Running Head: Nurses as Caregivers 1 Nurses as Caregivers: Identifying some Negative Aspects of Caregiving by Ashley Denise Bone

Communion is a focus on others and involves helping and caring for others and being attuned to others' feelings. By contrast, unmitigated communion is an extreme focus on others to the neglect of the self. The goal of the present study was to explore communion and unmitigated communion in a caregiving population where the benefits and hazards of an orientation towards others might be observed. A total of 61 nurses, 56 of whom were women, were interviewed for 30 minutes by phone or in person. The following traits were measured: unmitigated communion, communion, agency, self-esteem, externalized selfperception, feelings when help is rejected, anger, depression, and job distress. It was hypothesized that unmitigated communion would be associated with low self-esteem, externalized self perception, negative feelings about the self when others rejected help, holding anger in, depression, j ob distress, and intrusive thoughts about patients. Communion was not expected to be related to any of these outcomes. Results largely confirmed these hypotheses. Unmitigated communion was related to more distress in general, but not necessarily job distress. By contrast, communion was related to reduced job distress. Both unmitigated communion and communion were related to being distressed by intrusive thoughts about a specific patient, but only unmitigated communion was associated with having intrusive thoughts about patients in general. Thus, communion is associated with a concern for others, but not an involvement with others that causes negative effects on nurses' well-being. The degree of overinvolvement and self-sacrifice that is characteristic of unmitigated communion appears to be the root of the negative health effects experienced by these people. Nurses as Caregivers 3 Nurses as caregivers: Identifying some negative aspects of caregiving In general, people associate positive consequences with helping and caregiving behavior. However, research has shown that there can be both positive and negative consequences to helping that are reflective of personality traits that the helper possesses. There are two basic personality traits that reflect a concern for others. The first of these is communion, a term introduced by Bakan (1966) that focuses on a connection with others. Communion is a focus on others and involves helping and caring for others and being attuned to others' feelings. Communion is considered a positive focus on others because it has been linked to many positive outcomes reflecting people 's ability to connect with others, such as increased marital satisfaction (Antill, 1983), satisfying relationships (Helgeson, 1993), and reduced loneliness (Wheeler, Reis, & Nezlek, 1983). In addition to communion, agency, or a focus on the self, is required for optimal well-being (Bakan, 1966). Bakan (1966) suggested that the communal orientation should be mitigated by some focus on the self. Communion in the absence of agency may result in unmitigated communion. Unmitigated communion is a focus on others to the neglect of the self and is associated with negative health outcomes. Those possessing unmitigated communion tend to help others at their own expense (Helgeson, 1994). Although unmitigated communion and communion both reflect a concern for and focus on others and are modestly positively correlated (Helgeson, 1994; Helgeson & Fritz, 1996), there are several characteristics that distinguish the two. Unmitigated communion is associated with a negative view of the self and is characterized by an overinvolvement in others' problems to enhance others' views of themselves. Unmitigated communion is also associated with discomfort upon receiving support from others and a desire for others to take one ' s advice (Fritz & Helgeson, in press). More specifically, unmitigated communion is associated with low self esteem (Helgeson & Fritz, in press). Fritz and Helgeson (in press) suggest that people high in Nurses as Caregivers 4 unmitigated communion have a low regard for the self and turn to their social environment for self-esteem. Helgeson, Richardson, and Fritz (1997) found that unmitigated communion was associated with a high fear of negative evaluation. A combination of basing one ' s self perception on others, known as an externalized self perception, and perceiving that others do not value the self suggests why unmitigated communion is related to low self-esteem (Helgeson & Fritz, in press; Fritz & Helgeson, in press). Those high in unmitigated communion engage in maladaptive behaviors in order to enhance their self-worth in the eyes of others (Fritz & Helgeson, in press). Unmitigated communion is associated with feeling uncomfortable receiving support and feeling bad about the self when others reject one ' s advice or support (Helgeson & Fritz, in press). These individuals help to an extreme and are not only overly nurturant , but have intrusive thoughts about others ' problems. In two studies, Fritz and Helgeson (in press) showed that those high in unmitigated communion have intrusive thoughts not only about a close friend's problems, but about a stranger 's problems as well. In the first study, female college students were exposed to a stranger (confederate) discussing a problem and then contacted two days later to see if they were distressed about the problem. Unmitigated communion was associated with greater distress upon hearing a stranger disclose a problem as well as more intrusive thoughts about that stranger's problem two days later (Fritz & Helgeson, Study 3, in press). In a replication of that study with friends, unmitigated communion was again associated with intrusive thoughts about a friend's problem two days later (Fritz & Helgeson, Study 4, in press). Even more compelling are findings which show that unmitigated communion is associated with poor health. A study of cardiac patients demonstrated that unmitigated communion was associated with increased psychological distress and poor health outcomes (Helgeson, 1993). Similarly, in a study of adolescents with diabetes, unmitigated communion was associated with increased psychological distress and poor metabolic control (Helgeson & Fritz, 1996). In a study of adolescents, Gore, Aseltine, and Colten Nurses as Caregivers 5 (1993) found that a tendency to get overinvolved in others' problems, a feature of unmitigated communion, was associated with greater depression. Those characterized by unmitigated communion may be more susceptible to depression and despair (Malley & Stewart, 1988; Stewart & Malley, 1987; Stewart & Salt, 1981). None of these views or behaviors are reflective of communion. Therefore, unmitigated communion can be considered an unhealthy focus on others to the exclusion of the self (Helgeson & Fritz, 1996). An interesting population in which to study unmitigated communion is nursing. Nursing is a profession in which helping behavior plays a prominent role. Compared to other professions, it may attract a high number of unmitigated communion individuals. This study examines the nursing population in order to examine the negative as well as the positive aspects of caregiving. Some negative aspects of caregiving are job burnout and job distress. Nurses are especially vulnerable to burnout (Maslach & Jackson, 1982) because of a variety of stressors such as work overload, low job status, lack of control within the job setting, lack of criteria for measuring accomplishment, lack of feedback and support, and ambiguity and uncertainty about professional roles (Cherniss, 1980; Jayaratne & Chess, 1983; Maslach, 1978; Maslach & Jackson, 1981; Motowildo, Packard, & Manning, 1986; Wills, 1978). In addition, the emotional burden of nurses is high, including feelings of failure to respond to patients' needs and frustration to be of real help to the patient (Berlin, Ray, Nichols, & Perritt, 1987). There have been studies on nurses that show that those low in communal orientation tend to have burnout symptoms more often than those high in communal orientation (VanYperen, et al., 1992). That study defined a communal orientation as the desire to give and receive benefits in response to others' needs. Unmitigated communion was not examined in that study. W e hypothesize that nurses high in unmitigated communion will experience burnout more often than those low in Nurses as Caregivers 6 unmitigated communion because such people have one-sided relationships. They give without desiring receipt. In addition, they are vulnerable to distress when exposed to others' problems. We expect nurses high in unmitigated communion to experience intrusive thoughts about their patients, which could be related to burnout syndrome. This study focuses on the differences between communion and unmitigated communion in regard to personality traits, depression, and job stress. It is expected that those high in unmitigated communion will have lower self-esteem, an externalized selfperception, negative feelings about the self when others reject help, internalize anger, higher depressive symptoms, and increased job stress compared to those low in unmitigated communion. To test more specific ideas about unmitigated communion and caregiving, we considered who these people would help, if they would ever avoid helping, and what type of helping situation would be most distressing. We created scenarios about patients who needed help and manipulated two variables, whether the nurse could help or not and whether their help was recognized or not. The ability to help was manipulated by whether medication was available to reduce the patient 's pain. Help recognition was manipulated by whether the patient, a stroke victim, could still recognize people. W e predicted that those high in unmitigated communion would be more likely to help when their help was recognized and that they would avoid situations and experience distress when their help was not recognized. W e predicted that both high unmitigated communi