The stress of nursing can take quite a toll on nurses emotionally and psychologically. Learn to recognize the signs, what to do, and when to seek help.

Abbegail Eason, RN, remembers some of the most devastating moments she’s witnessed as a nurse: a teenage girl learning she would never walk again after being shot by a gang member, a mom who gave birth but then died from a cerebral aneurysm just days later, and a baby who was left in a store’s parking lot and ended up dying.

“In these types of situations, it’s almost impossible not to be affected after your shift is over,” says Eason, a holistic coach at Abbegail Eason, LLC.

“Every nurse is susceptible to suffering from emotional distress,” explains Lucia M. Thornton, RN, MSN, AHN-BC, a consultant, educator, and author of Whole Person Caring: An Interprofessional Model for ­Healing and Wellness. Thornton and other sources we interviewed say that while all nurses can be affected emotionally, those in particular specialties may be more apt to experience this kind of issue. Some of the areas where nurses are especially at risk: emergency departments and trauma, ­intensive care unit (ICU), hospice, ­oncology, ­pediatrics, HIV clinics, homeless medicine, high-risk pregnancy clinics, palliative care, and neonatal intensive care unit (NICU), among many others.

“Anyone who is empathetic and works in a caregiving role—including nurses and ­certified nursing assistants—are at risk for developing compassion fatigue and increased caregiver stress, which affects emotional health,” explains Karen Whitehead, MS, LMSW, DCC, CCFP, who provides counseling in the greater ­Atlanta area and at TurningPoint Breast Cancer Rehabilitation. “Nurses who over-identify with patients and blur boundaries, as well as nurses with personal trauma histories, poor social support, isolated working conditions, or a previous history of unmanaged anxiety are at greater risk. Feeling a lack of control about your work environment—­including schedule, lack of recognition, or sense of community—can also contribute to caregiver stress.”

“Working in these areas with these types of patients triggers the sympathetic nervous system and keeps the body in fight or flight mode. This heightened stress reaction can, over time, lead to compassion fatigue and ongoing emotional distress,” she adds.

It can also be especially difficult for nurses because they are on the frontline of patient care, says Carl J. Sheperis, PhD, NCC, CCMHC, MAC, ACS, LPC. “Aside from the ­ongoing stressors of variable schedules, budget cuts, and constant technology changes, nurses are faced with a broad range of emotions experienced by patients,” explains Sheperis, a licensed professional counselor as well as the program dean for the College of Social Sciences at the University of Phoenix. “According to the American Nurses Association 2011 Health and Safety Survey, over 56% of participating nurses had experienced some type of threat or verbal abuse from patients. All of these stressors compound and result in high incidences of compassion ­fatigue and burnout for nurses.”

Compassion Fatigue, Moral Resilience, and Burnout

Mary Bylone, RN, MSM, CNML, president of Leaders Within, LLC, and a former board member of the ­American Association of Critical-Care Nurses (AACN) often lectures and writes about the AACN’s healthy work environment standards. Bylone says that while compassion fatigue, ­moral resilience, and burnout are terms often used interchangeably because they do have a lot of overlap, they also have some differences.

“Burnout is best used to describe a situation in which an individual feels overwhelmed and exhausted. It can be seen when people sacrifice ­themselves for work or become overwhelmed with the feeling that the work is never done. Compassion fatigue refers to the weariness that develops from caring for individuals when the caregiver feels saddened that they cannot change the situation and give of themselves in the hope of relieving pain or suffering in the patient,” explains Bylone. “Moral resilience refers to the aspect of an individual’s character to rise above situations creating moral distress, such as being asked to provide futile care or care against a patient’s wishes. ­Resilience comes when the nurse is able to restore and maintain their integrity by challenging or pushing back when asked to do things they do not feel are right. It involves using one’s bold voice to speak up when others would remain silent—to ensure that the morally right thing is done.”

For the past decade, the AACN has addressed all these issues. Its National Teaching Institute recently held a special interactive session during which more than 300 nurses spent an afternoon sharing the types of experiences that would cause these feelings and sharing their solutions with their colleagues as well. “The AACN puts a lot of energy into hope and resilience rather than dwelling on the negative,” says Bylone.

Recognizing the Signs

“Experiencing emotional reactions is human and ­appropriate,” says Sheperis. “The key is recognizing when the emotional reactions are out of proportion to a situation or when they have a negative impact on you or others around you. Nurses are often good at compartmentalizing emotional reactions, but sometimes the compartments become full, and the emotions spill out.”

Some of the signs that a nurse is experiencing negative effects from emotional overload are: using a greater number of sick days and/or dreading going to work; ­feeling exhausted; problems ­sleeping; using drugs or alcohol to sleep; having work-related dreams, nightmares, or intrusive thoughts; being angry a lot either at work or home; yelling at patients or families; changes in mood or behavior at work; crying all the time; feeling angry at supervisors or coworkers; developing fears about the safety of friends or family; feeling less engaged in their personal and/or professional life; the inability to think clearly; headaches; gastrointestinal problems; irregular breathing patterns, feeling devalued, and losing the capacity to care about themselves, their patients, their family members, or really anyone.

This doesn’t even touch on the signs of clinical ­depression, which nurses may also ­experience. The point is that if nurses notice vast changes in themselves or in their coworkers, they may need to seek or suggest help.

Taking Action

The first action that nurses can take to keep their emotional health intact is to set boundaries, says Gail Trauco, RN, BSN-OCN, a grief mediator, owner of Front Porch ­Therapy, and author of Conquering Grief from Your Own Front Porch. Nurses can do small things to make themselves happy. “Be sure you have things that you visually see which create an immediate ‘happy sensation,’” suggests Trauco. “This can be a favorite coffee mug, bright-colored scrubs, flowers on your desk, or even a funny stethoscope cover.”

One of the biggest problems nurses have is that they tend to put everyone else’s care above their own, says Jill Howell, MA, ATR-C, LPC, a board-certified registered art therapist, professional counselor, and author of Color, Draw, Collage: Create Your Way to a Less Stressful Life. While she works at Pocono Psychiatric Associates, ­Howell worked with many nurses at the Pocono Medical Center. “It’s all about self-care—nurses will, of course, react by saying that they don’t have time,” says Howell. “Please ­remember what they say on the airplane—put your oxygen mask on first before you try to help others.”

When working with nurses, Howell would check in with them to see how they were dealing with work, give them an opportunity to vent, and make small self-care suggestions. She would also do quick guided meditations with them, teach a relaxation technique, or set up large sheets of mural paper and have them draw out their frustrations.

“I have found that most nurses, while they can care for others continuously, have a very difficult time in caring for themselves,” says Thornton. “Self-compassion is an important and useful practice for nurses to develop.”

“Nurses are givers. We go into the field because we are caretakers,” says Eason. “Many of us feel we are at our best when taking care of others.” She says that it’s important, though, for nurses to understand that they have to take care of themselves first. “­Ensure you are getting ­adequate, quality sleep. You are eating a well-balanced meal. You are getting adequate exercise. You are spending time cultivating a life that is meaningful, rich, and deep outside of work,” says Eason.

After a particularly stressful experience at work, Lisa ­Radesi, DNP, CNS, RN, ­academic dean at the School of ­Nursing, College of Health ­Professions, ­University of Phoenix, says that nurses and other staff should have a ­debriefing session and ­remember that, ­despite all of the “bad” that occurs in their jobs, the “good” is the most rewarding part of what they do.

“Nurses should work together to ensure that they are okay after an incident. If a nurse notices a coworker is not doing well, they should talk with the coworker and bring it to the attention of the supervisor or manager,” says Radesi. “Above all, nurses should feel comfortable ­seeking treatment and communicating about emotional issues they may experience. Keeping this information ­bottled up can lead to issues and stress that have long-lasting effects. Know that it is not weakness, but strength, to acknowledge emotional disturbances and respond to them accordingly.”

If you see a coworker in ­distress, you can do something as simple as strike up a conversation with her or him, advises Bylone. “Use open-ended ­questions to find out how they are doing. Sometimes hearing the other person’s story really puts things into perspective. Let them know you care, and you are there to help, if only to listen. Please do not watch them suffer alone. Left ­unattended, these feelings only deepen and create lasting ­impact, often causing them to leave the profession,” she says.

Seeking Professional Help

Let’s face it: there are times when a spa day, time out with friends, or a bubble bath just won’t cut it in alleviating emotional problems. That’s when nurses need to seek ­professional help.

“If you are experiencing distressing symptoms over an extended period of time, it’s a good idea to check in with a professional therapist or counselor,” says Whitehead. “Whether it is distress from work or something related to your life outside of work, connecting with a professional can help you be a more effective caregiver and build your own resilience to mitigate the effects of your chosen population at work.”

If you need professional help, first see if your workplace has a program for staff members. If not, Sheperis says that the National Board for ­Certified Counselors has a ­directory of board-certified counselors across the ­United States (visit nbcc.org for more info). PsychologyToday.com also has a therapist ­directory that includes ­profiles of providers who can help.

There’s no shame in ­seeking help to get better. Sheperis says, though, that all nurses should do whatever they can to prevent their emotional stress from getting to this level. “Most people only seek ­professional help after ­something in their life had caused significant distress. While it is important to seek help if you are reaching a level of burnout or compassion ­fatigue, it is much better to take ­proactive steps and to work with a counselor to build resilience prior to hitting an emotional wall,” he says.

Sheperis also suggests that nurses focus on wellness practices at the onset of their careers. “It is easy to become engrained in a high-pressure system and to become emotionally overwhelmed if you don’t have a set of wellness practices in place.”

Michele Wojciechowski

Michele Wojciechowski is an award-winning writer and author of the humor book Next Time I Move, They’ll Carry Me Out in a Box.

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