Public spirit and compassion fatigue: Focus on nurses' well-being

 

Trine Lykkegaard Sønderkær

 

VIA University College, lykkegaardtrine@hotmail.com

This paper discusses the concept of compassion fatigue in light of the importance that political decisions, especially the application of the concept of public spirit, have had on care and nursing in a Danish hospital context during the COVID-19 pandemic. The paper is based on recent research literature in the field as well as the author’s own participatory observation study. The paper suggests that nurses already show a sense of public spirit due to their authorization and professional ethics, but at the same time they must balance the ambiguity of nursing care. A linguistic-philosophical study of public spirit shows that the concept can have a discursive, double-binding and interpellative effect on nurses, who may therefore have an experience of inadequacy and compassion fatigue. In this context, compassion fatigue must be understood as the fact that nurses cannot provide the care they want or that is expected of them. Public spirit can be said to have had a renaissance and linguistic and moral supremacy during the COVID-19 pandemic. The paper views the concept of waywardness¹ as a possible response for how to prevent or completely avoid compassion fatigue, so that nurses instead have an experience of compassion / self-compassion. This could in the end be important for encouraging more nursing students and nurses who have the desire and opportunity to stay in the profession.

 

Keywords: Nursing care, compassion fatigue, public spirit, compassion, COVID-19 pandemic

 

 

Introduction

The purpose of this article is to conceptually clarify compassion fatigue. The article will also highlight the importance that political decisions have had on the care that nurses have been able to provide under the pressure that has existed and continues to exist in nursing. This pressure includes the government's use of the concept of public spirit as a focal point in the many direct and indirect appeals, especially to nurses during the COVID crisis.

 

The concept of compassion fatigue is not new. Already at the end of the 1990s, Professor Charles R. Figley introduced the concept as the gradual and increasing wear and tear on professional helpers' ability to empathize, care and show compassion (Isdal 2018).

 

The article supports the perspective that a focus on the concepts of waywardness, compassion and self-compassion can offer an answer to compassion fatigue. Such a focus could contribute to more nursing students and nurses staying in the profession. This perspective includes an understanding that the nurse has to “give herself the oxygen mask first” before she can help the patients, and that feeling powerless and compassion fatigue are not shameful.

 

The reason for dealing with the subject is that it is still highly topical. The COVID-19 pandemic has had a great impact on care and nursing (Lake et al. 2021 and Silverman et al. 2021). A brand-new Danish studio by Kaldal et al. (2022) Umbrella review: Newly graduated nurses' experiences of providing direct care in hospital settings shows that newly qualified nurses often lack support and experience emotional stress in their work as a nurse. This has consequences for the care and nursing performed (Kaldal et al. 2022). This problem is also showcased by The Danish Council on Ethics (Det Etiske Råd), which has published the report Omsorg I sundhedsvæsenet (2021), translated to ‘Care in healthcare’. The report states that care is demanding, that care should be protected through education and that care is a fundamental need for all people – and thus also for care professionals. The council writes, “How do we ensure sympathetic insight, empathy, spontaneity, and personal commitment in an environment where productivity goals, scarce resources and time rationing for good reasons play an important role?” (Det Etiske Råd 2021, p. 5).² When this problem is compared with the many vacant nursing positions and study places in nursing programs, and hence the great need to train more nurses, it suggests a need to focus on the conditions in which care and nursing exist.

 

Method

The article is based on studies and recent research literature on moral stress and compassion fatigue during and caused by the COVID-19 pandemic. The search for literature has been pragmatic, combining searches of databases like PubMed and subsequent chain searches. The search terms “compassion fatigue” AND “moral distress” AND “COVID-19” AND “nursing” AND “public spirit” are used with language variations in relation to English and Nordic terms. The search includes articles from 2020 onwards, and articles dealing with nursing outside the hospital are excluded. Findings from the following studies are included in the article: Hospital nurses' moral distress and mental health during COVID-19 (Lake et al. 2021) and Moral distress in nurses caring for patients with Covid-19 (Silverman et al. 2021).

 

These articles and my own empirical study form the basis for this article. The empirical data derive from collected data from participant observation studies in Danish hospitals' intensive care units, starting with the first critical admissions to intensive care units at the outset of the COVID-19 pandemic in early 2020, until the summer of 2021. The participant observation study included as a method 100 intensive care nurses' anonymous statements during the pandemic (Kristiansen & Krogstrup 2015 and Szulevicz 2020). Anonymity has been used to maintain spontaneity, confidentiality and authenticity in the study and at the same time to comply with ethical principles in health research (WMA 2022 and SSN 2003). The author has been part of the staff as an intensive care nurse in the contributing departments. Field notes from the experiences and stories of the intensive care nurses involved were written down along the way and form the background for the thematic division of headings in this article. Virginia Braun and Victoria Clarke defined one thematic analysis as “a method for identifying, analyzing and reporting patterns (themes) within data” (2006, p.79). The thematic analysis that forms the basis of this observational study is inspired by a “contextualist” method. This method lies between essentialism and constructionism. It can be understood as a focus both on theories – in this context within the subjects of ethics, philosophy of language, nursing and psychology – and on recognizing the experiences and opinions that those involved – in this case intensive care nurses – experience as the effect of a given discourse – here the political discourse that has made itself felt during the COVID-19 pandemic (Braun & Clarke 2006). In this way, empirical evidence is partly used as a starting point for the thematization and as a building block in relation to the framework in which literature takes on a role as a discursive basis for interpretation. From this, it must be understood that my own empiricism and other people's studies are equally weighted in covering the article's discussions.

 

The themes that emerged from the analysis of the observational study are: “The renaissance of the concept of public spirit is putting pressure on a pressured healthcare system”, “Are you allowed to say no?”, “A speech act”, “Public spirit as a trump card”, “Antagonism and double binds”, “Interpellation of Nurses”, “Compassion fatigue as a ‘breaking point’”, “The ambiguity of care”, “Waywardness and compassion as countermeasures”, “Who takes care of those who take care of others?” and “The health sector's inclusion of health professionals' well-being”. The thematic analysis is based on the six phases of Braun and Clarke's thematic analysis (2006).

 

The article uses a historical feature as well as a discursive and linguistic philosophical point of view in order to be able to analyze the themes and learn more about the concepts that have unfolded in the analysis of the observation study and the articles. In the following, analysis and discussion follow each thematic division. Finally, the conclusion summarizes the main points from the article's discussions and makes suggestions for future research.

 

The renaissance of the concept of public spirit is putting pressure on a pressured healthcare system

On 11 March 2020, Danish Prime Minister Mette Frederiksen stated at a press conference:

We will need a sense of public spirit. We will need helpfulness [...] Those who cannot be sent home are, among others, personnel in the health sector [...] Let us now show what we can do when it comes down to it [...] It will be tough. The situation is going to make huge demands on all of us. But of course very special demands for those of you who work in our hospitals. In the intensive care units. In the high-risk departments. We will need you very, very much in the very near future. (Statsministeriet 2020, 11 March).³

 

After this and many subsequent press conferences, the concept of public spirit takes on a very special appeal-like and morally symbolic meaning in Denmark, as a benchmark for how we should all act towards each other in the middle of a time of crisis. The concept of public spirit has had a renaissance, so to speak, after almost not having been used since the Second World War (Asmussen 2021, Kristiansen 2021 and Dohrman 2021).

 

Although the health service, including nursing, has been under pressure for several years, it seems that the COVID-19 pandemic and the government's appeals to give more, to show public spirit and live up to the “very special demands” that have put even more pressure on the nurses in the Danish hospitals (Pedersen 2021).

 

My own participant observation study shows how there can be a connection between public spirit and compassion fatigue said by one of the nurses:

I definitely believe that there is a connection between the concept of public spirit and care fatigue. We are getting tired in the department. Several people have resigned, because they either do not want to participate in the restructuring or the conditions that we have.⁴

 

In terms of authorization, nurses should live up to an obligation and professional ethics (Andersen 2022 and Dansk Sygeplejehistorisk Museum 2010). They can be hard pressed under the conditions that existed during and after the COVID-19 pandemic, and which, according to the observational study, are due to the government's appeals to show public spirit. The authorization itself already implies that nurses, given the normative starting point in their business, must show morally correct behavior and a sense of public spirit (Nortvedt 2010, Beauchamp & Childress 2003 and Bøgeskov 2022). When the prime minister asks nurses to show (even more) public spirit, findings from the observational study show that more nurses experience inadequacy, a feeling of not being able to act, and ultimately compassion fatigue. In this context, compassion fatigue as a concept must be understood as a mechanism that, according to nurse and psychotherapist Benedikte Exner, psychologist Per Isdal and docent Benjamin O. Bøgeskov, can arise due to external conditions and requirements such that nurses cannot provide the care they want to or that is expected of them. This is the mechanism that occurs when you know the right thing to do, but cannot do it (Exner 2011, Isdal 2018 and Bøgeskov 2022). According to Jacob Birkler, philosopher and former chair of the Danish Council on Ethics, nurses are exceptionally dutiful. He says about nurses that:

 

They have no doubts about what the right thing to do is, but they just don't have the framework. People do not understand the conditions they work under at all, where on the one hand they must be useful, but on the other hand are close to being exploited in certain situations […] That is precisely why we must be careful when we load them with obligations.⁵ (Søgaard 2020)

 

Are you allowed to say no?

During my own observation study, a nurse stated in continuation of the above quote, “Can you even allow yourself to say no?”.⁶ Caring can be said to be an essential ethical value for nursing, and a truly caring act is a meaningful act for nurses (Bøgeskov 2022, Bøgeskov 2019, Indenrigs- og Sundhedsministeriet 2023, Det Etiske Råd 2021 and Birkler 2009).

 

The above can be supported by two research articles that have investigated nurses' moral distress during the COVID-19 pandemic. According to philosopher Benjamin Bøgeskov (2022), moral stress and compassion fatigue can be compared, because the lack of compassion and care can eventually lead to a morally wrong action.

 

One of the two articles is a quantitative study by Lake et al. (2021) conducted in the USA, using a new validated COVID-19 Moral Distress Scale. The study investigated moral stress and mental health among 307 nurses who worked at the hospital during the first months of the COVID-19 pandemic. Silverman et al. (2021) carried out a qualitative study, also from the USA. They conducted 31 focus group discussions and interviews with nurses who worked in hospitals during the pandemic. The study showed that the special ethical requirements present during a pandemic are a possible causal explanation for the compassion fatigue and moral stress experienced by many nurses during the COVID-19 pandemic. The two articles infer that moral stress occurs for nurses who know well what moral actions are the right thing to do, but are unable to perform them. Moral stress is understood as the discomfort and inadequacy that can arise when a person does not feel able to live up to the moral obligation that is expected of them. The articles state that due to special ethical requirements during a pandemic, ethical dilemmas and moral stress can arise for the nurses, who are caught between providing the best individual patient care and providing good care for as many patients as possible. Moral stress is associated with emotions such as guilt, anger, frustration and powerlessness (Lake et al. 2021 and Silverman et al. 2021).

 

According to Bøgeskov (2019), it can be stated that time with patients seems to be nurses' core task, and when they feel that how they have to prioritize conflicts with their moral obligations, they may feel guilty about failing the patients. Bøgeskov states that there is a prevailing ideology of busyness, where political changes can put care and nursing to the test or in a bind, because a deep misunderstanding can arise. “This misunderstanding consists in the fact that what one party considers important (care and contact with the patient) is seen by the other party as irrelevant, or worse still: it is interpreted as an egotistical complaint about poor working conditions” (p. 78).⁷

 

The article containing this quote continues with a look at how political decisions and use of language, in Bøgeskov's words, seem to be able to put care and nursing in a bind.

 

A speech act

Language can have such great power that it can help create and change reality (Jørgensen & Philips 2005). Through the observational study, the nurses' statements and experiences show that the use of the concept of public spirit seems to have such a great discursive and moralizing power that it influences the nurses' ability to practice care. It may seem paradoxical that a concept such as public spirit, which at first seems to have a positive resonance, can also have a negative, albeit ambiguous, meaning for nurses. The observational study shows that, on the one hand, the concept of public spirit is encouraging and motivating, while on the other hand it can act as a moralizing pressure that can expose nurses to compassion fatigue.

 

A linguistic-philosophical study of the concept of public spirit shows that the concept can have a discursive, double-binding and interpellating effect on nurses. It may seem that the government's positioning through the COVID-19 pandemic can be compared with psychoanalyst Jacques Lacan's theory of the master discourse (Lacan 1969-1970). Prime Minister Mette Frederiksen has stood strong as the champion and an authority whose word is law in her speeches, which in some respects have addressed the healthcare staff directly. Application of the concept of public spirit can also be said to have become a cultural phenomenon, as a guideline internalized by many, including nurses, for the right thing to do. Many of the nurses from the observational study have experienced pressure due to the use of the concept of public spirit in a healthcare context. Based on psychoanalysis founder Dr. Sigmund Freud's (1948) concept of the cultural super-ego, the application of public spirit may have created additional pressure because the nurses probably tried to achieve satisfaction and recognition by living up to it. The cultural super-ego can be seen as a kind of societal ethics that makes demands based on a certain ideal, which at the same time can have a destructive force for the individual (Freud 1948). A cultural super-ego can be said to be found in the prime minister's speeches, for example referred to as: “Our joint efforts are of crucial importance.”⁸ (Statsministeriet 2020, 30 March). Several nurses have stated that the concept of public spirit has been applied to hospital wards. The concept seems to have spread like wildfire, as a cultural guideline for a certain ideal. This is illustrated by the following quote from the observational study, where an intensive care nurse talks about the importance the prime minister's speech about public spirit had on her work:

It gave me recognition – that is, to be recognized for my work – and it gave me faith that it everything would work out, and while you're there, you just accept it as a condition, do your best and think okay then, this is what I need to do right now.⁹

 

Public spirit as a trump card

The concept of public spirit can be said to be discursive, which is justified below based on the discourse theory of the two philosophers Ernesto Laclau and Chantal Mouffe (1997). According to them, articulation is a linguistic practice which puts concepts together and connects them. This creates a new conceptual identity, which Laclau and Mouffe call discourse (Laclau & Mouffe 1997). The concept of public spirit has roots back to 1936, used by Prime Minister Thorvald Stauning and author Ejnar Howalt as an ideological concept (Kristiansen 2021, Asmussen 2021 and Howalt 1936). Now it has been used in a new context in relation to several concepts that describe conditions, including limitations and restrictions, that society has needed to deal with during the COVID-19 pandemic. This articulatory process has resulted in a political discourse applied in relation to nursing, where staff has often been encouraged to act in concert and participate in the coronavirus preparedness. Public spirit as a concept can be seen as what Laclau and Mouffe call a nodal point, which takes precedence over other concepts and may have acted as the rallying point that has tied the discourse together. In a way, it can be said to have created an understanding of the COVID-19 pandemic. Laclau and Mouffe also use the concept of hegemony – the fact that a concept or a specific linguistic discourse acts as a guide (Laclau & Mouffe 1997 and Jørgensen & Philips 1999). The government's discourse on the concept of public spirit during the COVID-19 pandemic can be seen as hegemonic, having a kind of linguistic supremacy – a “trump card” – that has symbolized how we all, including the country's nurses, should navigate during the COVID-19 pandemic. One could say it in such a way that public spirit as a concept cannot be countered or criticized by other concepts, which has given it a moral potency. Mette Frederiksen stated, “We will need a sense of public spirit […] We show a sense of public spirit. That's what works.” (Ministry of State 2020, 11 March) and “[…] thus we also share a power that cannot be reduced to a formula. But which has proven invaluable. Public spirit” (Statsministeriet 2020, 30 March).¹⁰ The concept of public spirit during the COVID-19 pandemic can be said to have a hegemonic effect, because it has had the effect of setting norms and governing – and in some respects even governing behavior. As expressed by a nurse from the observational study:

I felt a strong obligation to sign up when I was contacted by emergency services last year. Especially after the government's announcements. But I was divided because on the one hand I wanted to sign up; I thought that I was now needed (with emphasis on “me”) as a nurse. On the other hand, my family pulled on me. They thought I should look after them and myself.¹¹

 

Antagonism and double binds

The above quote leads us to look at what Laclau and Mouffe call antagonism, a term that refers to discourses that clash or conflict with each other in a battle for meanings (Jørgensen & Philips 1999). This has been experienced by several nurses from the observation study, because the meaning of the concept of public spirit has been experienced differently based on the role of care professional and the role of mother, father, spouse, lover, friend or otherwise “ordinary” member of society. The study shows that for some it has created an identity conflict and a feeling of not being able to live up to the government's messages and appeals. In this way, these messages and appeals may have created conflicting or ambiguous messages for nurses, who have had to figure out how to prioritize between their own and their family's risk of infection and survival, and on the other hand, their role as care professional.

 

According to anthropologist and researcher Gregory Bateson (2005), contradictions or ambiguities – which Bateson calls double binds – often exist in human communication. Double binds arise easily if the recipient of a particular message does not know what to expect. This is a situation we have been in many times during the COVID-19 pandemic, often expressed as “untrodden land” (Statsministeriet 2020, 30 March). Frederiksen's press conference speeches have not been entirely consistent. She stopped using the concept of public spirit from one day to the next, for instance. According to Bateson, negative “orders” can exist as part of double binds, which can be difficult to live up to. During the COVID-19 pandemic, we saw this exemplified as “threats” by the prime minister to further shut down the country if we could not live up to a low infection rate and reduce hospitalizations. as in the example below.

I also want to honestly say that if we do not succeed in the next two weeks. If the numbers start to rise too violently. Or if we start gathering inside or outside again. Not keeping distance. Then we can't start to open up – we might have to tighten up even more instead (Statsministeriet 2020, 30 March).¹²

 

This can be called a double bind, as the increase or decrease in the infection numbers did not necessarily depend exclusively on individuals’ compliance with restrictions. According to Bateson, many reinforcements, in the form of praise and recognition, may be necessary to maintain the relationship between sender and receiver when double binds exist (Bateson 2005 and Keiding & Laursen 2005). Healthcare staff have experienced many such double binds during the COVID-19 pandemic, both from the government but also from the population. One of the nurses from the observation study says, “Yes, in relation to being recognized for one's work, it kind of makes you want to fight on and think that this is where I can help. But afterwards the reactions came. Then you can sort of see all the things that were too hard and maybe weren't right.”¹³

 

Another nurse from the observation study says that the value of recognition has been essential during the COVID-19 pandemic in relation to living up to the government's appeals to show public spirit. She states that it has been an obligation to help during the crisis, which has also given birth to a hero status.

 

Interpellation of Nurses

In continuing the above thread, it is relevant to include philosopher Louis Althusser's (1970) concept of interpellation. Interpellation must be understood as the act that a state power makes use of by approaching citizens with a desire for help in solving a specific task. A mutual dependence is created between the state and the citizens, who allow themselves to be interpellated, called upon or invoked. Althusser's own story about the policeman who shouts in the open street: “Whoah, you there!” (1970, p. 60), exemplifies how a certain person feels met and addressed (Højrup 1995 and Althusser 1970). The prime minister's words illustrate such interpellation:

More tests are a prerequisite for us to be able to open society again. I am happy that the authorities have announced that they will test far more people in the hospitals. But testing in the healthcare system requires a lot of resources – including personnel (Statsministeriet 2020, 30 March).¹⁴

 

Based on this statement, it can be suggested that each individual health professional staff has been interpellated to provide more in the fight against coronavirus, since the fight requires a lot of health professional staff. From the observational study, a nurse said, “If the nurses did not take on this task, who would?” The study suggests that many nurses have felt a strong obligation to show public spirit and be part of the ideology that Mette Frederiksen has “called for” and in that way try to live up to the moral pressure and responsibility that she has both directly and indirectly stated with words such as “of course very special demands for you who work in our hospitals” (Statsministeriet 2020, 11 March).

 

Compassion fatigue as a “breaking point”

This article addresses the government's discourse in depth, including the use of the concept of public spirit as a possible cause of compassion fatigue among nurses in Denmark. The discourse must be seen in the light of the fact that it rests on something else. The Danish healthcare system has been under pressure for a long time (Det Etiske Råd 2021, Isdal 2018 and Korsgaard 2019), but the public spirit discourse may have been the “the final straw” in the nurses' experience of compassion fatigue. As Høgsted (2019) puts it, “No one can endure everything. Everyone has a breaking point where you can't take it anymore” (p. 28).¹⁵ A nurse from an intensive pandemic unit relates that:

Nurses are in principle happy to provide care. However, the working conditions, such as lack of recognition and conflicting demands, can result in one’s own capacity to provide necessary care for other humans being reduced or ultimately exhausted (a populist form of mental fatigue). Nursing then turns into mechanistic, reductionist care that in no way emphasizes relational care, which is the prerequisite for nursing.¹⁶

 

This view is supported by the metasynthesis of Nolte et al. (2017), who considers compassion fatigue to be “a state of exhaustion that limits the ability to engage in caring relationships”¹⁷. Isdal (2018) finds that people who work as helpers, as do nurses, activate something essential in the human being as an empathic person, and that it is also very common that these helpers like their work. The metasynthesis shows, however, that job satisfaction and high workload with the consequent risk of illness often go hand in hand. In addition, sickness absence statistics in Denmark indicate that the country's most burdensome and health-threatening work is within the social and health services, and that a simultaneous increase in sick leave within health and care work occurred during the COVID-19 pandemic (Danmarks Statistik 2022). According to Isdal (2018), the last 30 years of research suggest that working with people is more stressful than we realize. He mentions that a pandemic can be a trigger for compassion fatigue, because it is a dangerous situation with existential burdens. According to him, compassion fatigue manifests itself as both physiological and psychological reactions, ranging from fight and flight reactions from the sympathetic nervous system, to fatigue, difficulty concentrating, sleep problems and PTSD (Post-Traumatic Stress Disorder). According to Rigshospitalet chief psychologist Anders Korsgaard, it can be dangerous to have a job as a nurse, because the job is so meaningful but at the same time difficult to put aside and prioritize one's own needs. Paradoxically, some needs must be met if one is to continue to function as a helper (2019). A nurse from the study states that:

As a nurse, you experience quality of life in a profession that is very hard and that demands a lot from you, and you share a lot of yourself. You feel special when you can help others in their crisis. In that way you also get something out of it, but in the long run it saps your energy.¹⁸

 

This quote can be backed up by professor and researcher in psychology Paul Gilbert (2009), who says compassion fatigue can be understood as empathic overwhelm. As a counterpart to this, Høgsted (2019) maintains that there is still often an attitude that the right professional is someone who never breaks down and who can always withstand the pressure they are exposed to. Here she mentions professionals such as nurses in particular. She calls this attitude “the myth of the invulnerable helper” (p. 28). If you as a nurse cannot comply with this expectation, according to Høgsted, it can lead to a very painful feeling of shame that is associated with humiliation, violation and being outside the community (2019). Lake et al. (2022) have found in their quantitative research that a significant proportion of the nurses who have worked at the hospital during the COVID-19 pandemic (and especially nurses in intensive care units) have experienced long-term psychological problems like anxiety, withdrawal and sleep problems. My own observational study supports this finding, where a nurse who returned to her ward after being part of the coronavirus pandemic unit, says, “I think it's so different how you react. I feel like a slob, inadequate because I wasn’t able to do it, but all my colleagues could.”¹⁹ Furthermore, in general in the observational study quite a few nurses expressed a feeling that “I’m the only one who can't cope with the pressure,” where they often say at the same time that it is embarrassing or a defeat to not be able to perform adequately.

 

The ambiguity of care

Philosophy professor Arne Johan Vetlesen (2001) refers to the ambiguity of care, where care professionals are divided between the ideology of care on the one hand and, on the other, productivity thinking, which do not always go hand in hand. One could say that the ideology of care has one discourse, while productivity thinking, including technical-economic management, has another, and in that way there will be a risk of what Laclau and Mouffe call antagonism (Laclau & Mouffe 1997 and Jørgensen & Philips 1999). One could imagine that clashes or conflicts arise in relation to how both care and public spirit are to be understood. The nursing theorists Benner and Wrubel (2001) estimate that society's devaluation of care may be a considerable source of nurses' experience of stress and lack of coping within nursing. This is supported by Bøgeskov (2022), who states that, due to external conditions, nurses must compromise their own ethical nursing values.

 

The above can be supported by the observation study, in which a nurse says that she left the care profession because she could no longer see herself working in the fast-paced society that exists right now. She states, “It is impossible to keep taking on more, but I also cannot say no to patients – that would be civil disobedience – it’s as if there is no longer room for humanity.”²⁰ Vetlesen (2001) continues this thread in describing that care has become alien to us, the core of care from the beginning – the closeness and empathy for another person's existence – now seems more and more transformed into a sector where the same confidentiality and humanity no longer exist as before.

 

Waywardness and compassion as countermeasures

In hypothesizing that the government's discourse, including the use of public spirit, may be one of the causes of more nurses experiencing compassion fatigue, it seems relevant to also look at how such fatigue could be prevented or completely avoided.

 

The concept of compassion fatigue has as its counterpoint the concept of care satisfaction – or compassion satisfaction – which includes the feeling of meaningfulness and success in the performance of care professionals' work (Høgsted 2019). In recent years, many psychologists and researchers who work with care professionals have discussed the concept of compassion, which can be described as both being aware of one's own and others' suffering and as feeling a desire or a motivation to alleviate suffering. Gilbert (2009) mentions self-compassion as a contributing factor in alleviating mental disorders. This is to be understood as an understanding, acceptance, kindness and forgiveness for oneself. Mindfulness can also be included in this list. Psychologist and author Sarah Parry (2017) states that compassion is often one of the qualities that lead individuals into social work. She believes that the emotions that care professionals experience every day are often so intense and sometimes destructive that care professionals should develop the ability to handle them, for example by means of reflection and supervision. Parry (2017) writes about care professionals who are very self-critical, and who, with the help of different models, can become kinder to themselves and proactively counteract their own inner critic in order to experience a greater degree of compassion satisfaction – and a lesser degree of compassion fatigue. This can be seen in a quote from a nurse in the observation study, who indirectly gives similar advice as a possible perspective on or prevention of compassion fatigue:

It has felt as if we have been and are just pieces in a game. We have been thrown around. I think that people should have listened a little more to all those who expressed that they could not do it. Many individuals felt unsafe. Many are on sick leave now. It has to be important to listen and find out each individual's competencies and what each person is capable of.²¹

 

Who takes care of those who take care of others?

Isdal (2018) disputes the idea that little has been written about how to help and treat care professionals who have been affected by compassion fatigue and thus become ill from their work. Isdal's own advice as a psychologist includes a greater focus on the fact that it is not shameful to face the wall, that you are not sick or insane but just a human being, that everything will get better again, and in the end, it strengthens us as a person and helps us to have such experiences. The concept of self-centeredness and self-compassion can be seen as the opposite of public spirit, because the first concepts center on the individual and public spirit of community and concern for others. The observation study noted a tendency for more nurses to try to free themselves from the moral concept of public spirit when faced with a question such as: “Can you even allow yourself to say no?” One could imagine that waywardness might actually be what is required of nurses to be able to take care of themselves. Can you even take care of others if you don't take care of yourself? No is the obvious answer and can be traced back to the symbolism of putting the oxygen mask on yourself before helping your fellow passengers on a plane.

 

One could imagine that compassion fatigue could be reduced or completely avoided by increasing the focus on compassion, including self-compassion, and perhaps with a future focus on waywardness. Perhaps it would have made a difference for the nurses if the prime minister had addressed them more directly in her speeches and pointed out that they should also remember to take care of themselves. In this way, the ambiguities, double binds and misunderstandings that the speakers may have caused could perhaps have been avoided. Historian and PhD candidate Emil Skaarup (2020) provides a perspective for this. He views public spirit as a moral attitude where individuals allow the interests of society to exceed their own. He believes that self-will or waywardness is ultimately better both for society as a whole and for individuals. He states inspirated by the Scottish moral philosopher Adam Smith: “By pursuing his own interest he frequently promotes that of society more effectually than when he really intends to promote it. Society really thrives better with individualism than with public spirit”²² (Skaarup 2020). As a point of discussion, professor and senior researcher Peter Dieckmann (2021) says that:

If emotional stress is a condition for working in the health care system, then we must become more adept at learning to deal with it [...] But also for those who are in training. My dream is that there will soon be mandatory courses that health professionals look forward to participating in because they will help them to be prepared for the conditions they will have to deal with throughout their working lives.²³

 

Based on this quote, it seems clear that there is a need to look at and act on the well-being of care professionals.

 

The health sector's inclusion of health professionals' well-being

The metasynthesis by Nolte et al. (2017) shows that compassion fatigue in nursing practice is common internationally, and that the need is urgent for future research on improving the working environment for nurses and how nurses can best be supported. Nurses carry out many different tasks in the performance of nursing care, but “the essential product they deliver is themselves” (Joinson 1992). Care requires that nurses give something of themselves, which is why it seems incredibly relevant that an international focus on the health sector is moving towards the development of fourfold goals that will include the well-being of health professionals for the first time, in addition to the existing goals of promoting health, saving money and increasing the patient's quality of life (Bøgeskov 2022).

 

Bøgeskov (2022) believes that ethical reflection (Sygeplejeetisk Råd 2017) can counteract moral stress and compassion fatigue. Here he states three points of attention, under which ethical reflection is included in the third point. The first point is that we cannot always excuse everything by the fact that nurses do not have enough time and proper conditions. There must be “a delicate balance between understanding that unreasonable conditions can lead someone to break their ethical principles, and that unfair terms do not excuse breaking one's principles” (p. 248).²⁴ This shows that we must not completely remove the personal responsibility for compassion fatigue among nurses, but there must be an understanding that the conditions in which nursing exists do have an impact on the nurses themselves. The next point Bøgeskov makes is that the ethical or philosophical lens used to view the concepts of moral stress and care fatigue influences how they are understood. Right now the focus in Denmark is on a culture of resilience, which Bøgeskov refers to as virtue ethics. He questions whether it would be better to focus on a virtue such as humility, understood to mean that it should be acceptable for nurses to ask for help and not always be able to live up to the ideal of nursing care – in this context, perhaps to live up to the moral empowerment inherent in the government's discourse, including the use of the concept of public spirit. In addition to the two points mentioned, Bøgeskov believes that ethical reflection and ethical argumentation can counteract moral stress and compassion fatigue in nursing. It must be understood as a tool that can help nurses to act based on their conscience. According to Bøgeskov, this requires that nurses see and experience – during their training – how ideals can be practiced in concrete situations that contain ethical challenges (Bøgeskov 2022). This could be experienced as part of simulation training in clinical education during basic education for the bachelor's degree in nursing. Silverman et al. (2021) have found that a positive ethical climate can reduce moral stress in nurses.

 

Closing

The discussion of the themes in this article indicates a trend that focuses on nurses' well-being, reducing compassion fatigue, and a discourse both in the government and in the health sector that prioritizes health professionals' working environment. Waywardness and compassion will probably play an important role in encouraging the retention and recruitment of nursing students and nurses to the profession. Furthermore, it can be suggested that minimizing or preventing compassion fatigue will support the ability of nurses to show empathy and care and to enter into relationships – likely with more qualified care and nursing for the patient's benefit as a gain. We might even dare say that nurses could be interpellated and “called upon” to focus on their own well-being and self-compassion, perhaps even to use it when necessary to gain hegemonic power and become an unequivocal part of the healthcare model. This article does not provide a clear answer to how this focus on a larger discourse without double binds and antagonisms might be integrated as part of individual nurses' practice, although the need according to the article seems great. It can be suggested that future research should focus on how to ensure adequate support and prioritization of nurses' well-being.

 

 

Notes

1 Wayward / Waywardness is here used as an English translation of the Danish word ‘egensind’. ‘Egensind’ means being self-willed and stubborn; having one's own ideas and opinions about things. – To follow one’s own mind when the society or your culture dictates a different type of behavior.

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