Nurses’ schedules can leave them little time to recuperate from arduous patient care. They might stress about missing family birthdays, recitals, sports games, and holidays. They are not necessarily paid commensurate to their sacrifices. Nurses told me about sleepless nights during which they were so worried about patients that they called the unit to check on them, and days off that they spent doing something for a patient instead of for their family. And it is difficult to explain the letdowns of the job to people who aren’t nurses. “People don’t know how hard it is to compartmentalize your life when you have a bad day at work, like when a patient dies or declines, and then you have to come home and act like nothing is wrong,” a Maryland OR nurse said. “Your husband and children have a difficult time understanding and it’s impossible to explain. They don’t teach that in nurses’ training.”

Workplace stressors are affecting nurses’ mental health across the world. In Quebec, where the local nursing union has asked the government to end sixteen-hour shifts because understaffed nurses are “overworked and exhausted,” five nurses killed themselves in an eighteen-month span. At least one of them left a suicide note in which she blamed her hospital’s working conditions. When the woman’s sister-in-law contacted the hospital, she was allegedly told, “She’s not the first to commit suicide and she won’t be the last.”

In 2013, the U.K.’s Royal College of Nursing announced that 82 percent of nurses go to work while sick because they worry that understaffing would harm patient care. Reporting that stressed nurses are “forced to choose between the health of patients and their own,” the RCN revealed that staff shortages and increased workloads caused more than half of surveyed nurses to become ill. In a separate report, South African nurses conveyed similar issues, in addition to poor security, lack of government support, and unhygienic hospitals.

Burnout, compassion fatigue, and PTSD

Experts estimate that approximately 30 percent of nurses are burnt out, which has been defined as a “loss of caring.” Burnout symptoms include irritability, difficulty concentrating, low energy, and sustained thoughts of quitting. Many nurses also experience a related but lesser known condition that is often confused with burnout. “Compassion fatigue,” also called secondary traumatic stress disorder, can occur when empathetic nurses unconsciously absorb their patients’ traumatic stress. They experience the traumas emotionally, sometimes mirroring the patients’ anxiety. As they pour their energy and compassion into caring for their patients, many of whom do not improve, they fail to care properly for themselves and/or their own families. The resulting sense of helplessness has been called “a combination of physical, emotional, and spiritual depletion” and “a state of psychic exhaustion.”

This can happen to nurses who treat children the same age as their own or to nurses who have nothing in common with their patients. A St. Louis oncology nurse quoted Holocaust survivor and psychiatrist Viktor Frankl to States News Service in 2012: “ ‘What is to give light must endure burning.’ I think people who care for others understand. Caregiving is painful.”

The ANA lists compassion fatigue symptoms including anxiety, depression, disrupted sleep, memory problems, fatigue, headaches, upset stomach, chest pain, and poor concentration. Nurses suffering from compassion fatigue might be less able to feel empathy toward patients or their families and more likely to abuse drugs or alcohol; they might avoid or dread working with certain patients.

Distinguishing characteristics of burnout versus compassion fatigue vary by the expert, but there seems to be a general consensus that burnout is caused by stress related to the job (understaffing, lack of support) while compassion fatigue is caused by stress related to the patients (connections with patients or families, caring for the suffering or dying). Burnout can lead to emotional exhaustion, but compassion fatigue causes heavy- heartedness. Michigan nurse and staff educator Shari Simpson explained at an Association of Pediatric Hematology/Oncology Nurses annual conference, “Compassion fatigue does not mean one is no longer capable of feeling compassion. It’s the feeling of compassion weigh[ing] so heavily on you that the way you experience life is affected.”

Both conditions, author Deborah Boyle wrote, “are associated with a sense of depletion within the nurse, a ‘running on empty’ feeling.” And nurses can experience burnout and compassion fatigue at the same time. A trauma nurse in North Carolina was hit by this double whammy. “Doctors are demanding, patients are demanding, management is demanding. If the doctor orders a wrong medication, and the nurse gives it to the patient, whose fault is it? It’s your fault for giving it. If a drunk patient gets out of bed and falls, it’s your fault for not being there to stop him, but the doctor won’t give you an order for restraints. Everything in hospital healthcare comes down to the nurse. Every second of every shift, you are giving, doing, running, caring—it’s draining,” she said.

For this nurse, the combination of compassion fatigue and burnout contributed to a depression that bordered on suicidal. “I have had days where I would have rather crashed my car than go into work. I was getting sucked dry. The neediness of everyone! It’s like a never-ending rendition of ‘If you give a mouse a cookie’ and as nurses we don’t like to fail. It’s not allowed,” she said. “As a nurse I am completely in tune with my patients, their needs, and the needs of their family. I really can lose track of myself. If it comes down to helping a patient to the bathroom or being able to empty my own bladder after eight hours, it’s going to be the patient every time. It’s not totally healthy. But I can’t imagine doing anything else.”

On a particularly bad day, she arrived at a preshift meeting in which supervisors scolded the nurses. “What I heard was, ‘Customer service is really lacking in the Emergency Department. It doesn’t matter what’s going on in your personal life. We don’t care. It is always all about the patients,’ ” she remembered. “And this whole time, I had been thinking of killing myself. In my head, I kept putting a gun in my mouth and pulling the trigger; it was like I was watching a movie over and over again.” Eventually, the nurse confided in a psychiatric resident and her husband, who helped her to pull through. Today she is a stable, healthy nurse who continues to love her work.

Employees in any helping profession can be afflicted with compassion fatigue, including social workers, counselors, chaplains, and humane workers. But nurses are particularly vulnerable, Boyle wrote, because “they often enter the lives of others at very critical junctures and become partners, rather than observers, in patients’ healthcare journeys. Acute care nurses in particular often develop empathic engagement with patients and families. This, coupled with their experience of cumulative grief, positions them at the epicenter of an environment often characterized by sadness and loss.” Simpson calculated that if an inpatient nurse sees an average of even just four patients during a twelve-hour shift, in twenty years she will care for more than 11,000 patients and families. A clinic nurse who sees ten patients per shift will care for nearly 43,000 patients. Those numbers require an extraordinary amount of compassion.

It is possible that the nurses who care the most might bear the highest risk. Researchers report that some types of personalities are more susceptible to stress and compassion fatigue, such as people who are overly conscientious, perfectionistic, and self-giving. And nurses are already highly empathizing people. “We are programmed to be able to do it all; we give our life and soul to the profession,” said a Florida psychiatric nurse. “Sometimes, if you feel you can’t help an individual, you feel you have failed.”