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Introduction   

Hospice nurses are invaluable resources for both patients and their caregivers. They provide comfort care, education, and work to coordinate various aspects of end-of-life care. In addition to this, hospice nurses tend to be an emotional support system. They go through the dying experience time and time again, day in and day out. Exposure to suffering, dying, and death is part of their everyday job.

Just as no two patients are alike, no two death experiences are alike. Hospice nurses, already members of what is often considered one of the most caring professions, find themselves needing to be emotionally strong and often, suppress emotions, while those around them grieve appropriately. Such actions may lead to compassion fatigue.

Learning how to adequately cope with this situation is imperative to achieving a positive work-life balance and prevents nurses from leaving their profession.

Hospice Nursing

Hospice nursing is different from other forms of nursing; care is focused on comfort and quality of life and not on curing terminal illness. “Comfort in the end-of-life stage is defined as an integrated process of nursing interventions, in which nurses create a peaceful, home-life environment, build trust, and deliver emotional support to the patient’s family/caregivers, which allow for proximity and social-cultural support between the patient and family, as well as alleviate their physical suffering” (3).

Although often used interchangeably with palliative care, they are separate types of care provided for those with chronic and terminal diseases. The main difference is that hospice is offered in the last 6 months of life, where palliative care is available at any point in one’s diagnosis for symptom management.

A physician must certify a patient as terminally ill (1). Patients often have complex needs at the end of life, as well as the need for symptom management.

Hospice nurses help manage symptoms associated with terminal illness, like pain and nausea (to name a few) but are also emotionally available for their patients and their caregivers. “Hospice is a model of high-quality, compassionate care for people suffering from a life-limiting illness. It provides expert medical care, pain and symptom management, and emotional and spiritual support tailored to the patient’s needs and wishes” (2).

Working with hospice patients can be complex and emotionally draining for nurses due to the continuous suffering and exposure to death and dying. Nurses find themselves under a lot of emotional pressure with little support for their own emotional well-being.

Hospice nursing is also unique because the nurse typically forms relationships with both the patient and their family. When a patient dies, the nurse loses not only the relationship with the patient but also with the family. The concept of loss is an everyday part of the job for a hospice nurse.

Compassion Fatigue

In general, nurses are required to be compassionate professionals. This is especially true for hospice nurses, as they care for patients who are not only at the end of their life but are typically having difficulty with symptom management and in both physical and mental anguish.

The definition of compassion fatigue has evolved from the concept of burnout to a more specific definition. Compassion fatigue is like exhaustion and results from repeatedly caring for sick, dying, and suffering patients. It is often defined as cynicism, and emotional exhaustion occurring in a health care professional. The healthcare professional was once committed and cared for their patients (6).

Hospice nurses care for patients that are suffering and dying in a continuance and are therefore at a significant risk of suffering from compassion fatigue. Working in hospice does not mirror reality where one is allowed to grieve and express their emotions when an unfortunate event, like a death, occurs. Instead, hospice nurses must learn to regulate their emotions and maintain a strong demeanor in the presence of patients and their families.

The relationship between emotional regulation and compassion fatigue is not a coincidence. Hospice workers tend to regulate their emotional responses to death and dying. This is done to help support and strengthen patients and their families during difficult times.

If a hospice nurse is perceived as upset or sad, patients and their families may become discouraged and feel that their nurse is incompetent. Clinicians with high levels of compassion fatigue typically regulate their emotions in response to suffering and death on a constant basis (7).

Needing to display positive reactions and emotions while suppressing negative ones repeatedly with the hopes of positively influencing patients and their families in a commonality in hospice. This is not a natural or normal display of emotions. Nurses are human and should be allowed to grieve and show appropriate emotions when applicable.

Hospice nurses are typically strong and steer away from any perceived weakness while in the company of their patients and their patient’s caregivers. Unfortunately, this can lead to compassion fatigue.

The signs of compassion fatigue vary, but they typically cause changes in one’s ability to feel, think, and ultimately, work. A hallmark sign of compassion fatigue is a loss of the ability to feel both sympathy and empathy for others. If one can no longer feel sympathy or empathy, they are unable to act with a caring nature. They have lost their compassion. Now, that once caring nurse, is emotionally unavailable (8).

The signs and symptoms of compassion fatigue are not merely a part of the job. They simply do not get better with time. If not addressed, compassion fatigue can progress and manifest itself in other ways. Compassion fatigue can start to take a physical toll with obvious symptoms. “In the short term, compassion fatigue can underlie a number of physical health complaints, including headaches and migraines; nausea, vomiting, and diarrhea; and chronic pain and fatigue, all psychosomatic” (8).

It can also put patient care in jeopardy, as a nurse that has become desensitized, detached, and unable to care for themselves cannot adequately care for someone else in need.

A person experiencing compassion fatigue exhibits changes in behavior that are likely to be noticed by both patients and co-workers. The outward changes caused by compassion fatigue are not subtle and patients might start to ask what is going on. In addition, co-workers may notice differences in behavior and ability, and may ask about it out of concern (9).

Hospices nurses care for patients that are dying, suffering, and in both physical and emotional distress. Repeated exposure to this put hospice nurses at an increased risk for compassion fatigue. Knowing the causes and signs of compassion fatigue is an important first step in reducing the risk of experiencing it.

What To Do? 

Reducing the risk of compassion fatigue involves resilience. The first step for a hospice nurse that is noticing changes within is to be aware of compassion fatigue. Only then can one move towards resiliency. This can be easier said than done as being resilient is something that is learned and not innate.  

“Resilience is a complex construct with many definitions. Although it can be understood as a capacity or outcome, it is most often referred to as a process, both dynamic and multifaceted, whereby individuals draw on their personal (internal) and contextual (external) resources, and use specific strategies, to navigate challenges and work toward adaptive outcomes” (9). 

Being resilient means having the ability to go through hard experiences and come out stronger in the end. Hospice nurses are known for providing education and encouragement to both patients and caregivers in hopes of a more positive outcome and experience. Hospice nurses evoke a sense of strength and competence in the hardest of times. This is what makes them uniquely prepared for this type of nursing. This intrinsic ability can be drawn upon to fight compassion fatigue. 

Hospice nurses should also try to separate their professional life from their private life. Understanding that work is work and should be left there is especially important in the hospice setting. Being personally impacted by every loss in hospice is emotionally taxing and not ideal.

Prevention Strategies 

Self-care, self-care, self-care. Implementing self-care is the primary tool to prevent compassion fatigue. Nurses should have an outlet to relieve stress and take their mind off work. Self-care usually means different things to different people.  

This may include exercise, dietary changes, improved sleep habits, and other things that are supportive of physical and mental health. Engaging in such activities can help nurses learn to cope with the stressors they encounter at work (10).  

Nurses should also ensure that they have a positive work life balance. Being able to separate work from home life is especially important, although it might be hard at times. Taking time for positive activities that promote mental health is an important factor in reducing the risk for compassion fatigue. 

Lastly, the workplace bears some responsibility in preventing compassion fatigue. Nurses that do not have support on the job are likely to have some degree of compassion fatigue. There are many things that an employer can do to support its nurses. “The workplace should support nurses in achieving healthy self-care and self-awareness practices, encourage self-assessment, and aid nurses in obtaining interventions to mitigate compassion fatigue.  

Policy should support a healthy workplace allowing adequate breaks, productive workflow, flexible schedules, and support systems through leadership and teamwork collaboration. Education should be offered to nurses and organizations over compassion fatigue and burnout to increase awareness and foster a culture change” (10). 

Reducing the risk of compassion fatigue is multifactorial. Practicing self-care along with receiving outside support is instrumental in compassion fatigue prevention.

Grieving 

Hospice nurses, like nurses in many other specialties, experience death throughout their profession. Hospice nursing is unique in that its sole purpose is to help prepare their patients and their patient’s families for death. With death comes a loss, which extends beyond the loss of a life. Not only do hospice nurses lose their patients, but they also lose the families and bonds that they formed throughout the entire dying process.  

After a patient dies, the hospice nurse is expected to move on and care for the next dying patient. There may be little to no time to grieve the losses. Grief is connected to loss and is related to the feelings one exhibits after a loss. Repeated exposure to grief and loss may lead to compassion fatigue, moving through grief is imperative. For hospice nurses to assist others in the grieving process, they too must be able to grieve properly (5) 

Grief allows pain to be processed and people to heal after a loss. Everyone experiences grief differently. In 1969, Dr. Elisabeth Kubler-Ross initially identified the five stages of grief. The stages are Denial, Anger, Bargaining, Depression, and Acceptance.

• Denial allows a person to cope and move through the stages of grief in their own time.  
• Anger is normal and should be allowed to be expressed by the grieving individual. Anger allows that person to feel a sense of connection. 
• Bargaining may be experienced at any point during the grieving process. It may include “what if” statements and represents the point that a person can finally move through grief in their own healing process. 
• Depression is the stage when a person realizes that the situation is in fact real. A person may become withdrawn during this stage. 
• Acceptance means acknowledging and accepting that the situation is permanent. This does not mean one is completely healed, but instead, they are now able to live again. 

(12) 

There is no specific amount of time required to move through all five stages. Everyone moves through them at their own pace. When allowed to grieve naturally, nurses can be expected to move towards healing and growth.

Resources and Support 

There are many resources available for nurses who are either at risk or are already experiencing compassion fatigue. Nurses should do a self-assessment to get a better understanding of any potential risk factors. Since the workplace is the primary source of compassion fatigue related stressors, it is imperative that nurses have access to resources and support while at work.  

Nurse leaders should make this a priority for their staff. This can be accomplished by acknowledging that staff do experience trauma and stress on the job. Nurse leaders can assist nurses in need by supplying resources and assisting them in their efforts to move through the stress and practice self-care (11).  

In the event where additional help is needed, and a nurse is unable to prevent compassion fatigue dealing with a supervisor directly, nurses should seek out other resources such as professional organizations or employee assistance programs.

Conclusion

Hospice nurses provide compassionate care to dying patients on a continuous basis. Unfortunately, caring for hospice patients involves repeated exposure to death, dying, and suffering. This exposure, combined with a need to suppress certain emotions, can lead to a compassion deficit known as compassion fatigue.

Nurses in this state are unable to properly care for patients and are at risk for mental and physical decline if their compassion fatigue is left untreated.

After a loss, hospice nurses should be allowed to move through the grieving stages at their own pace, rather than suppress their emotional responses to death and dying. Fortunately, there are prevention strategies and resources available to help nurses combat compassion fatigue. Practicing self-care should be an integral part of a hospice nurse’s life and is important in reducing the risk of compassion fatigue.

A hospice nurse that does not experience compassion fatigue is likely to enjoy a rewarding career for many years.

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