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Do nurses care too much?

Dr Raj Persaud
Consultant Psychiatrist at the Maudsley Hospital, London

The kind of nurse who consults with me in my outpatient clinic is a high-achiever, who has moved rapidly through the career grades to get to the top of the profession at quite a young age. But then mysteriously s/he gets depressed and needs time off work following a relatively minor incident in which a patient expresses dissatisfaction with her/his standard of care.

This is the striking difference between the large number of nurses and doctors who end up coming to see me for psychiatric help. Both are overworked, but the nurses complain much more of the emotional demands of their jobs - in particular the stress of dealing with patients. Doctors don't seem to mind so much if a patient doesn't appear happy with what they have done, as long as the doctor knows that nothing untoward was done on a strictly clinical or technical basis. Nurses, however, care deeply about the emotional reaction of patients to their care.

Recent research into the emotional demands of nursing suggests a quite surprising reason why nursing is so stressful that it leads to so much burnout and large numbers leaving every year - basically, nurses often care too much for their patients.

This may be an astonishing claim - after all, isn't the whole point of nursing to be someone who cares more than the average professional for their clients? Don't we want our nurses to care for us in a more meaningful way than we want our accountant to? Actually the research, and my clinical experience, suggests this is not the case.

Helga Jonsdottir, a nurse researcher from Reykjavik, recently conducted a survey of 300 patients attending a hospital department investigating what they felt were the things that nurses did that made them feel cared for. Choosing from a list of over 60 possible options, the top 10 activities that made patients feel most cared for reflected the strictly technical aspects of the nurse's job. For example, the top four were that they wanted the nurses to know what they were doing in terms of clinical proficiency, to know when it is necessary to call a doctor, to know how to give injections and IVs, and to know how to handle medical equipment properly. Contrast this top four list with the bottom four items, which were: "helping me understand my feelings", "being sensitive to my feelings and moods", "asking me how I like things done" and "encouraging me to talk about how I feel".

This, plus a series of other recent studies, finds that nurses consider expressive or emotional behaviours to be the most important things they do that make patients feel cared for. Yet patients, in contrast, hold competent technological knowledge and physically based caring behaviours as the most important.

The danger for many nurses is that in trying to provide emotional support the professional boundaries get blurred and they end up getting too emotionally involved. This inevitably leads to psychological collapse when, despite all this emotional effort, the nurse detects that the patients are not happy with their care. Nurses take this as a personal rejection rather than as a technical one.

There is a balance to be struck between too much emotional detachment and excessive emotional involvement. A recent study found that nurses with less than a year's experience were more sensitive to causing pain to their patients than nurses with 6-10 years' experience, suggesting that "nurses become desensitised to patients' physical suffering after repeated exposure to it". There is also a general unwritten rule that surgeons shouldn't operate on their own spouses or children, the thinking being that caring too much for the person you are looking after could impair your decision-making and technical abilities.

So, if caring too much can impair your ability to provide effective assistance, then it follows that using emotional barriers to cope with the "emotional labour" of working with patients is part of the nurse's job. This means caring at a deeply emotional level is not necessarily inherent within the nurse's role, and that if you want to do the job properly and for a long time it's important to be aware that, even as a good nurse, it's possible to care too much.