Compassion does not [cause] fatigue but burnout can, Patricia Jakel, RN, MN, AOCN, explains. “Compassion cannot fatigue. That is not a true terminology. [Compassion] is like an endless well; you [just] have to make sure that you put back into it.”

Jakel, an advanced practice nurse at University of California Los Angeles Health, and coeditor-in-chief of 

spoke at a well-being discussion at the 47th Annual Oncology Nursing Society Congress. In the lecture, she addressed how the oncology nurse can put themself first both professional and personally and what they require from their institutions to deliver quality care to their patients.

Nurses need to be supported by their institutions, says Jakel. This does not mean gifts or lunches, but resources for staff. There needs to be knowledge that there will be a full team of nurses helping on a night shift, for example.

Furthermore, creating thoughtful boundaries are essential to longevity, she notes, adding, “If you are mindful and you are present with that patient, and not thinking about—and I am guilty of this—'I have to pick up my son at preschool’ or ‘I've got to do this [or that]’, and you really spend the time with them, [you can] walk out of the hospital and say ‘OK, that is behind me. I need to move forward and be mindful of my family and be mindful of what I need to do now.’ That [will] really restore your compassion.”

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Patricia Jakel, RN, MN, AOCN, discusses burnout and compassion fatigue in acute oncology care.

Patricia Jakel Comments on Combating Burnout in the Acute Care Setting

Suppose you have a 45-year-old patient with triple-negative breast cancer, who has recently experienced a recurrence in her liver, causing her to restart treatment. Historically, she has experienced treatment-related pain, including peripheral neuropathic pain. She is also constantly preoccupied with worries for her young children, the irrational behavior of her mother toward her husband, and guilt over the financial burden of her disease and what it represents for her family.

One day, this patient arrives in the clinic, complaining of pain on her right side radiating to her back. Would you say she is experiencing social, emotional, spiritual, or visceral pain?

Pain emerged as an area of clinical specialization in the 1960s, and with research and clinical application, this led to a better understanding
of the individual meaning of pain.

 By the 1970s, the field of pain had its own journal (Pain) and associa- tion (International Association for the Study of Pain). Providers began to acknowledge the impact of pain and sought out new ways to address it.

As we know, oncology nurses everywhere are advocates for relieving pain. Margo McCaffery taught millions of nurses that pain is “whatever the experi- encing person says it is, existing whenever and wher- ever the person says it does.”

 An important concept to remember is that pain and suffering are related but not necessarily the same.

Dr Cicely Saunders, a professional trained in the 3 disciplines of nursing, social work, and medicine, coupled with a strong personal religious faith, developed the background for the concept of “total pain.” From Saunders’ work with dying patients, the concept of total pain was formulated to include physical, psychological, social, emotional, and spiritual elements. Total pain is a concept that has been used in hospice since 1960 and is now widely utilized in palliative care patient models.

For example, Hospice of the Western Reserve utilizes the following 9 pillars of the total pain/hospice model:

The hospice model of care is based on the concept of total pain, which acknowledges that patients with serious and life-limiting illness suffer because of phys- ical, emotional, social, and spiritual sources of pain and suffering.

Pain and suffering are related but not necessarily the same. Pain, whether physical or emotional, has a phys- iologic basis. On the other hand, suffering arises when we apply meaning to or tell ourselves stories about the pain we are experiencing.

Pain can often be alleviated or improved with medi- cation, whereas suffering often is resistant to medi- cation. Failing to recognize the difference can lead to overmedication and oversedation of patients who have serious and life-limiting illness.

 Seriously ill patients and their families often resist the recommendation for a hospice referral because of concern about oversedation and overmedica- tion. Understanding the role of the hospice team in addressing total pain can enable the referring physi- cian to alleviate these concerns.

Suffering can be successfully evaluated and treated
by using a spiritual pain model that addresses the following 4 aspects: forgiveness, meaning, relatedness, and hope.

Pain and suffering, particularly in the setting of terminal illness, often involves and affects the care- givers and the patients. The hospice team can be a valuable resource in terms of time and expertise in helping the referring physician address and manage the complex impact of pain and suffering on family relationships.

The hospice transdisciplinary team is made up of compassionately skilled professionals from many disci- plines who work as a cohesive and integrated unit. This allows the patient and family to receive focused care that addresses the complexity of terminal illness.

The appropriate management of suffering, especially spiritual pain, requires time and is best delivered by hospice involvement early in the course of a terminal illness. 

Appropriately timed referrals that allow sufficient time for hospice to do this important work are funda- mental to maximizing quality of life and achieving peace for both the patient and caregiver.


Although this model is referencing hospice/palliative care and is designed specifically for that setting, these same principles can and should be applied for all institu- tions treating for patients with cancer.

We care for patients who use pain medication to cope with a potential terminal diagnosis, reduce terror and anxiety, and escape from difficult family or financial situations. Oncology nurses must assess the total pain of their patients by considering the physical, psychological, social, emotional, and spiritual elements.



Returning to the question of the young patient with breast cancer, it is fair to say she is experiencing all the aforementioned options. She will need assistance from the entire health care team to alleviate her total pain, alongside her chronic and acute pain.

Fortunately, this is where oncology nurses can truly make all the difference. By remaining vigilant in assessing fatigue, nausea, constipation, sleep, and sexual relationships, we can create a comprehensive profile of this patients’ total pain assessment and consequently provide a more thoughtful and comprehensive care strategy for our patients. 



Collier R. A short history of pain management. 

.2018;190(1):E26-E27. doi:10.1503/cmaj.109-5523

Nursing Practice Theories Related to Cognition, Bodily Pain, and Man-Environment Interactions

Ong CK, Forbes D. Embracing Cicely Saunders’s concept of total pain.

. 2005;331(7516):576. doi:10.1136/bmj.331.7516.576-d

The total pain model - 9 key points. Hospice of the Western Reserve. September 2020. Accessed March 10, 2022. https://bit.ly/3MR66Q2

Goebel JR, Doering LV, Lorenz KA, Maliski SL, Nyamathi AM, Evangelista LS. Caring for special populations: total pain theory in advanced heart failure: applications to research and practice. 

. 2009;44(3): 175-185. doi:10.1111/j.1744-6198.2009.00140.x

Articles

Oncology nurses must assess the total pain of their patients by considering the physical, psychological, social, emotional, and spiritual elements.

Understanding “Total Pain” in the Context of Oncology Care

Oncology nurses often encounter patients who are experiencing some of the darkest times in their lives, and it is important that they develop ways to cope, explained Patricia Jakel, RN, MN, AOCN, a clinical nurse specialist at UCLA Healthcare System. Jakel referred to an essay by a palliative care specialist that said if [nurses] are present in the moment with their patients, then outside of working hours, they will be more present and mindful, too. In doing so, nurses can decrease the amount of compassion fatigue that they experience. Jakel learned this firsthand when she went from 

Jakel also pointed out that compassion fatigue is different from burnout, though the two terms are often used interchangeably. Burnout has less to do with the patient, and can happen when oncology nurses get frustrated at staffing issues, pay, and other workplace conditions.

Mindfulness is key when it comes to preventing compassion fatigue.

Present at the Bedside, Present in Life: Overcoming Compassion Fatigue

It is an exciting time to be an oncology nurse. Over the past several decades, cancer treatment has considerably changed patient outcomes and adverse effect (AE) profiles. One of the most dramatic changes is the concept of immunotherapy, which has been studied for more than a century. Recent discoveries have led to a new class of immune agents.1 The rising stars in cancer treatment are the agents that modulate and strengthen the body’s immune response when battling the cancer. They include the following classes: checkpoint inhibitors, chimeric antigen receptor T cells, monoclonal antibodies, bispecific antibodies, and oncolytic viral immunotherapy.2 The highly unique, and often life-threatening, AEs motivate oncology nurses to have a fundamental understanding of all immunotherapies.

Immunotherapies offer challenges for nurses trying to deliver safe and evidence-based care. One way to assure this happens is by maintaining initial and annual competencies. Oncology nurses are on the front lines of administering immune therapy. Therefore, competencies should be obtained for safe handling and AE profile management. Competent nurses should have knowledge of the following: mechanism of action, administration principles, toxicity and adverse reactions, and nursing assessment and management.3 Oncology nurses are experts in handling AEs from earlier cancer drugs caused by a compromised immune system; however, the new classes of immune therapeutics may cause overwhelming inflammatory responses and autoimmunity.4 Nursing management for the “new” immunotherapy AE profile requires competent nurses to understand that management differs from traditional chemotherapy and biotherapy.

Many oncology patients may have received chemotherapy and are more familiar with the AE profile. As oncology nurses, we need to assist patients in understanding the difference between traditional chemotherapy, immunotherapy, and targeted therapy. As you educate your patients on immunotherapy, discuss the advantages of it over the more traditional approaches by emphasizing the following: 1) the immune system can distinguish between normal cells and cancer cells, and attack the unhealthy cancer cells; 2) compared with traditional chemotherapy, immunotherapy is generally less toxic and patients experience a good quality of life (QOL). The events associated with the immunotherapy agents are infections, inhibition of angiogenetic pathways, severe inflammatory syndromes, and autoimmune disorders.

As the FDA rapidly approves new treatments, oncology nurses are challenged to understand and manage the very distinct AE profiles of all immunotherapies. The most common AEs are associated with “turning on” the immune system: dermatitis, pruritus, fever, chills, diarrhea/colitis, and extreme fatigue.5 However, there are rare adverse reactions that can be life-threatening and occur 6 to 12 weeks after the initiation of therapy. Olszanski and Zitella noted that most adverse reactions are mild and most of the immunotherapy drugs are well tolerated.

Safe administration is a priority for nurses and the Oncology Nursing Society (ONS). The quick growth of the immunotherapy field often means that nurses are administrating agents for the first time in their practice. Thus, procedures and policies must be created and followed. ONS states that until more is understood about long-term AEs and the safety of healthcare workers, immunotherapy should be treated with the same level of care and security as other anticancer agents. 3 The safety standards set forth by the American Society of Clinical Oncology (ASCO) and ONS include guidelines to reduce errors in all areas of chemotherapy administration that should serve as the bases for policies and procedures adapted for immunotherapy safety.

Oncology nurses need to have an understanding of the basic concepts of immunotherapy and be aware of 2 important principles of immunotherapy treatment:

1) Immunotherapy is often given in combination with other modalities: chemotherapy, radiation therapy, and other immuno- oncology agents.

2) Dose reduction is not a principle of immunotherapy treatment. The dose is either held or given in full.5 By using the principles of chemotherapy safety outlined in Chemotherapy and Biotherapy Guidelines and Recommendation for Practice, 7 nurses can deliver research-based safe care, reduce medication errors, and reduce hazardous exposure from these new agents.

In February, ASCO named Immunotherapy 2.0 as the advancement of the year. The rate of research in this incredible field has been breathtaking. Oncology nurses stand to play a pivotal role in these new therapies, especially with AE management.

They have been excellent in improving chemotherapy patients’ QOL by being experts in chemotherapy-induced nausea and vomiting, neutropenia, fatigue, and other AEs. Nurses should bring the same evidence-based practices to managing immunotherapy patients and become experts in the specialty. Patients look to us for guidance, education, and keeping them safe during treatment. They trust us as we guide them along their treatment trajectory. New oncology therapies offer nurses a new challenge, and we will accept this challenge with our patients’ safety and QOL as our primary motivations.

Patricia Jakel, RN, MN, AOCN, is an advance practice nurse for the Solid Tumor Program at UCLA Healthcare. She oversees the care of 25 to 35 patients receiving chemotherapy, radiation therapy, symptom management, and end of life care. Jakel mentors new nurses to the art of oncology nursing. 

1. Farkona S, Diamandis EP, Blasutig IM. Cancer immunotherapy: the beginning of the end of cancer? BMC Med. 2016; 4:73. doi: 10.1186/s12916-016-0623-5.

2. Fridman WH, Zitvogel L, Sautès-Fridman C, Kroemer G. The immune contexture in cancer prognosis and treatment [ePub ahead of print]. Nat Rev Clin Oncol. 2017. doi: 10.1038/nrclinonc.2017.101.

3. Wiley K, LeFebvre K, Wall L, et al. Immunotherapy administration: Oncology Nursing Society recommendations. Clin J Oncol Nurs. 2017;21(2): 5-8. doi: 10.1188/17.CJON.S2.5-7.

4. Kroschinsky F, Stolzel F, von Bonib S, et al; Intensive Care in Hematological and Oncological Patients (iCHOP) Collaborative Group. New drugs, new toxicities: severe side effects of modern targeted and immunotherapy of cancer and their management. Crit Care. 2017;21(1):89. doi: 10.1186/s13054-017-1678-1.

5. Olszanski AJ, Zitella LJ. Advances in the use of immunotherapy in oncology. J Adv Pract Oncol. 2017;8(3):221-225. doi: 10.6004/jadpro.2017.8.3.2.

6. Neuss MN, Gilmore TR, Belderson KM, et al. 2016 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards, including standards for pediatric oncology. Oncol Nurs Forum. 2017;44(1):31-43. doi. 10.1188/17ONF 31-43.

7. Polovich M, Olsen M, LeFebvre K. Chemotherapy and Biotherapy Guidelines and Recommendation for Practice. 4th ed. Pittsburgh, PA: Oncology Nursing Society; 2014.

“New oncology therapies offer nurses a new challenge, and we will accept this challenge.”

Patricia Jakel, RN, MN, AOCN

Articles

Patricia Jakel Comments on Combating Burnout in the Acute Care Setting

Understanding “Total Pain” in the Context of Oncology Care

Present at the Bedside, Present in Life: Overcoming Compassion Fatigue

Immunotherapy Is Rapidly Changing Nursing Practice