Compassion in Nursing

I glanced across the stuffy conference room at my small group of students. We just spent the past eight hours (though it felt like twenty-four) on a busy, acute care general medicine unit, tending to a host of chronic illnesses for our frequent flyer patients. This group of students was closer to graduation than most, but still embodied the spirit of a novice. In our clinical debriefing most afternoons, this group was energetic, occasionally bordering on rambunctious, as they recalled a day spent in the trenches of the hospital.

Today was different. There was no witty banter, no peaks of adrenaline, and no contagious enthusiasm after a solid day of learning. As I tried to pull conversation out of each person, I locked eyes with the one student who was usually our superstar. She had the ability to connect with any patient, family, or staff member, while simultaneously providing near flawless nursing care. Today, her gaze drifted from mine, with the look I’ve come to recognize with ease after years of teaching: Please don’t call on me.

I respected her non-verbals, but after a couple more minutes of complaining from her peers, she broke down. I watched, completely helpless, as the tears streamed down her face. Attempting to allow her space in an already crowded room, I tried to engage her peers in a diversion, but it was met with silence. Finally, her voice cracking, she spoke words that have stuck with me ever since.

“You’re always telling us that our nursing interventions never have to end, since we can be compassionate to our patients long after medical interventions have stopped or failed. But, after days like today, I don’t think you’re right anymore. That can’t be the answer, not if I’m going to have to feel this bad and keep coming back to do it again.”

I sensed this was coming, as this particular student had a really rough patient assigned this shift. She cared for him the week prior, where they developed an excellent rapport. But in the week that passed, this patient wound up in intensive care, developing delirium as a result. That, coupled with his baseline diagnosis of hepatic encephalopathy, led to harassment and heartbreak for my student.

Her peers provided support; they were burned out too. And it wasn’t by midterms or research papers, but by the overwhelming privilege and pressure of being mentally and emotionally present with their patients. There was no amount of self-care that could make it better, and no lesson that I could teach to counter the words I had been saying for my entire career.

This group went on to their own jobs as new clinicians in multiple health systems, and many have returned to our grounds as graduate students. As I catch up with our returning students, I am floored that they remember what I said next on that afternoon in the stuffy conference room. 

Compassionate care has its limits. Nursing interventions, though they can continue after all other resources have been exhausted, begin and end with the nurse at the patient’s side. And recognizing the limits, and humanity, of the nurse providing care, is absolutely critical if we are to make our calling into a career. Compassion without resiliency is finite, no matter how dedicated the novice or expert might be to their profession.

Admitting our limitations doesn’t make for a glamorous cover or sales pitch for nursing as a career. However, it’s the first vital step to ensuring that we will return to the bedside after the toughest days. As the most trusted profession, we must learn to trust ourselves, and to recognize our limits as we provide compassionate care to our entrusted patients.

I have changed my tune a little over years of teaching. Instead of acting as the cheerleader for never ending compassion, I now acknowledge when the moment has come to step back and turn our gaze inward. And in that moment, I teach my students to practice resiliency without putting up a barrier between the nurse and the patient as a defense mechanism. As walls go up, over time, it becomes harder to break them down, and let compassion flow toward the next patient. This practice of resiliency comes in many forms, and varies across the board, though it is essential to each and every nurse.

Just this week, our faculty prepare to say farewell to another class, another group ready to extend their new skills and compassion into the world. This class, unlike any other, have had their final year in school upended by a pandemic. Never has there been a greater need for resilience in our nursing workforce. On the last day of class, I struggled to find the words, just as they struggled in their search for questions. In years past, I could say with some degree of confidence that I understood the stakes as they entered this new chapter. This year, after two decades in healthcare, my advice is unsteady.

I would leave our graduates with only one piece of advice. Though compassionate care starts with nursing, over time, this care is not a perpetual fountain pouring out to our patients. Instead, compassion must first be applied inward, toward nourishing our own spirits. And once that inward grace is given, we have the profound privilege of seeing our former students extend their compassion into the world.