Nurses demonstrate clinical skill and patient compassion so routinely that it is little wonder they are designated the most trusted profession year after year. But such routine excellence can have its toll in terms of burnout and “compassion fatigue.”
There is accumulating evidence that “meaningful recognition” of the sacrifice that nurses and other healthcare workers make can boost resilience and stave off burnout, says Lesly A. Kelly, RN, PhD, an assistant professor in the College of Nursing and Health Innovation at Arizona State University in Phoenix.
“We talk a lot about how nurses are hardy and resilient, but we have to remember, too, that sometimes that’s not necessarily a wonderful thing,” she says. “We want to make sure that we are not resilient just for the sake of all these adverse events being thrown at us.”
To examine the effect of meaningful recognition programs on compassion fatigue, Kelly and colleagues conducted a multicenter national study1 of critical care nurses. An online survey was completed by 726 ICU nurses in 14 hospitals with an established meaningful recognition program, and 410 nurses in 10 hospitals without such a program.
“Meaningful recognition was a significant predictor of decreased burnout and increased compassion satisfaction,” Kelly and colleagues concluded. “Additionally, job satisfaction and job enjoyment were highly predictive of decreased burnout, decreased secondary traumatic stress, and increased compassion satisfaction. … In addition to acknowledging and valuing nurses’ contributions to care, meaningful recognition could reduce burnout and boost compassion satisfaction.”
Compassion fatigue was defined as a “combination of burnout, psychological and physiological responses to prolonged chronic emotional and interpersonal stressors, and secondary traumatic stress.” To counter these effects, there are programs like DAISY (Diseases Attacking the Immune System), a foundation established by the parents of a patient who died of an immune disorder. To honor the clinical skill and compassionate care of the nurses involved, they created the DAISY Foundation in 1999.
“They were so moved by their nursing care that they decided to recognize the nurses that had cared for him,” Kelly says. “They just thought of doing this for one hospital, and the idea really spread and was picked up by some of the professional organizations. It’s interesting how the idea of ‘we need to recognize our nurses’ [struck a chord].”
This DAISY model of standardized meaningful recognition of nurses is now used in 2,800 healthcare facilities in all 50 states and 17 countries. (For more information on the program, visit: http://bit.ly/2qvUaYI.)
In the study, nurses were asked about overall job satisfaction, enjoyment, stress, and intent to leave their position and profession.
“For nurses in the sample, burnout was predicted by increased job stress, decreased job satisfaction, and decreased job enjoyment,” Kelly and colleagues reported. “Meaningful recognition through a nomination for [a] DAISY Award was negatively predictive of burnout, meaning that those with a nomination reported lower burnout.”
Hospital Employee Health asked Kelly to comment on the issues raised by the study in the following interview, which has been edited for length and clarity.
HEH: Can you elaborate on this concept of a meaningful recognition program?
Kelly: The American Association of Critical-Care Nurses uses meaningful recognition as one component of a healthy work environment. It is recognizing nurses for what they do in a meaningful way. You want to make sure it is equal to the work that they do, and that it is done in a manner that is significant to them. If something significant happened in the context of burnout, trauma, and things like that, there are very specific ways that we talk about recognition and responding.
DAISY is just for nurses, but there are other ones that hospitals have established for other employees as well. Formal recognition should be standardized and available to everyone. You want to make sure that one leader is not doing it one way and another leader is doing it another way. An employee may [be confused] about how recognition occurs in their facility. [It should be] very publicized that this is the way that a patient can acknowledge the care that a nurse provides, or an employee can recognize another employee.
HEH: You found that these recognition programs have some protective effect against nursing burnout?
Kelly: An interesting thing that we found in our study is that there is benefit in decreased burnout and increased compassion satisfaction from not only getting the award, but from getting the nomination. In the ICU nurses, we had about a 20% nomination rate and a 9% to 10% award rate. So, you are talking about a lot more nurses nominated than are getting awards, but you get the benefit even from being nominated. A lot of that has to do with how you handle your nomination process. We tell people who they were nominated by, and give them the actual letter that the patient or other employee wrote about them. We tell them the words that were said about them, and that’s what really gives them meaningful recognition.
HEH: Can you comment a little more about compassion fatigue and how it arises? Also, the paper alludes to “secondary traumatic stress.”
Kelly: Compassion fatigue comes from the combination of burnout and secondary trauma. Burnout is that emotional exhaustion and depersonalization, the lack of a feeling of personal accomplishment. Secondary trauma is familiar to those in healthcare and other fields. It is when someone experiences a traumatic event, and then we as the caregiver pick up those feelings of stress and trauma and become the secondary victim. It’s a natural byproduct of the work that we do, but we can mitigate the effects by putting resources in place to support our caregivers. There is a lot of literature out there on how to do that — debriefing and acknowledging are very important. We have to have resources in place and have a way to process these emotions. Also, we have new nurses coming in that have to build their resiliency. They need to see the older nurses going through the process of building their resilience.
Those two things — burnout and secondary trauma — contribute to compassion fatigue. You get the cumulative effect of those building up and then you have compassion fatigue. The balance, the other side, is compassion satisfaction, and that’s the joy derived from our work. A lot of times when we are really burned out and we have too many secondary [trauma] events, the compassion fatigue is really high — the balance is mismatched.
HEH: Not to put too fine a point on it, but do healthcare workers then experience a difficulty or an inability to actually feel compassion for their patients?
Kelly: I think that can happen. There are definitions out there that say that you have a lack of compassion. That’s part of the burnout definition, too. Depersonalization is part of the burnout definition, so you feel impersonal. You have “removed” yourself [emotionally] and have a lack of caring for patients.
HEH: You note that nearly 20% of nurses are leaving their positions in their very first year, and many recent graduates leave nursing altogether.
Kelly: There are quite a few [researchers] who have had that same finding. The younger nurses in the millennial generation are having the highest compassion fatigue. We don’t know exactly why. These studies are cross-sectional and we are surveying at one point in time. But we have some assumptions.
We see nurses not staying in their positions very long. There is a lot of risk of these nurses even leaving the profession. They are thinking it is one thing when they are getting into nursing, but it might turn out to be something different. Their burnout and compassion fatigue may increase, and then they leave the profession.
We also have to remember that nursing is different today than it was for previous generations. It’s not necessarily harder, but it is different. So, resiliency [programs] have to change. It’s not just burnout and how the different generations handle it. The work environment, the available resources, and other things contribute to it.
HEH: How can meaningful recognition programs improve nurse retention?
Kelly: Some people get a job in one setting and then go try another setting, and that’s OK. We want nurses to find the right fit, but when nurses move on you have to find another nurse and train them up. It is hard to have nurses leave, but it is good for a nurse to find the right setting and the right fit. Leaders should recognize nurses, to make sure they are in the right setting and then keep them in that setting. I have talked to leaders and told them you can use meaningful recognition to your advantage. It is not necessarily costly. A lot of times they say they don’t have the budget to give all nurses raises, and that kind of thing. [I recommend] recognizing nurses in a way that is meaningful to them. It can be letters [from patients], acknowledgment, adjusting schedules. There are a lot of different ways meaningful recognition can be budget-friendly and a powerful tool for leaders to help with retention.