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Research Spotlight: What About the Nurses?

In an already challenging frontline role, Emergency Department nurses caring for patients with opioid addiction and substance abuse risk compassion fatigue, burnout, and traumatic stress, note FCN researchers in a compelling study. 

According to the Centers for Disease Control and Prevention (CDC), nearly 841,000 people have died since 1999 from a drug overdose and over 70% of drug overdose deaths in 2019 involved an opioid. 

Opioids are substances that work in the nervous system of the body or in specific receptors in the brain to reduce the intensity of pain. Opioid Use Disorder (OUD), which includes problematic patterns of opioid use, is a lifelong, chronic disease which is blind to gender, geography, religion, race, age and economic status. Emergency department (ED) staff routinely treat patients with OUD, some of whom are brought in as frequently as several times a day, for reversal of the overdose with naloxone (Narcan), providing care, treatment, education, and services in what is often a complex, fast-paced, fractured, understaffed and under-resourced system.   

OUD exacts a heavy toll from patients and their loved ones. But what happens to the nurses caring for those addicted to opioids? Two faculty set out to answer that and other questions in their 2019-2020 study “Using a Needs Assessment Inquiry to Identify Compassion Fatigue in Nurses Caring for Those Addicted to Opioids,” funded by a $125,000 award from Independence Blue Cross Foundation.

Clinical Assistant Professor Sue Ellen Alderman, MSN, RN, PMHCNS, calls opioid misuse the “pandemic within the pandemic.” A psychiatric-mental health clinical nurse specialist, she wanted to contribute even more involved in solutions to the crisis. She was already teaching students about substance use disorder (SUD) and the opioid epidemic, emphasizing the science behind addiction, and discussing beliefs and attitudes surrounding the issue such as “disease versus moral flaw,” all with the goal of a more educated nursing workforce equipped to deliver enhanced, comprehensive care to patients.

Professor Elizabeth B. Dowdell, PhD, RN, AFN-C, FAAN, and Coordinator of Undergraduate Research, is a nurse scientist who has focused her research and scholarship examining vulnerabilities, risk taking, and violence across the lifespan, including her pioneering research exploring the interrelationships among various forms of electronic aggression. As a pediatric forensic nurse and former ED clinician she has experience working in and understanding the complexities associated with delivering patient care in a clinical site that requires nurses to demonstrate critical thinking skills, quality patient care, communication and leadership.

In this opioid misuse crisis ED nurses across the country have been reporting intense and stressful work environments such as those currently being experienced in Philadelphia. To better understand the perceptions and feelings of ED nurses, the study was undertaken at an urban ED in Philadelphia that routinely cares for patients with OUD. This unique study included three undergraduate research assistants, now-junior Emily Holland and Naja Foushee ’20 BSN, RN, MS and Shaun McGovern ‘20 BSN, BS, RN who were students in the 14-month second degree accelerated BSN track.

This study used a mixed methods design with five research questions to identify and explore the perceptions and beliefs of ED nurses related to providing care to patients with OUD. To generate richer data and understanding, the faculty used focus groups (primarily run by Prof. Alderman) with ED nurses to garner candid qualitative data.  At the end of each focus group Prof. Alderman demonstrated for all participants a relaxation exercise. “I wanted to give them something,” she said, and led them in 10-minutes of deep breathing exercises and stretching that could be done in the ED. She hopes that “hospitals teach stress management and self-care to nurses who ignore themselves.” Quantitative data was collected using a survey that asked about their quality of life, OUD knowledge levels, and demographics.

In October 2019, the team launched focus groups in the ED interviewing a total of 53 ED nurses.  The picture was one of nurses in a state of hypervigilance, ready for verbal or physical aggression from patients and families- all within a “revolving door” environment with patients with OUD and SUD. Nurses had frequent encounters with patients returning with overdoses, abscesses, or other drug-related medical problems. Additionally, some of the nurses were not fully aware of recovery programs and available resources. The researchers say that for these reasons, “the nurses often expressed feelings of compassion fatigue” towards those patients. “I think the opioid stuff probably gets me more than the traumas for the simple fact that it’s exhausting. It’s just exhausting. They come back and they come back,” shared one ED nurse. Nurses who reported feeling tired and frustrated when interacting with OUD/SUD patients shared stories about how working in the ED influenced their behaviors at home.

Depending on their own personal experience with people with OUD or SUD, the nurses may or may not be more empathetic to their patients.

To deal with feelings of stress, some nurses had various ways of trying to relax after a shift, such as talking to family members (or not) about their day, sharing with peers, listening to relaxing music or drinking alcohol. The researchers point out that one quote: “We are nurses, we’re not robots. We are human,” was one of the most powerful and comprehensive statements from the ED nurses. It summarized how many felt about themselves and is supported by survey findings indicating high scores of nurse compassion fatigue correlated with burnout, secondary traumatic stress, and feeling tired of working with patients who have OUD/SUD or who overdose, all of which in turn, affects staff turnover and nurse well-being. 

Patients with OUD/SUD related problems are commonplace in today’s ED where nurses witness devastating illness, suffering, and trauma on a daily basis. In the focus groups, many nurses shared feeling like they were suppressing their emotions in order to survive recurring feelings of helplessness, guilt, sadness, frustration, and anger. The researchers further note that “consequences of these encounters have far-reaching implications that can have an impact on patient care, influence patient advocacy, interdisciplinary communication, access and referral to treatment as well as RN levels of compassion fatigue.” For the future, it is imperative that we understand the effects of compassion fatigue and recognize the signs and symptoms. While most of the nurses shared negative feelings supporting the finding of compassion fatigue, it is important to note that some nurses did share positive stories and feelings. Most talked about having hope that change would happen in the ED, with staffing, management, and workload. The researchers recommend building on or growing hope and other related positive feelings, even if difficult to find, in order to increase compassion while decreasing fatigue. Without these efforts, the destructive effects of compassion fatigue will continue to manifest in adverse outcomes for both nurses and patients.