. Lying Down in the Ever-Falling Snow is a description of this phenomenon as experienced by Canadian health professionals. Health sciences literature uses compassion fatigue to refer to a diminished capacity for compassion in the health professions. Without compassion, one cannot genuinely and sensitively engage with the person entrusted to one’s care.

The simple meaning of the words compassion (to suffer together with)¹ and fatigue (from the Old French fatiguer, to be weary)² seems to capture what has befallen health professionals with compassion fatigue. They are too weary to be with the suffering of others in the way they once were. A psychologist whose experience informed this book told us that compassion fatigue touched the core of who she understood herself to be: When I care less, I really feel like I am losing a part of myself.

Compassion fatigue in health professionals has deep repercussions for patients and clients, as well as their families. Health professionals experiencing the phenomenon are unable to reach out with the attentiveness necessary for healing and comfort. Author Christopher Hitchens, who passed away from cancer in December 2011, eloquently recounted his entrance into the world of the seriously ill when emergency services arrived in answer to his call for help: They arrived with great dispatch and behaved with immense courtesy and professionalism. I had the time to wonder why they needed so many boots and helmets and so much heavy backup equipment, but now that I view the scene in retrospect I see it as a very gentle and firm deportation, taking me from the country of the well across the stark frontier that marks off the land of malady.³ Those entering the land of malady need to be met by professionals able to enact their expertise caringly and compassionately. They need to be truly greeted,⁴ to be reached out to and connected with during their time of need. Without such a greeting, the possibility arises that they will be more harmed than helped.⁵

A Relational Ethics Perspective on Health Care Practice

We came to the study of compassion fatigue through a shared belief that ethical health care practice is grounded in relationships. A relationship is the space within which care is given and received. Nurse philosopher Sally Gadow conceives of this space as a moral world that patient or client and professional inhabit together.⁶ Such cohabitation is required if the patient or client is to be seen and touched in the way necessary to safe, ethical treatment and care. Health professionals profess to their society that they will use their expertise and skill in a trustworthy way; yet, such trustworthiness is diminished if the particular needs and situation of the patient or client cannot be acted upon in a fitting way that is adapted to the particular person in the here and now.⁷ Absent this recognition of the unique individual (as opposed to mere identification of the person as a case of disease, injury, or disability) and the patient or client is made more vulnerable and becomes alone in a significant way.⁸ But what happens when the ability to reach out to the individual in one’s care is weakened by compassion fatigue? What happens when compassion seems to become a dangerous thing, a threat to the well-being of the caregiver? As a phenomenon that poses a risk to the foundational care relationship, compassion fatigue demands to be understood.

The Phenomenon of Compassion Fatigue

When we went to the health sciences literature, we learned that much has already been written about compassion fatigue, including the results of scale development that allows its measure. Yet, we did not find research that showed in a rich way what it is like to become compassion fatigued as a health professional, nor did we find clear understanding of whether compassion fatigue was a unique phenomenon or simply a new name for experiences such as burnout, vicarious traumatization, or moral distress. With a grant from the Caritas Foundation⁹ in Edmonton, Alberta, Wendy Austin (a registered nurse and professor who holds a Canada Research Chair in Relational Ethics in Health Care), Erika Goble (an anthropologist with experience in the arts and caring for persons with disabilities), and Brendan Leier (a philosopher and clinical ethicist), along with a colleague, Paul Byrne (an intensivist and Director of the Dossetor Health Ethics Centre at the University of Alberta), completed a small pilot study of nurses’ compassion fatigue using the qualitative research method of interpretive inquiry. This study, published in the journal Ethics and Social Welfare, opened up for us what it is like to have compassion fatigue as a nurse and showed that compassion fatigue did, in fact, appear to be a unique experience.¹⁰ The nurses described the way they began to shield and distance themselves from patients and families, as they felt unable to help them cope with their suffering. Running on empty was a phrase used by one research participant that echoed the others’ experiences. The nurses felt impotent and without hope that they could return to the nurse I used to be.

This work motivated the pursuit of a national, interdisciplinary study of compassion fatigue. We were intrigued by the complexity of the relational engagement between health professionals and persons in their care. We perceived the need to explore how this engagement changed in the way that it was lived during compassion fatigue. Our research began with the question: What is compassion fatigue like? We wanted to begin there, with a description of compassion fatigue as it is lived, before we sought explanations of it or tried to measure it across the health professions. Therefore, hermeneutic phenomenology was chosen as a means to explore the phenomenon deeply.

Hermeneutic phenomenological research is a form of human science inquiry that involves radical reflection on the way a human experience is lived. It is radical in the sense that it tries to get to the root or origin of the experience, finding what is essential to its lived meaning. In this approach, researchers empirically seek anecdotes, images, poetry, and literature that allow a phenomenon to be uncovered. The task is then to create a rich, descriptive, and interpretive text that shows the phenomenon in such a way that those who have experienced it can say, Yes, that is it! This form of inquiry opens us to an understanding that is more pathic in nature than it is intellectual or technical.¹¹ That is, it is knowledge that is embodied and relational; it is knowledge situated in our experience of the world. The word pathic comes from the Greek pathos (suffering) and is the root in words such as empathy, sympathy, and telepathy, which imply emotional connection. This type of understanding is highly relevant for health professionals because it reflects the nature of professional practice itself. The phenomenologist Max van Manen writes that: The competence of professional practitioners is itself largely tied into pathic knowledge. Professional knowledge is pathic to the extent that the act of practice depends on the sense and sensuality of the body, personal presence, relational perceptiveness, tact for knowing what to say and do in contingent situations, thoughtful routines and practices, and other aspects of knowledge that are in part prereflective, pre-theoretic, pre-linguistic.¹² Therefore, to understand compassion fatigue in a situated, embodied, and relational way, a pathic way may not only provide insight into the reality of health professionals suffering from compassion fatigue, but it may offer knowledge useful to one’s professional practice.

For a research team with the necessary skills and experience to complete such a phenomenological study, Wendy, Erika, and Brendan were joined by Sharon Brintnell (an occupational therapist, professor, and current President of the World Federation of Occupational Therapists), Leon Kagan (psychiatrist and clinical professor), Linda Kreitzer (social worker, professor, and author of Social Work in Africa), and Denise Larsen (a chartered psychologist, professor, and Director of Research at the Hope Foundation of Alberta). As an interdisciplinary research team, we were awarded funding for the study by the Social Sciences and Humanities Research Council of Canada. Our study received research ethics approval from the University of Alberta’s Health Research Ethics Board and the University of Calgary’s Conjoint Health Research Ethics Board.

We began the research with a countrywide recruitment of health professionals who self-identified as having experienced compassion fatigue. We conducted individual research conversations with them, in person or by telephone, asking them to tell us about an experience that they associated with compassion fatigue and to share how having compassion fatigue feels. We asked if and how it had changed their practice and what, if anything, they had tried to do to cope with it. We also asked them to identify what changes to their work environment would prevent or relieve compassion fatigue. These conversations form the basis of the description of health professionals’ compassion fatigue presented here.

In addition to these accounts, we sought to inform our inquiry with literary sources (fiction, poetry, biography) and artwork (photographs, paintings, sculptures). For example, sculptures of grief—portraying a person or angel with the head down on one arm and the other arm drooping down at the side¹³—captured in an image what participants expressed in words. Throughout the project, we collaborated to reflect upon and interpret these various sources. The collaborative process of the research was also sustained in writing the book: an individual team member took the lead to write a particular chapter, then the team came together to discuss, edit, and rewrite. As the principal investigator, Wendy undertook the responsibility of ensuring that the text flowed with a consistent voice. Of course, all the research activities contributed to the resulting text. The list of authors for our book is alphabetical. This book, like the health care system itself, is interdisciplinary in its very nature, for the experience of compassion fatigue transcends disciplinary practice.

A Glimpse Ahead

The structure of this book reflects in some ways our own exploration of the phenomenon of compassion fatigue. We begin with a discussion of compassion, sharing our position that it seems an essential moral virtue that perhaps forms the ground of care itself. We then take the reader through the different understandings of compassion fatigue that have been published to date, including the connections made with burnout and vicarious and secondary trauma. The chapter A New Way of Understanding Compassion Fatigue is where we explicitly explain the research method of hermeneutic phenomenology and outline our specific research activities. This is followed by four chapters presenting the research results, a description of compassion fatigue as experienced by Canadian health professionals. The description is organized around four aspects of human experience: body, time, space, and relations. Being phenomenological descriptions, these chapters will require that the reader engage with the text in a way somewhat different from that required for the rest of the book. We hope we have succeeded in creating a text that evokes what compassion fatigue is like, as it is lived. The chapter following this series is about hope; we believe hope—and its absence, hopelessness—to be important in understanding compassion fatigue. The final chapter is about survival; that is, it presents our ideas about ways to consider preventing and overcoming compassion fatigue. It is crucial to note that a phenomenological description is not the basis for recommendations; as with other qualitative research, it is not generalizable. What it can do, however, is point to ways to use the understanding it offers and to inspire ways of thinking and rethinking about the phenomenon explored. This is the basis of what we offer in the final chapter.

We cannot stress enough how grateful we are to the many health professionals across our country who so intimately and thoughtfully shared their experiences. They did so to promote a deeper understanding of what happens when a health professional can no longer sustain compassionate caring. They did so to help us all find ways to respond to this very serious phenomenon. Our hope is that this book does justice to their contributions.

A Canadian Metaphor: Lying Down in the Snow

As a final note, we wish to explain the guiding metaphor of this book. During our research, we discovered James Orbinski’s book, An Imperfect Offering: Humanitarian Action in the Twenty-First Century, in which he tells of his work as a humanitarian physician and of his struggle to understand how to respond to the suffering of others.¹⁴ Writing of his time in Rwanda as the head of mission with Médecins Sans Frontières (Doctors Without Borders) during the 1994 genocide, Orbinski describes his decision, when the civil war was pronounced over, to return home to Canada instead of going off to work, at Médecins Sans Frontières’s request, at a refugee camp in Zaire: I was spent. I had nothing left to give.¹⁵ His decision came late one day in the children’s ward of the Red Cross Hospital, where he examined a girl, still in her school tunic, who told of the terrible things she witnessed. Orbinski writes of the way his heart started to race and how he felt an overpowering despair…. It felt like something was broken that could never be fixed.¹⁶ Once home in Ontario, the unbearable memories of Rwanda possessed him; his parents found him very changed. His father cautioned him: You can’t just lie down in the snow, James…. Do you hear me? You can’t just lie down in the snow. You’ve got to get up. You’ll find your way.¹⁷

These words of a father to a son struggling to continue as a physician in the aftermath of an incredibly painful experience resonated with what we were learning about compassion fatigue. This metaphor of lying down in the snow, lost and overcome, could be applied to the many health professionals who shared with us their experience of compassion fatigue. Just as winter is beautiful but dangerous, the privilege of being with the ill, the injured, and the suffering is both beautiful and dangerous, too. It seems an apt metaphor to help us reveal facets of the experience of health professionals with compassion fatigue.

Metaphors are very valuable—necessary, we have learned from cognitive science¹⁸—to imaginative thinking. As we transfer perceptions from one phenomenon to another, we are moved to see things in new and diverse ways. Situations can be opened up such that we are invited to re-envision our understanding of experience. Thus, we made the decision to use lying down in the snow as an organizing metaphor for this book.

We imagine the pain, ills, and suffering of patients, clients, and their families as falling snow. We can picture such suffering, like snowfalls, to range in amount, intensity, and duration. There are gentle snowfalls, expected given the time of year. There are snow flurries, sudden in coming and going with rapid changes in intensity. And there is the blizzard, a freezing winter storm, with strong winds and blowing snow, blinding us to where we are as the horizon disappears in a whiteout. We imagine health professionals as residing in this metaphorically snowy world (where there are also times of warmth and sun) and expected to respond to all weather conditions with deep knowledge and quick skill.

If they are appropriately resourced with what is necessary for cold, hazardous climes (warm clothes and boots, shovels and sand, shelters away from the wind) and are made aware of the various risks (like frostbite and hypothermia) and how to reduce and to meet them, health professionals can reside here safely. If they are with reliable companions and do not need to travel too far without sufficient rest, they can do what is required of them. When dealing with blizzard conditions, where the way becomes difficult and unclear (as happened in 2003 during the SARS epidemic),¹⁹ they can draw on their courage and wisdom to survive until the storm is over or relief and rescue come. However, they need to know that they can trust in their society that these will come.

We use this organizing metaphor with some reservations. We have tried not to belabour its use whereby, rather than enhancing thinking about compassion fatigue, the metaphor gets in the way. We have tried not to force the metaphor upon the phenomenon, and we hope that it does not distance readers who cannot relate to living in a cold and snowy clime. As Canadians, we also do not want to contribute to the mistaken idea that Canada is a land of continuous winter! That said, the metaphor is one to which we can strongly relate, and we have found it helpful to our thinking. Admittedly, we may have been influenced by the fact that on the December day in 2009 when we held a research retreat to work on the project, our city of Edmonton was the coldest place on the planet save for a spot in Siberia.²⁰

The author Pierre Berton, who called himself and his fellow Canadians a winter people,²¹ has written about our denial of winter.²² He wrote that it is an attitude by which we create a weatherproof world in our cities. One of his examples is West Edmonton Mall, among the world’s largest shopping malls, where beneath a dome of glass you can go to the beach and ride waves of water, visit the carnival and ride a roller coaster, or see trained seals while you shop. We devise the means to ignore our natural environment. The denial of winter points to another form of denial, one that concerns compassion fatigue. It may be that one response to health professionals’ compassion fatigue will be to diminish the centrality of relationships in the clinical encounter. Even in tax-based, publically funded health systems such as Canada’s, customer service models of care seem to be gaining dominance, making marketplace rather than moral community the overall framework. With customer service, the patient’s or client’s custom is sought and health care interactions become commodified, even scripted. There is a form of civility to these prescribed interactions, but genuine engagement with the suffering person is made less possible. There is an artificiality to it that denies the deep reality of pain, suffering, and death, and the real challenge involved in healing and comforting.

We are hoping that with this work we will contribute to an alternate approach to that of denial. When Adam Gopnik delivered the 2011 Massey Lectures,²³ his chosen topic was winter. He said that we oppose the threatening blank bitterness of winter just by looking at it, and by saying what it’s like. Names, he says, are the footholds, the spikes the imagination hammers in to get a hold on an ice wall of mere existence.²⁴ We hope that in our description of compassion fatigue we are creating a foothold toward understanding this phenomenon for the reader and for health professionals and the society that depends on them.

Notes

1 See compassion in An Etymological Dictionary of the English Language, ed. Walter W. Skeat (Oxford, UK: Clarendon Press, 1888), 125.

2 See fatigue in Etymological Dictionary, 204.

3 Christopher Hitchens, Topic of Cancer, Vanity Fair (September 2010), http://www.vanityfair.com/culture/features/2010/09/hitchens-201009.

4 Arthur Frank, A Renewal of Generosity: Illness, Medicine and How to Live (Chicago: University of Chicago Press, 2004).

5 Dawson Schultz and Franco Carnevale, Engagement and Suffering in Responsible Caregiving: On Overcoming Maleficence in Health Care, Theoretical Medicine 17, no. 3 (1996): 189–207.

6 Sally Gadow, Narrative and Exploration: Toward a Poetics of Knowledge in Nursing, Nursing Inquiry 2 (1995): 211–14. See also Joanne D. Hess, Gadow’s Relational Narrative: An Elaboration, Nursing Philosophy 4, no. 2 (2003): 137–48.

7 H. Richard Niebuhr, The Responsible Self: An Essay in Christian Moral Philosophy (Louisville, KY: Westminster John Knox Press, 1962).

8 Gadow, Narrative and Exploration.

9 The grant for Compassion Fatigue: The Experience of Nurses was funded by the Caritas Health Group Foundation from 2006 to 2007. In 2008, the Caritas Health Group became Covenant Health.

10 Wendy Austin, Erika Goble, Brendan Leier, and Paul Byrne, Compassion Fatigue: The Experience of Nurses. Ethics and Social Welfare 3, no. 2 (2009): 195–214.

11 Max van Manen, Phenomenology of Practice, Phenomenology & Practice 1, no. 1 (1997): 11–30.

12 Van Manen, Phenomenology of Practice, 20.

13 Many of these sculptures, such as the Grieving Lady Monument in an Edinburgh cemetery, seem inspired by the 1884 sculpture by William Wetmore Story that marks his grave in the Protestant cemetery in Rome.

14 James Orbinski, An Imperfect Offering: Humanitarian Action in the Twenty-First Century (Toronto, ON: Doubleday Canada, 2008), 15.

15 Orbinski, Imperfect Offering, 252.

16 Orbinski, Imperfect Offering, 253.

17 Orbinski, Imperfect Offering, 258.

18 George Lakoff and Mark Johnson, Metaphors We Live By (Chicago: University of Chicago Press, 2003).

19 The outbreak of severe acute respiratory syndrome (SARS) was concentrated in Canada in the Toronto area and resulted in a travel ban to that city. It also raised fears that the virus would affect thousands throughout the country as it had been doing in other countries. Health professionals were ill-equipped to deal with such an outbreak, and many of them contracted the disease themselves.

20 Clara Ho, Only Siberia Was Colder, Edmonton Sun, 13 December 2009, http://www.edmontonsun.com/news/edmonton/2009/12/13/12141366.html.

21 Pierre Berton, Winter (Toronto, ON: Stoddart Publishing, 1994), 27.

22 Berton, Winter, 195.

23 Adam Gopnik, Winter: Five Windows on the Season (Toronto, ON: House of Anansi Press, 2011). See also http://www.cbc.ca/ideas/episodes/massey-lectures/2011/11/07/the-2011-cbc-massey-lectures-winter/.

24 Gopnik, Winter, 5.

WHAT IS COMPASSION?

It is a feeling common to all mankind that they cannot bear to see others suffer…. This feeling of distress is the first sign of humanity.

Mencius

Before exploring the experience that is called compassion fatigue, compassion itself must be looked at. Compassion manifests in contemporary health care amid ambiguity and paradox. Some argue that the very means by which institutional care is