Compassion fatigue

Compassion fatigue is a condition characterized by emotional and physical exhaustion leading to a diminished ability to empathize or feel compassion for others, often described as the negative cost of caring.[1] It is sometimes referred to as secondary traumatic stress (STS).[1] According to the Professional Quality of Life Scale, burnout and STS are two interwoven elements of compassion fatigue.[2]

Compassion fatigue is considered to be the result of working directly with victims of disasters, trauma, or illness, especially in the health care industry.[3] Individuals working in other helping professions are also at risk for experiencing compassion fatigue.[4] These include child protection workers,[5] veterinarians,[6] teachers,[7] social workers, palliative care workers,[8] journalists,[9] police officers,[10] firefighters, animal welfare workers, public librarians, health unit coordinators,[11] and Student Affairs professionals.[12] Non-professionals, such as family members and other informal caregivers of people who have a chronic illness, may also experience compassion fatigue.[3] The term was first coined in 1992 by Carla Joinson to describe the negative impact hospital nurses were experiencing as a result of their repeated, daily exposure to patient emergencies.[1]

People who experience compassion fatigue may exhibit a variety of symptoms including lowered concentration, numbness or feelings of helplessness, irritability, lack of self-satisfaction, withdrawal, aches and pains, or work absenteeism.[1]

Journalism analysts argue that news media have caused widespread compassion fatigue in society by saturating newspapers and news shows with decontextualized images and stories of tragedy and suffering. This has caused the public to become desensitized or resistant to helping people who are suffering.[13]

History

Compassion fatigue has been studied by the field of traumatology, where it has been called the "cost of caring" for people facing emotional pain.[1]

Compassion fatigue has also been called secondary victimization,[14] secondary traumatic stress,[15] vicarious traumatization,[16] and secondary survivor.[17] Other related conditions are rape-related family crisis[18] and "proximity" effects on female partners of war veterans.[19] Compassion fatigue has been called a form of burnout in some literature. However, unlike compassion fatigue, “burnout” is related to chronic tedium in careers and the workplace, rather than exposure to specific kinds of client problems such as trauma.[20] fMRI-rt research suggests the idea of compassion without engaging in real-life trauma is not exhausting itself. According to these, when empathy was analyzed with compassion through neuroimaging, empathy showed brain region activations where previously identified to be related to pain whereas compassion showed warped neural activations.[21][22]

There is some recent academic literature suggesting that compassion fatigue is a misnomer and should be replaced with the term, empathy fatigue. Evidence supporting this change comes from a burgeoning literature examining the neurophysiology of empathy versus compassion meditation practices.[23] Whereas empathy can be defined as feeling what another feels and cumulative negative effects over time can come from the accretion of the assumptions of others painful emotions and experience. Compassion relates to a feeling of caring, loving or desire to improve the lot of others and may or may not require awareness of others' feeling and emotions, but instead arises from a humanistic or even altruistic desire for subject to be free of suffering. Studies of training of compassion practices among health care provides has demonstrated positive effects compared to empathy practices which do not improve provider functioning.[24]

In academic literature, the more technical term secondary traumatic stress disorder may be used. The term "compassion fatigue" is considered somewhat euphemistic. Compassion fatigue also carries sociological connotations, especially when used to analyze the behavior of mass donations in response to the media response to disasters. Measures of compassion fatigue include the ProQOL (or Professional Quality of Life Scale), Secondary Traumatic Stress Scale, Compassion Fatigue Self Test for Helpers, and the Compassion Fatigue Scale—Revised.[25][26]

Risk factors

Several personal attributes place a person at risk for developing compassion fatigue. Persons who are overly conscientious, perfectionists,[27] and self-giving are more likely to suffer from secondary traumatic stress. Those who have low levels of social support or high levels of stress in personal life are also more likely to develop STS. In addition, previous histories of trauma that led to negative coping skills, such as bottling up or avoiding emotions, having small support systems, increase the risk for developing STS.[28]

Many organizational attributes in the fields where STS is most common, such as the healthcare field, contribute to compassion fatigue among the workers. For example, a “culture of silence” where stressful events such as deaths in an intensive-care unit are not discussed after the event is linked to compassion fatigue. Lack of awareness of symptoms and poor training in the risks associated with high-stress jobs can also contribute to high rates of STS.[28]

In healthcare professionals

Between 16% and 85% of health care workers in various fields develop compassion fatigue. In one study, 86% of emergency room nurses met the criteria for compassion fatigue.[29] In another study, more than 25% of ambulance paramedics were identified as having severe ranges of post-traumatic symptoms.[20] In addition, 34% of hospice nurses in another study met the criteria for secondary traumatic stress/compassion fatigue.[20]

Compassion Fatigue is the emotional and physical distress caused by treating and helping patients that are deeply in need, which can desensitize healthcare professionals causing them a lack of empathy for future patients.[30] There are three important components of Compassion Fatigue: Compassion satisfaction, secondary stress and burnout.[31] It is important to note that burnout is not the same as Compassion Fatigue; Burnout is the stress and mental exhaustion caused by the inability to cope with the environment and continuous physical and mental demands.[32]

Healthcare professionals experiencing compassion fatigue may find it difficult to continue doing their jobs. While many believe that these diagnoses affect workers who have been practicing in the field the longest, the opposite proves true. Young physicians and nurses are at an increased risk for both burnout and compassion fatigue.[33] A study published in the Western Journal of Emergency Medicine revealed that medical residents develop Compassion Fatigue and within this group medical residents who work overnight shifts and that work more than eighty hours a week are in higher risk of developing Compassion Fatigue.[34] In these professionals with higher risk of suffering from Compassion Fatigue, burnout was one of the major components. Burnout is a prevalent and critical contemporary problem that can be categorized as suffering from: emotional exhaustion, de-personalization, and low sense of personal accomplishment.[35] They can be exposed to trauma while trying to deal with compassion fatigue, potentially pushing them out of their career field. If they decide to stay, it can negatively affect the therapeutic relationship they have with patients because it depends on forming an empathetic, trusting relationship that could be difficult to make in the midst of compassion fatigue. Because of this, healthcare institutions are placing increased importance on supporting their employees emotional needs so they can better care for patients.[36]

Another name and concept directly tied to compassion fatigue is moral injury. Moral injury in the context of healthcare was directly named in the Stat News article by Drs. Wendy Dean and Simon Talbot, entitled "Physicians aren’t ‘burning out.’ They’re suffering from moral injury."[37] The article and concept goes on to explain that physicians (in the United States) are caught in double and triple and quadruple binds between their obligations of electronic health records, their own student loans, the requirements for patient load through the hospital and number of procedures performed – all while working towards the goal of trying to provide the best care and healing to patients possible. However, the systemic issues facing physicians often cause deep distress because the patients are suffering, despite a physician's best efforts. This concept of Moral Injury in healthcare[38] is the expansion of the discussion around compassion fatigue and 'burnout.'

Caregivers

Caregivers for dependent people can also experience compassion fatigue, which can become a cause of abusive behavior in caring professions. It results from the taxing nature of showing compassion for someone whose suffering is continuous and unresolvable. One may still care for the person as required by policy, however, the natural human desire to help them is significantly diminished desensitization and lack of enthusiasm for patient care.[39] This phenomenon also occurs among professionals involved in long-term health care, and for those who have institutionalized family members. These people may develop symptoms of depression, stress, and trauma. Those who are primary care providers for patients with terminal illnesses are at a higher risk of developing these symptoms. In the medical profession, this is often described as "burnout": the more specific terms secondary traumatic stress and vicarious trauma are also used.

Mental health professionals

Mental health professionals are another group that often suffer from compassion fatigue, particularly when they treat those who have suffered extensive trauma. A study on mental health professionals that were providing clinical services to Katrina victims found that rates of negative psychological symptoms increased in the group. Of those interviewed, 72% reported experiencing anxiety, 62% experienced increased suspicion about the world around them, and 42% reported feeling increasingly vulnerable after treating the Katrina victims.[40] Social workers are being exposed to stressful experiences in their day to day work activities. Many social workers are at a constant battle not only within their casework but within themselves. A social worker's career comes at a personal price with putting personal beliefs aside, managing compassion fatigue, and getting the mental help needed to cope with the traumas that are dealt with daily. The way a social worker feels must be put aside when in the field due to the possibility of those feeling swaying the appropriate action that must be taken. If a social worker is consciously aware of compassion fatigue and burnout happening within themselves early on, then they hold the capability to seek the help needed to combat them before any negative impression is felt externally. Being able to objectively evaluate situations at work aides in keeping social workers professionally safe. Self-awareness of compassion fatigue and burnout flow into the mental and physical management that keep those feelings under control. When a social worker puts in the time to take care of themselves their personal life and work life are both positively influenced.[41]

Critical care personnel

Critical care personnel have the highest reported rates of burnout, a syndrome associated with progression to compassion fatigue. These providers witness high rates of patient disease and death, leaving them to question whether their work is truly meaningful. Additionally, top-tier providers are expected to know an increasing amount of medical information along with experienced high ethical dilemmas/medical demands. This has created a workload-reward imbalance—or decreased compassion satisfaction. Compassion satisfaction relates to the “positive payment” that comes from caring.[42] With little compassion satisfaction, both critical care physicians and nurses have reported the above examples as leading factors for developing burnout and compassion fatigue.[43] Those caring for people who have experienced trauma can experience a change in how they view the world; they see it more negatively. It can negatively affect the worker's sense of self, safety, and control.[44] In ICU personnel, burnout and compassion fatigue has been associated with decreased quality of care and patient satisfaction, as well as increased medical errors, infection rates, and death rates, making this issue one of concern not only for providers but patients.[35] These outcomes also impact organization finances.[42] According to the Institute of Medicine, preventable adverse drug events or harmful medication errors (associated with compassion fatigue/burnout) occur in 1% to 10% of hospital admissions and account for a $3.5 billion cost.[45]

Those with a better ability to empathize and be compassionate are at a higher risk of developing compassion fatigue.[46] Because of that, healthcare professionals—especially those who work in critical care, are regularly exposed to death, trauma, high stress environments, long work days, difficult patients, pressure from a patient’s family, and conflicts with other staff members- are at higher risk.[45] These exposures increase the risk for developing compassion fatigue and burnout, which often makes it hard for professionals to stay in the healthcare career field. Those who stay in the healthcare field after developing compassion fatigue or burnout are likely to experience a lack of energy, difficulty concentrating, unwanted images or thoughts, insomnia, stress, desensitization and irritability.[39] As a result, these healthcare professionals may later develop substance abuse, depression, and suicide.[47] A 2018 study that examined differences in compassion fatigue in nurses based on their substance use found significant increases for those who used cigarettes, sleeping pills, energy drinks, antidepressants, and anti-anxiety drugs. Unfortunately, despite recent, targeted efforts being made to reduce burnout, it appears that the problem is increasing. In 2011, a study conducted by the Department of Medicine Program on Physician Well-Being at Mayo Clinic reported that 45% of physicians in the United States had one or more symptoms of burnout. In 2014, that number had increased to 54%.[35]

In student affairs professionals

In response to the changing landscape of post-secondary institutions, sometimes as a result of having a more diverse and marginalized student population, both campus services and the roles of student affairs professionals have evolved. These changes are efforts to manage the increases in traumatic events and crises.[48]

Due to the exposure to student crises and traumatic events, student affairs professionals, as front line workers, are at risk for developing compassion fatigue.[49] Such crises may include sexual violence, suicidal ideation, severe mental health episodes, and hate crimes/discrimination.[50]

Some research shows that almost half of all university staff named psychological distress as a factor contributing to overall occupational stress. This group also demonstrated emotional exhaustion, job dissatisfaction, and intention to quit their jobs within the next year,[51] symptoms associated with compassion fatigue.[52]

Factors contributing to compassion fatigue in student affairs professionals

Student affairs professionals who are more emotionally connected to the students with whom they work and who display an internal locus of control are found to be more likely to develop compassion fatigue as compared to individuals who have an external locus of control and are able to maintain boundaries between themselves and those with whom they work.[49]

In lawyers

Recent research shows that a growing number of attorneys who work with victims of trauma are exhibiting a high rate of compassion fatigue symptoms. In fact, lawyers are four times more likely to suffer from depression than the general public. They also have a higher rate of suicide and substance abuse. Most attorneys, when asked, stated that their formal education lacked adequate training in dealing with trauma. Besides working directly with trauma victims, one of the main reasons attorneys can develop compassion fatigue is because of the demanding case loads, and long hours that are typical to this profession.[53]

Prevention

There is an effort to prepare those in the healthcare professions to combat compassion fatigue through resiliency training. Teaching workers how to relax in stressful situations, be intentional in their duties and work with integrity, find people and resources who are supportive and understand the risks of compassion fatigue, and focus on self-care are all components of this training.[54]

Personal self-care

Stress reduction and anxiety management practices have been shown to be effective in preventing and treating STS. Taking a break from work, participating in breathing exercises, exercising, and other recreational activities all help reduce the stress associated with STS. Conceptualizing one's own ability with self-integration from a theoretical and practice perspective helps to combat criticized or devalued phase of STS. In addition, establishing clear professional boundaries and accepting the fact that successful outcomes are not always achievable can limit the effects of STS.[55]

Social self-care

Social support and emotional support can help practitioners maintain a balance in their worldview.[56] Maintaining a diverse network of social support, from colleagues to pets, promotes a positive psychological state and can protect against STS.[55]

Self-compassion as self-care

In order to be the best benefit for clients, practitioners must maintain a state of psychological well-being.[57] Unaddressed compassion fatigue may decrease a practitioners ability to effectively help their clients. Some counselors who use self-compassion as part of their self-care regime have had higher instances of psychological functioning.[58] The counselors use of self-compassion may lessen experiences of vicarious trauma that the counselor might experience through hearing clients stories.[59] Self-compassion as a self-care method is beneficial for both clients and counselors.[60]

Mindfulness as self-care

Self-awareness as a method of self-care might help to alleviate the impact of vicarious trauma (compassion fatigue).[61] Students who took a 15 week course that emphasized stress reduction techniques and the use of mindfulness in clinical practice had significant improvements in therapeutic relationships and counseling skills.[62] The practice of mindfulness, according to Buddhist tradition is to release a person from “suffering” and to also come to a state of consciousness of and relationship to other people's suffering. Mindfulness utilizes the path to consciousness through the deliberate practice of engaging “the body, feelings, states of mind, and experiential phenomena (dharma).”[63] The following therapeutic interventions may be used as mindfulness self-care practices:

Scales Used for Assessment Administration Measure Accessible
Professional Quality of Life Measure ProQOL[65] self -test compassion satisfaction, burnout, and secondary traumatic stress online, available
Compassion Fatigue and/Satisfaction Self Test for Helpers[66] self-test compassion fatigue online, available
Maslach Burnout Inventory[67] administered burnout available for purchase

Compassion fade
Main article: Compassion fade

The difference between compassion fatigue and compassion fade is that compassion fatigue is more about the people the individual works and interacts with often, whereas compassion fade is the individual’s attitude towards helping certain amounts of people they don’t know or as aid needed in the world rises. Compassion fade is when the need and tragedy in the world go up, the amount of desire to help goes down.[68] For example, a person is more likely to donate more money, time, or other types of assistance to a single person suffering than to disaster aid or when the population suffering is larger.[69] It is a type of cognitive bias that helps people make their decision to help.[70]


See also

References
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