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Compassion FatigueCompassion FatigueA presentation for nursesA presentation for nurses

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Created by Amy OCreated by Amy O’’Leary MN, OCN Leary MN, OCN

Why should we as nurses be concerned about Why should we as nurses be concerned about compassion fatigue?compassion fatigue?

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Can be emotionally and professionally Can be emotionally and professionally devastatingdevastating66

Causes are unavoidable in nursingCauses are unavoidable in nursing66

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Difficult to recognize unless aware of Difficult to recognize unless aware of compassion fatiguecompassion fatigue66

Lack of recognition inhibits effective treatmentLack of recognition inhibits effective treatment66

ObjectivesObjectives

Define the concepts of compassion fatigue (CF), Define the concepts of compassion fatigue (CF), burnout, and compassion satisfactionburnout, and compassion satisfaction

List the possible causes and contributing factors List the possible causes and contributing factors for compassion fatig efor compassion fatig e

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for compassion fatiguefor compassion fatigue

Propose strategies to reverse and reduce Propose strategies to reverse and reduce compassion fatiguecompassion fatigue

Presentation OverviewPresentation Overview

Exploration of relevant concepts with further Exploration of relevant concepts with further explanation through case reportsexplanation through case reports

Discussion of contributing factorsDiscussion of contributing factors

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Signs of compassion fatigueSigns of compassion fatigue

Interventions for compassion fatigueInterventions for compassion fatigue

Compassion and EmpathyCompassion and EmpathyIsnIsn’’t this why we went into nursing?t this why we went into nursing?

Compassion: Compassion:

Sympathetic consciousness of otherSympathetic consciousness of other’’s distress, s distress, together with a desire to alleviate ittogether with a desire to alleviate it44

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Empathy: Empathy: An emotional engagementAn emotional engagement55

Highly presentHighly present77

Sensitively attunedSensitively attuned77

HeartfeltHeartfelt77

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Compassion SatisfactionCompassion Satisfaction

The pleasure derived from the work of helpingThe pleasure derived from the work of helpingothersothers77

Symbiotic relationship between nurse and Symbiotic relationship between nurse and patientpatient77

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patientpatient77

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CF is progressive and cumulative

Compassion discomfort (temporary, Compassion discomfort (temporary, removable by rest) removable by rest) Compassion stress Compassion stress

(Stress level increases and endurance (Stress level increases and endurance d )d ) C i f iC i f i 33

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decreases) decreases) Compassion fatigueCompassion fatigue33

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The Cost of CaringThe Cost of Caring77

““Compassion fatigue is a state where the Compassion fatigue is a state where the compassionate energy that is expended has compassionate energy that is expended has surpassed restorative processes.surpassed restorative processes.””

(C 2010 237)(C 2010 237)33

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(Coetzee, 2010, p. 237)(Coetzee, 2010, p. 237)33

Secondary Traumatic Stress DisorderSecondary Traumatic Stress Disorder

State of exhaustion and dysfunctionState of exhaustion and dysfunction33

Directly related to traumatic patient experiencesDirectly related to traumatic patient experiences22

Manifest symptoms similar to PTSDManifest symptoms similar to PTSD33; ;

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-- depressiondepression

-- generalized anxietygeneralized anxiety

-- avoidanceavoidance

-- hyperhyper--arousal arousal

BurnoutBurnout

Burnout = Burnout = mental distress andmental distress and work performancework performance77

Related toRelated to77::

F iF i

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FrustrationFrustration

Powerlessness Powerlessness

Inability to achieve work goalsInability to achieve work goals

•Frequent/inappropriate anger

•Apathy/Indifference

•Unresponsiveness

Irritability

CF r/t: Patient Contact & Use of Self

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Burnout r/t: Work Environment

STSD r/t:Traumatic events

•Hyper-arousal

•Avoidance

•Intrusion

•Powerlessness

•Cynicism

•Detachment

Irritability

Depression

Sleep difficulty

Concentration

Energy

Absences

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Case Report 1Case Report 1

Sarah has worked as a nurse for a medical Sarah has worked as a nurse for a medical surgical unit for 7 years. She takes care of many surgical unit for 7 years. She takes care of many different patients with different needs throughout different patients with different needs throughout her work week. The unit is very busy. In addition, her work week. The unit is very busy. In addition, the patients on Sarahthe patients on Sarah’’s unit are very sick, s unit are very sick, terminally ill or dying and need intense emotional terminally ill or dying and need intense emotional support.support.

O i h i l i f hO i h i l i f h

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Over time the emotional strain of her Over time the emotional strain of her patientpatient’’s pain and anguish leads to compassion s pain and anguish leads to compassion discomfort, and her enthusiasm and sensitivity discomfort, and her enthusiasm and sensitivity towards patienttowards patient’’s needs begins to diminish.s needs begins to diminish.

She eventually becomes emotionally She eventually becomes emotionally overwhelmed, evoking the desire to stay overwhelmed, evoking the desire to stay uninvolved and disconnected from patientuninvolved and disconnected from patient’’s s suffering. She no longer cries over the loss of a suffering. She no longer cries over the loss of a patient or provides emotional support. She has patient or provides emotional support. She has become compassion fatigued.become compassion fatigued.6,76,7

Case Report 2: Letter from a patient

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I felt a bit like this olI felt a bit like this ol’’ dog; I had complete dog; I had complete faith and trust in you! Thank you for being my faith and trust in you! Thank you for being my night nurse during my recuperation from the night nurse during my recuperation from the splenectomy and hysterectomy. Isplenectomy and hysterectomy. I’’m getting m getting stronger. Tomorrow begins the second phase of stronger. Tomorrow begins the second phase of th h lith h li th h th T i ht Ith h th T i ht I

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the healingthe healing-- the chemotherapy. Tonight, as I the chemotherapy. Tonight, as I prepare for this transition, I am prepare for this transition, I am soso grateful grateful to all to all the nurses who took such excellent postthe nurses who took such excellent post--op care op care of me. I am especially grateful to youof me. I am especially grateful to you-- for your for your willingness to calm me by talking with me. God willingness to calm me by talking with me. God bless you for your compassion and intelligence.bless you for your compassion and intelligence.

CF and Compassion SatisfactionCF and Compassion Satisfaction

Negative correlation between CF and Negative correlation between CF and compassion satisfactioncompassion satisfaction99

le els of compassion satisfaction fo nd inle els of compassion satisfaction fo nd in

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levels of compassion satisfaction found in levels of compassion satisfaction found in RNRN’’s with <10 yrs experiences with <10 yrs experience99

levels of compassion satisfaction in ICU RNlevels of compassion satisfaction in ICU RN’’s s vs ED RNvs ED RN’’ss99

Factors Contributing to CFFactors Contributing to CF33

Prolonged, continuous and intenseProlonged, continuous and intense

Use of self Use of self

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Contact with patientsContact with patients

Exposure to stressExposure to stress

Possible CF AssociationsPossible CF Associations

1.1. Personal FactorsPersonal Factors

2.2. Patient ConditionsPatient Conditions

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3.3. System IssuesSystem Issues

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Personal FactorsPersonal Factors

Ethnicity?Ethnicity?88

Experience?Experience?99

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Coping strategies?Coping strategies?8,98,9

Patient ConditionsPatient Conditions99

Patients experiencing serious physical, Patients experiencing serious physical, emotional, financial threats, or imminent death emotional, financial threats, or imminent death

Challenging behaviors such as confusionChallenging behaviors such as confusion

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Challenging behaviors such as confusion, Challenging behaviors such as confusion, combative and aggressive behavior combative and aggressive behavior

Futile care, aggressive medical care despite of Futile care, aggressive medical care despite of patient diagnosispatient diagnosis

System IssuesSystem Issues

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System Issues Associated with CF9

8 hour shifts 8 hour shifts

number of days worked number of days worked

census census

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acuity acuity

Heavy patient assignmentsHeavy patient assignments

Possible Signs of CFPossible Signs of CF33

Physical Physical

EmotionalEmotional

Social Social

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IntellectualIntellectual

PhysicalPhysical

Accident proneAccident prone1,3,61,3,6

ExhaustionExhaustion1,3,61,3,6

HeadachesHeadaches1,3,61,3,6

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Difficulty in falling and staying asleepDifficulty in falling and staying asleep1,2,3,61,2,3,6

Susceptibility to infectionSusceptibility to infection1,3,61,3,6

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EmotionalEmotional

Anger to frequent or intense for the Anger to frequent or intense for the situationsituation1,31,3

ApatheticApathetic1,31,3

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Desire to leave nursingDesire to leave nursing1,31,3

DepressionDepression1,31,3

IrritabilityIrritability1,31,3

Social EffectsSocial Effects33

Unresponsiveness Unresponsiveness

Callousness Callousness

Indifference Indifference

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Avoidance of emotionally charged situationsAvoidance of emotionally charged situations

IsolationIsolation

IntellectualIntellectual

Poor judgementPoor judgement33

Disinterest in introspectionDisinterest in introspection33

Disordered thinkingDisordered thinking33

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Short attention spanShort attention span1,31,3

ForgetfulForgetful1,31,3

Interventional StrategiesInterventional StrategiesWhat can we do now?What can we do now?

PersonalPersonal

SelfSelf--awarenessawareness

SelfSelf--carecare

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ProfessionalProfessional

Responses at workResponses at work

Reaching out to colleaguesReaching out to colleagues

Consider the patientConsider the patient

Personal: Focus on selfPersonal: Focus on self--awareness and selfawareness and self--care…what care…what youyou have control overhave control over

SelfSelf--AwarenessAwareness

A combination of selfA combination of self--knowledge and dualknowledge and dual--awareness, the clinician can monitor patient awareness, the clinician can monitor patient needs work environment and his or her ownneeds work environment and his or her own

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needs, work environment, and his or her own needs, work environment, and his or her own experience….it is a psychological process that experience….it is a psychological process that may expand onemay expand one’’s range of choices and allow for s range of choices and allow for more creative responses.more creative responses.77

How can I cultivate selfHow can I cultivate self--awareness?awareness?

Formal interventionsFormal interventions

Mindful MeditationMindful Meditation

Reflective WritingReflective Writing

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Informal interventionsInformal interventions

Suggestions from the expertsSuggestions from the experts

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Mindful MeditationMindful Meditation4,74,7

““ A process of developing careful attention to A process of developing careful attention to minute shifts in body, mind, emotions, and minute shifts in body, mind, emotions, and environs while holding a kind nonj dgmentalenvirons while holding a kind nonj dgmental

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environs while holding a kind, nonjudgmental environs while holding a kind, nonjudgmental attitude toward self and others.attitude toward self and others.””

(Kearney, 2009, p. 1160)(Kearney, 2009, p. 1160)77

““The only way to learn compassion is The only way to learn compassion is through our own broken hearts, we have to through our own broken hearts, we have to

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back up and pass through our own pain.back up and pass through our own pain.””(Matthew Fox)(Matthew Fox)

Reflective WritingReflective Writing

Writing in an emotional way is a form of Writing in an emotional way is a form of selfself--care that increases selfcare that increases self--awareness by awareness by promoting reflectionpromoting reflection77

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promoting reflectionpromoting reflection77

Informal: Suggestions from the expertsInformal: Suggestions from the experts

Allow yourself to have personal timeAllow yourself to have personal time66

Set priorities and maintain balanceSet priorities and maintain balance66

Prompt yourself to do some act of centering Prompt yourself to do some act of centering h dh d 77

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each dayeach day77

Understand your own mortality and abilitiesUnderstand your own mortality and abilities66

Be reasonable about what you can and cannot Be reasonable about what you can and cannot dodo66

SelfSelf--Care: Personal StrategiesCare: Personal Strategies

““ The heart must first pump blood to itself The heart must first pump blood to itself ””(Shauna Shapiro)(Shauna Shapiro)

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Maintain a healthy lifestyleMaintain a healthy lifestyle11

Eat well balanced meals Eat well balanced meals

Get enough sleep Get enough sleep

Exercise Exercise

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Nurture social relationshipsNurture social relationships

Engage in community activitiesEngage in community activities11

Make time to connect with friends and familyMake time to connect with friends and family11

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Take time to laugh and have funTake time to laugh and have fun11

Participate in faith communitiesParticipate in faith communities88

Seek out Calming and Restful Seek out Calming and Restful ExperiencesExperiences

Develop hobbies and interestsDevelop hobbies and interests11

Enjoy music, reading, gardeningEnjoy music, reading, gardening11

Appreciate natureAppreciate nature11

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Consider counselingConsider counseling11

Discover your own spiritualityDiscover your own spirituality1,61,6

Get massagesGet massages88

Professional Strategies:Professional Strategies:to utilize at workto utilize at work

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Accept your reactions as normal responses to Accept your reactions as normal responses to specialized workspecialized work11

Appreciate the importance and meaning of your Appreciate the importance and meaning of your workwork11

Reward yourself after a stressful situation or Reward yourself after a stressful situation or l i kl i k77

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completing a taskcompleting a task77

Stay connected to the outside worldStay connected to the outside world77

Develop a role shedding ritualDevelop a role shedding ritual77

Give yourself time to take a breakGive yourself time to take a break77

Reach out to colleagues Reach out to colleagues Because they have been there tooBecause they have been there too

Debrief with colleagues to help deal with Debrief with colleagues to help deal with emotions after a traumatic eventemotions after a traumatic event77

Consider forming a CF support groupConsider forming a CF support group11

D l i iD l i i 11

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Develop a supportive environmentDevelop a supportive environment11

Take time talking with an experienced colleague Take time talking with an experienced colleague to discuss patient situationsto discuss patient situations55

Have a realistic tolerance of failureHave a realistic tolerance of failure44

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Realize when Enough is EnoughRealize when Enough is Enough99

Trade assignments Trade assignments

Consider reducing hours, and amount of days Consider reducing hours, and amount of days worked worked

S i h hifS i h hif

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Switch shifts Switch shifts

Take vacations Take vacations

Consider the patient Consider the patient Help renew your sense of compassion satisfactionHelp renew your sense of compassion satisfaction

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Set and maintain clear limits and boundaries on Set and maintain clear limits and boundaries on therapeutic relationshipstherapeutic relationships1,61,6

Focus on patientFocus on patient’’s strengths and good qualities s strengths and good qualities rather than their distress and negative qualitiesrather than their distress and negative qualities11

Deliberately make connections with patients, use Deliberately make connections with patients, use

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y py phumor, look for something unique in a patienthumor, look for something unique in a patient’’s s room, or notice the patientroom, or notice the patient’’s birth date or ages birth date or age77

Find a way to touch the patient during a visit or Find a way to touch the patient during a visit or assessment to help you feel connectedassessment to help you feel connected77

In Conclusion….In Conclusion….

All nurses are at risk for compassion fatigue, and All nurses are at risk for compassion fatigue, and must be empowered to avoid and overcome itmust be empowered to avoid and overcome it

““You can gain control over this problem You can gain control over this problem l thr h r l h i r tl k dl thr h r l h i r tl k d

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only through real changes in your outlook and only through real changes in your outlook and reaction to the stress in nursing. Periodically reaction to the stress in nursing. Periodically reflect, assess, nurture, and renew yourself so reflect, assess, nurture, and renew yourself so youyou’’ll stay emotionally fitll stay emotionally fit”” (Joinson, 1992, p. 121)(Joinson, 1992, p. 121)66

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Any Questions?

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References1. Absolon, P., & Krueger, C. (2009). Compassion fatigue

nursing support group in ambulatory care gynecology/oncology nursing. Journal of Gynecologic Oncology Nursing, 19, 1, 16-19.

2. Adams, R. E., Boscarino J. A., & Figley, C. R. (2006) Compassion fatigue and psychological distress among social workers: A validation study.A i J l f O h hi 76 (1) 103 108American Journal of Orthopsychiatry, 76 (1), 103-108. Doi:10.1037/0002-9432.76.1.103

3. Coetzee, S. K., & Kloper, H. C. (2010). Compassion fatigue within nursing practice: A concept analysis. Nursing and Health Sciences, 12, 235-243. doi: 10.1111/j.1442-2018.2010.00526.x

4. Compassion. (n.d.) In Merriam-Webster’s online dictionary. Retrieved from http://www.merriam-webster.com/dictionary/compassion.

References continued5. Huggard, P. (2003). Compassion fatigue: how much can I

give? Medical Education, 37: 163–164. doi: 10.1046/j.1365-2923.2003.01414.x

6. Joinson, C. (1992). Coping with compassion fatigue. Nursing. 22(4), 116-121. Doi: 00152193-199204000-00035.

7. Kearney, M. K., Weininger, R. B., Vachon, M. L., Harrison, R. L. & Mount, B. M. (2009). Self-care of physicians caring for patients at the end of life: “Being connected... a key to my

i l ” JAMA 301 (11) 1155 1164survival.” JAMA, 301 (11):1155-1164 doi:10.1..1/jama.2009.352.

8. Quinal, L., Harford, S. & Rutledge, D. N. (2009). Secondary traumatic stress in oncology staff. Cancer Nursing, 32 (4), E1-E7. doi: 10.1097/NCC.0b013e31819ca65a

9. Yoder, E. A. (November 01, 2010). Compassion fatigue in nurses. Applied Nursing Research, 23, 4, 191-197. doi:10.1016/j.apnr.2008.09.003

Self-Care Assessment Worksheet This assessment tool provides an overview of effective strategies to maintain self-care. After completing the full assessment, choose one item from each area that you will actively work to improve. Using the scale below, rate the following areas in terms of frequency: 5 = Frequently 4 = Occasionally 3 = Rarely 2 = Never 1 = It never occurred to me Physical Self-Care ___ Eat regularly (e.g. breakfast, lunch and dinner)

___ Eat healthy

___ Exercise

___ Get regular medical care for prevention

___ Get medical care when needed

___ Take time off when needed

___ Get massages

___ Dance, swim, walk, run, play sports, sing, or do some other physical activity that is fun

___ Take time to be sexual—with yourself, with a partner

___ Get enough sleep

___ Wear clothes you like

___ Take vacations

___ Take day trips or mini-vacations

___ Make time away from telephones

___ Other:

Psychological Self-Care ___ Make time for self-reflection

___ Have your own personal psychotherapy

___ Write in a journal

___ Read literature that is unrelated to work

___ Do something at which you are not expert or in charge

___ Decrease stress in your life

Source: Transforming the Pain: A Workbook on Vicarious Traumatization. Saakvitne, Pearlman & Staff of TSI/CAAP (Norton, 1996)

___ Let others know different aspects of you

___ Notice your inner experience—listen to your thoughts, judgments, beliefs, attitudes, and

feelings

___ Engage your intelligence in a new area, e.g. go to an art museum, history exhibit,

sports event, auction, theater performance

___ Practice receiving from others

___ Be curious

___ Say “no” to extra responsibilities sometimes

___ Other:

Emotional Self-Care ___ Spend time with others whose company you enjoy

___ Stay in contact with important people in your life

___ Give yourself affirmations, praise yourself

___ Love yourself

___ Re-read favorite books, re-view favorite movies

___ Identify comforting activities, objects, people, relationships, places and seek them out

___ Allow yourself to cry

___ Find things that make you laugh

___ Express your outrage in social action, letters and donations, marches, protests

___ Play with children

___ Other:

Spiritual Self-Care ___ Make time for reflection

___ Spend time with nature

___ Find a spiritual connection or community

___ Be open to inspiration

___ Cherish your optimism and hope

___ Be aware of nonmaterial aspects of life

___ Try at times not to be in charge or the expert

___ Be open to not knowing

Source: Transforming the Pain: A Workbook on Vicarious Traumatization. Saakvitne, Pearlman & Staff of TSI/CAAP (Norton, 1996)

___ Identify what in meaningful to you and notice its place in your life

___ Meditate

___ Pray

___ Sing

___ Spend time with children

___ Have experiences of awe

___ Contribute to causes in which you believe

___ Read inspirational literature (talks, music, etc.)

___ Other:

Workplace or Professional Self-Care ___ Take a break during the workday (e.g. lunch)

___ Take time to chat with co-workers

___ Make quiet time to complete tasks

___ Identify projects or tasks that are exciting and rewarding

___ Set limits with your clients and colleagues

___ Balance your caseload so that no one day or part of a day is “too much”

___ Arrange your work space so it is comfortable and comforting

___ Get regular supervision or consultation

___ Negotiate for your needs (benefits, pay raise)

___ Have a peer support group

___ Develop a non-trauma area of professional interest

___ Other:

Balance ___ Strive for balance within your work-life and workday

___ Strive for balance among work, family, relationships, play and rest

Source: Transforming the Pain: A Workbook on Vicarious Traumatization. Saakvitne, Pearlman & Staff of TSI/CAAP (Norton, 1996)

Questions for Case Report #1:

1. Can you identify with any of Sarah’s story? 2. What are your stress triggers at work?

Questions for Case Report #2:

1. What are some patient experiences that evoke feelings of compassion satisfaction?

2. How do these experiences help you cope better with patient demands? How do

these experiences affect you and your ability to continue nursing?


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