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How trying to ease constant pressures on healthcare teams, especially since the pandemic began, has affected nurse managers, plus how to spot the signs and seek support
When Aly Foyle was working as a sister on an outpatient cancer unit, small, strange changes started to creep into her working practice.
Nursing Standard. 37, 7, 31-33. doi: 10.7748/ns.37.7.31.s18
Published: 06 July 2022
She started to shut her door when she was in her office, did not engage as much with her team or patients, felt more tired and was impatient when dealing with what would previously have been relatively small issues.
‘I felt a bit tired and sad,’ Ms Foyle recalls. ‘I just started to feel intolerant and didn’t want to engage with patients or staff, which was not me at all. Even just closing my door when I was in the office, putting that barrier there for staff, was not like me.’
After finding herself in tears over incidents she would previously have taken in her stride, she spoke to her manager, who suggested she take a few days off. This turned into a four-month absence for the experienced and dedicated nursing manager, with a diagnosis of compassion fatigue and depression.
Experiences such as Ms Foyle’s are at the heart of an issue discussed by nurses at RCN congress 2022 in Glasgow last month.
Compassion fatigue and burnout have been an issue of concern in the nursing workforce in recent years, and the debate at this year’s congress focused on the impact on nurse managers.
Compassion fatigue, sometimes described as the ‘cost of caring’, is where emotional and physical exhaustion lead to a reduced ability to empathise or feel compassion for others.
While there is no universal definition, it is often used in the context of the experiences of healthcare staff. More loosely, it refers to when people feel unable to respond to a request for help because they have faced so many demands already.
‘I spent a lot of time thinking about what I could change, and if I should leave nursing’
Aly Foyle, nursing manager who experienced compassion fatigue
Burnout is described by NHS Employers as an emotional, mental and physical state of exhaustion, caused by excessive and prolonged periods of stress. Common in health and social care occupations, it can result in a poorer physical state, mental health problems, reduced job satisfaction, absenteeism and professional errors, says NHS Employers.
Signs and symptoms of burnout include tiredness, lowered immunity, change of appetite, a sense of failure and self doubt, decreased satisfaction and sense of accomplishment, and loss of motivation. It can cause behavioural changes, including isolating from others, procrastination and withdrawal from responsibilities.
Evidence suggests rates of compassion fatigue and burnout are high in the nursing profession: the 2021 RCN employment survey found 68% of nurses felt under too much pressure at work.
While it has come to the fore during COVID-19, the issue of compassion fatigue among nurse managers has had less focus. There is limited research on how it affects senior nurses, but a recent review in Spain found burnout affected about 30% of nurse managers.
Senior nurses say it is a hidden issue. University of Southampton lecturer in nursing workforce Chiara Dall’Ora says: ‘What emerges from this literature is that work overload is a big factor – when there are staff shortages it’s the managers who need to step in,’ she says. ‘Lack of support was also implicated, as well as feeling inadequate to face the significant responsibilities of the job.’
British Association of Critical Care Nurses chair Nicki Credland, who is head of department for paramedical, peri-operative and advanced practice at University of Hull, says being a nurse manager is a high-pressure role.
More senior staff are responsible for the safety and quality of care, writing policies, staff rotas and ensuring adequate numbers of staff, and nurses in these roles can feel pressure from above and below, she adds.
‘Trying to write a rota for an intensive care unit with no staff is stressful,’ says Ms Credland.
‘You are in the middle, trying to protect and support your staff, but at the same time there is that tier of staff above saying you have to manage with fewer staff and less equipment that is pushing down on you.’
When more junior members of staff need support with the emotional toll of their work, they often turn to their line manager, a more senior nurse. ‘The manager is taking on the burden of some of that distress of their staff,’ she says.
» If you are considering the possibility that you have compassion fatigue, you have already taken the first step by acknowledging it: denial is common among those who are experiencing it, says the Compassion Fatigue Awareness Project
» Compassion fatigue should not be viewed as a personal failure, but more as a measure of the pressures you have been under and what you have been exposed to
» If you feel you need support, your employer should be able to signpost you to a counselling or occupational health service
» Your line manager may also be able to help in other ways, for example by ensuring you are able to take breaks and access debriefings and supervision
» RCN members can also contact the college’s counselling service for support: tinyurl.com/rcnmember-support
A management role is also more likely to creep beyond the boundaries of a shift, giving little time off from work pressures.
‘When you are a clinical nurse you do a 12-hour shift and go home. Until you go back on shift you often don’t have to think about it,’ she says. ‘But the higher up you go, the more work you have that falls outside of those normal working hours. That switch-off from work is virtually non-existent.’
Ms Credland line-manages more than 30 staff in her university job and says she is virtually always on-call. ‘There is no end to my working week. If I’m needed at 4am, that is just how it is. It is the same if you are a ward manager, you don’t stop thinking about work because you still have that overall responsibility.’
Managing people can be difficult, and exerts an often underestimated pressure. Ms Foyle says that the accumulation of the pressures that fall on a nursing manager pushed her into compassion fatigue and depression.
‘I had worked in cancer care for 25 years and I loved it, but it takes a toll,’ she says. ‘But, even more than that, managing people can be difficult, especially managing people in a cancer care environment. At that point I had had enough, and I wasn’t an effective nurse or manager. My tank was completely empty.’
‘The higher up you go, the more work you have that falls outside of those normal working hours. Switch-off from work is virtually non-existent’
Nicki Credland, pictured, chair of the British Association of Critical Care Nurses
Up to 1 in 3 nurse managers are affected by burnout
Source: International Journal of Environmental Research and Public Health article – Burnout in Nursing Managers
68% of nursing staff say they feel under too much pressure at work
Source: RCN 2021 employment survey
57% of nursing staff were either thinking about leaving their job or actively planning to leave
Source: RCN 2021 employment survey
She says she received excellent help from staff support and occupational health services at the Royal Marsden NHS Foundation Trust in London, where she worked, and this was key to her recovery.
‘The hospital and my husband were fantastic, and I spent a lot of time thinking about where it had gone wrong, what I could change going forward, and if I should leave nursing,’ she says.
When it comes to support that can help nursing managers who are struggling, a number of leading organisations highlight the importance of being able to access clinical supervision and take time for reflective practice.
In March 2022, the Point of Care Foundation, the Florence Nightingale Foundation, Foundation of Nursing Studies and the Queen’s Nursing Institute Scotland issued a statement about the need for, and value of, reflective practice in the profession. Despite the recognised pressures and trauma of working through the pandemic, such time to reflect is often sidelined and seen as ‘a self-indulgent luxury for those who aren’t busy enough with the “real” work,’ the statement says.
Opportunities to share difficult experiences – for example through Schwartz rounds, where all staff members can discuss and reflect on the emotional toll of caring – can prove elusive, says David Jones, head of staff experience at the Point of Care Foundation.
He says nursing managers are under-represented at Schwartz rounds. ‘We hear consistently that it is hard to get the space to come to Schwartz rounds,’ he says. ‘We are worried because of the effect that is likely to have further down the line.’
Mr Jones says he sees nursing managers take on almost ‘parental responsibility’ for their staff.
‘It is a particular phenomenon where they care for their staff way beyond standard management practice, and they feel wretched about what they have asked their staff to do over the past couple of years,’ he says.
‘The emotional burden of that is different and they also have their own challenges and burdens, and it is a lot of pressure on them. This is a group of amazingly resilient people, but it feels hard.’
Research carried out by the Point of Care Foundation also found senior leaders find it difficult to get the same benefits from Schwartz rounds as other members of staff.
‘They found sharing emotions, even in the protected environment of the round, to be challenging as they feared it might undermine their credibility as leaders by being perceived as weak and vulnerable, and cause some level of distress to staff,’ the researchers, who interviewed 25 senior leaders, said.
‘In times of crisis, we often look to our leaders. Sometimes we expect too much of them. Leaders are not superheroes – they are human too, subject to the same emotional challenges as everybody.’
The researchers noted that the leaders are relatively good at finding support elsewhere, and often rely on personal networks of family and friends, and on their peers, with whom it is easier to be more open.
Ms Credland says switching off from work is important. She swims three times a week, a precious time when she is entirely away from her phone and work demands.
For senior nurses who do experience compassion fatigue, Ms Foyle urges seeking help as early as possible. She found the support available through her employer invaluable, and would recommend nurses find out what is available in their workplace.
Nursing leaders who are struggling should not think of this as the end of their career or their ability to be a good nurse, she adds.
» Feelings of helplessness and powerlessness
» Reduced empathy and sensitivity towards others
» Feeling overwhelmed and exhausted by work demands
» Feeling numb and emotionally disconnected
» Loss of interest in activities you used to enjoy
» Increased anxiety, sadness, anger and irritability
» Difficulty concentrating and making decisions
» Difficulty sleeping
» Physical symptoms, including headaches, nausea, upset stomach and dizziness
» Neglect of self-care
After four months of recovery, Ms Foyle returned to work and was later promoted to matron. She recently left the role, but only because she felt the time was right. She says while it is difficult to be open and honest about what she experienced, she felt she had to: ‘If I was feeling like this, I knew other people would be too.
‘People were often surprised, as I am gregarious and quite fearless and resilient. I want people to realise that just because you look strong on the outside, it doesn’t mean that there is not a whole lot going on inside. I fear we will slowly but surely continue to lose staff to what, in many cases, is a preventable problem.’
She channelled the experience into becoming a better nurse, she says. ‘I’m a much better manager for my experience, and a better person.’
Compassion fatigue awareness project compassionfatigue.org
Point of Care Foundation pointofcarefoundation.org.uk