Jan Powers, a clinical nurse manager in the pediatric oncology unit at the Georgetown Lombardi Comprehensive Cancer Center, remembers how hard it was for her team after the death of a child. They met with an art therapist, who brought clay.
"There was a lot of pounding and kneading, and while we made our pots and whatever, people started to talk," she said of the session last summer. "When your hands are occupied and you're not in the spotlight, it's easier to say things like 'I feel really bad' or 'This child touched my heart and I'm grieving.' It gives staff a chance to create out of something that is hurtful and painful."
Finding ways to help nurses relax, reflect, refocus or re-energize is critical in helping them to prevent or overcome burnout, according to researchers and nurse managers.
"Nurses are particularly at risk for becoming overwhelmed and depleted," says Cynda Hylton Rushton, a professor in the School of Nursing at Johns Hopkins University. They "provide direct, 24/7 care, and they often must confront the limits of what medicine can do for people. Nurses can begin to feel helpless or have a sense that they are not actually helping. They can begin to question what they are doing and how they are benefiting others."
Experts say that preventing professional burnout is an essential aspect of promoting quality patient care. "When the clinician suffers, so does the patient," Rushton says. "We don't provide the quality care we want to offer when we ourselves are depleted."
The arts and humanities program at Georgetown's cancer center uses creative arts to help patients and their families and to promote staff morale.
Its activities include journal writing, dance and movement, quilting and painting. Sometimes for just five or 10 minutes at a stretch, artists -- both volunteers and paid professionals -- help staff members manage stress and develop coping skills. Nancy Morgan, the program's director, holds journal-writing sessions to allow people "to say something about their experiences, to solve problems, to come to terms with what they've experienced."
She notes that when dancers first appeared at an intensive care unit to lead staffers in a brief stretching exercise, it raised some eyebrows. "But people have come to see that it's not just for fun, but because it can make you a better nurse or doctor." Several of the artists have been patients and are eager to give back to an organization that helped them through their illness.
Nurses at Inova Mount Vernon Hospital in Virginia were offered knitting classes last year by a local nonprofit, Project Knitwell, as a way to cope with workday stress and as a team-building experience. Nurse manager Freda Osei says that she was skeptical at first, thinking she wouldn't be coordinated enough to knit. Instead, she says, "it was great just learning a new skill. It was so calming. After I learned the initial stitches, I just went home and kept going."
Malene Davis, chief executive of Falls Church, Va.-based Capital Caring, says that her hospice and palliative care organization takes several approaches to preventing burnout.
"In hospice, you really have to be proactive in helping staff at the bedside as well as the staff who support them," she says. Each new staff member participates in an extensive orientation program that addresses how to recognize and prevent compassion fatigue. Davis says that the structure of hospice, which relies on interdisciplinary teams to care for patients and families, is also helpful. "A team discusses every case and relies on each other. There's a sense of unity, a feeling that you aren't in it alone."
She notes that hospice-care providers experience "cumulative losses" in their day-to-day interaction with people near the end of life. In addition to working to promote work-life balance among the staff, Davis encourages her managers to realize that burnout is not a sign of weakness, nor is it a sign that someone is in the wrong profession. Instead, she says, individuals need support.
"Since we've begun to focus on these issues, staff turnover has decreased and staff satisfaction has increased," she says. "We want to create a positive environment for everyone, a place where people recognize quality as a business strategy."
Officials at Gilchrist Hospice Care, based outside Baltimore, echo her sentiments. Lin Simon, Gilchrist's director of quality, says that "hospice is not something you can put down at the end of the day. You think of the people you've touched and helped. It's not like parking buses in a garage! It stays with you."
When Gilchrist noticed signs of mounting stress among her staff, she engaged someone to work on a meditation program with them. Six of her workers participated in a two-hour meditation session where they learned to calm and center themselves. Since that session last spring, she says, the people who participated seem "less harried and haggard. We talk to each other about staying positive." The session was so successful that it is being repeated for a larger group.
In the Gilchrist orientation program, new employees reflect on their reasons for becoming involved in hospice and on their own experiences of loss, death and dying. They are encouraged to turn to one another for support and mentoring, to talk to each other, and to grieve and reflect on their experience.
"Often, it's a matter of telling someone your story, of being heard and then of moving on to the next patient," says Don Hohne, a chaplain at Gilchrist. "We want to encourage people to feel, to have genuine empathy, but to set appropriate boundaries."
Barbara Lombardo, a nurse practitioner at University Hospitals Case Medical Center in Ohio, who has conducted research on compassion fatigue, says that sometimes it's the basics that matter. "Maybe they just need to be sure to take their lunch or dinner break. Get to the lounge or get outside, take a deep breath, or do other simple things at work. Follow healthy living interventions and eat right and exercise. There are things people can do in just a few minutes to refocus on themselves."
In the meantime, nurses such as Laurie Dohnalek, who directs oncology and medicine services for the nursing service at MedStar Georgetown University Hospital, appreciate the efforts to engage them in the arts.
"The positive energy transcends to patient care," she says. "No matter what you do or how you do it, art is an opportunity to express yourself and work through things you might not be able to work through in other dimensions. As nurses, our priority is to be the best we can be for ourselves and for our patients, and this is a positive way to do that."