A dark horse: Illuminating the price of compassion fatigue

Patty Pate, CVT, VTS(ECC), CCFE
Technician clinical educator, Ethos Veterinary Health, Woburn, MA
Posted on 2018-04-10 in Staff wellness.

National Suicide Prevention Lifeline: 1-800-273-TALK (8255)

The concept of compassion fatigue has been around for decades, and the veterinary profession is no stranger to it. Although it wasn’t until recently, with the sad passing of Dr. Sophia Yin, that the topic has routinely taken center stage in educational forums. Veterinary medicine, as a profession, has one of the top suicide rates in the nation. The types of personalities the profession attracts coupled with erratic work schedules, suffering patients, disappointed owners and access to potent medications, can make it all too easy to take that final step. Compassion fatigue is a complex phenomenon that can be prevented in most cases, and it is the responsibility of everyone employed in the veterinary profession to learn about silent threat to ensure healthy teams throughout.

Burnout, secondary traumatic stress and compassion fatigue

Compassion fatigue and burnout have been used interchangeably but, in fact, these terms are not synonymous with one another. To truly understand what compassion fatigue is one must learn about its components: burnout and secondary traumatic stress.

Burnout can be defined as an individual’s physical and emotional exhaustion. It is typically in response to an individual’s work environment which where they are employed.

Secondary traumatic stress is a condition that occurs in response to the exposure of trauma and suffering of others. It can be a result of exposure to the same type of trauma over a prolonged period or it can result from one very extreme event. In the case of veterinary practitioners and their teams, it is not only the exposure to sick, suffering or traumatized patients, but to the client’s suffering as well: their sadness, worry, despair, grief, and sometimes anger.

Compassion fatigue is a combination of both burnout and secondary traumatic stress. It is so complex that often it becomes difficult to determine if and when a person might be suffering. Factors such as compassion satisfaction and resilience need to be weighed against the levels of burnout and secondary traumatic stress to determine the level of compassion fatigue an individual may be experiencing.

The true difference: a person suffering from burnout can most likely recover by taking a vacation, or in more extreme cases, by changing their place of employment. Individuals suffering from compassion fatigue need to take more drastic measures to heal. Because compassion fatigue incorporates secondary traumatic stress with burnout, individuals suffering from extreme compassion fatigue will most likely need to leave the profession altogether to escape the physical, psychological and spiritual toll on them.

Who’s at risk?

On some level, everybody working in the veterinary profession is at risk for developing compassion fatigue. Each member of the team, from veterinarians and technicians to client care and management, will be exposed to the horrors and the sadness that accompanies caring for sick animals, day in and day out. Thankfully, not everyone is equally susceptible to compassion fatigue. According to Dr. Kathleen Ayl, author of When Helping Hurts: Compassion Fatigue in the Veterinary Profession, specific internal and external variables have been identified that can have a strong impact on an individual’s susceptibility to compassion fatigue. Internal variables consist of factors from within one’s human nature. These can be ingrained in an individual’s personality, and include lack of assertiveness, perfectionism, and sensitivity to suffering. While external variables consist of an individual’s work-related stresses in the environment and various other influences, such as time constraints, exposure to death and grief, and unresolved personal trauma.

Internal variables

As human beings, it is hard-wired in our DNA to empathize with those around us. Neurologists identified what are called mirror neurons, which contribute to a person’s ability to empathize. These visuospatial neurons allow us to interpret the experiences of others and develop emotional responses based on our perceptions or experiences, which is why most of us cringe when we watch another person receive a flu shot. In a sense, it gives us the ability to experience life vicariously through others: the good, the bad and the ugly. It’s when the negative influences overwhelm a person to the point of imbalance that they become susceptible to CF.

Individuals who lack assertiveness are not feeble or weak. Rather, they are the professionals who give 110% of themselves to everyone around them 100% of the time. They are more susceptible because they struggle to establish personal boundaries not only with their clients but coworkers, friends and family as well. These individuals will almost always say “yes” to helping someone before considering the emotional cost or burden it will entail.

Some think that veterinary medical profession attracts the perfectionists while others argue that the educational rigor and process of becoming a veterinary practitioner creates perfectionism in the profession. Either way, the quintessential “type A” personality can be found in all occupations of veterinary medicine. These individuals have extremely high expectations of themselves, putting their work first and constantly self-scrutinizing. A true perfectionist is his or her own worst critic. They are the ones who dwell on the loss of a patient as a personal failure. When coupled with the stress and expectations of a client, a perfectionist will put themselves under insurmountable pressures to succeed.

Traumatologist Dr. Eric Gentry believes that all individuals who enter the healthcare field have a pre-existing level of compassion fatigue and their motives to help others are driven by their own need to fix themselves. These individuals identify with the sick and traumatized on a deeper level. They can feel convinced that helping a patient in need is more important than anything. Those sensitive to suffering can be considered to have some of the highest empathic abilities, able to sense the slightest changes in an individual’s feelings or tone. With this, they run the risk of transference, absorbing the emotional state and carrying the burden on their own.

External variables

Work-related environmental stressors can contribute to an individual’s susceptibility to compassion fatigue. Loud barking and incessant whining can not only be distracting but also grate on an individual’s patience level. A lack of supplies or essential equipment may contribute stress for the veterinary team, creating high levels of anxiety as teams feel unable to effectively care for their patients.

High patient load coupled with limited support staff can lead to significant pressure and time constraints. Depending on the employer, some clinicians are held to very lofty expectations to see a certain number of patients per day or to accumulate specific revenues. These goals lead to high patient loads and long, unpredictable hours, and the stress then trickles down to the rest of the team. Employees can leave feeling inadequate, like their contributions weren’t enough. They may take work home with them because they are unable to keep up. They may even take it with them as they replay the day’s events over and over, analyzing “what went wrong” and counting up all the ways they feel they failed.

Veterinary professionals are exposed to five times more death than their counterparts in human medicine. Euthanasia is one of the most frequent tasks that a veterinarian is asked to perform on a daily basis, and veterinarians are trained to advocate for their patients by discussing the benefits of euthanasia to ease suffering. Although peacefully ending a patient’s suffering can be considered a gift, euthanasia can take its toll on everyone involved. Hospital staff all experience euthanasia differently, but all would agree that it is a devastating loss to the client as they bid farewell to a member of their family. The constant exposure to suffering, sadness, and grief can be an emotional drain on everyone on the team.

Past personal traumatic experiences can affect an individual in profound ways if proper measures haven’t been taken to resolve these feelings. Situational events that occur many years later can evoke a strong emotional response in some individuals as they flashback to those moments in their lives. Finding resolution, sometimes with the help of a professional, is needed to achieve balance and to prevent these moments from affecting one’s daily work environment.

Identifying the symptoms

Compassion fatigue can be broken down into three phases. The first phase is compassion discomfort and is only a temporary change. Compassion discomfort can manifest itself as tiredness, limited attention span and decreased excitement and enthusiasm. This can be a transient change and can be reversed by rest and relaxation.

If an individual does not take the correct measures of self-care, they can move into phase two: compassion stress. As an individual’s stress levels increase, their endurance and resiliency decrease. The individual can fatigue easily, have decrease performance or attention to detail, be uncharacteristically short with others or have trouble concentrating.

Individuals suffering compassion stress can quickly move into the third and final phase, compassion fatigue, where the individual may feel indifference or apathy. Individuals suffering from compassion fatigue can have any number of somatic, behavioral, cognitive, emotional or spiritual disturbances, ranging from physical illness to an individual questioning the meaning of life (table 1). Some feel that once this phase of compassion fatigue is reached, unless intense counseling is sought, many will not be able to recover. It’s in this phase the individuals will feel the need to leave the profession or sometimes consider suicide.

Knowing the cost

Compassion fatigue has personal and professional ramifications. It not only consumes the individual (table 1) but these effects can then carry over into the workplace. They can cascade from one to the next if left unaddressed. Some ways compassion fatigue has been shown to affect the hospital:

Disgruntled team(s)
More employee complaints
Excessive overtime
High turnover rates
Higher wage expenses
Low client satisfaction
Lost revenue

Each one of these effects has its own set of repercussions.

Staying healthy

The key to staying healthy can be boiled down to knowledge, balance and good self-care practices. Risk factors for compassion fatigue are different for everyone in the field. If an individual knows what their limits and triggers are it will help them to know when to employ advanced self-care measure and maintain a good work/personal life balance.

Self-assessment tools such as the Professional Quality of Life Scale (ProQOL) and the Resilience Scale are excellent resources to estimate an individual’s likelihood to suffer from compassion fatigue. The ProQOL provides quantitative insight on an individual’s compassion satisfaction and compassion fatigue, broken down into secondary traumatic stress and burnout scores. Compassion satisfaction is a reflection of the pleasure that an individual gets from the work he or she does. Higher scores indicate a positive feeling towards the job one performs.

Resilience is the ability to physically and mentally adapt to environmental changes. An individual’s resilience to stressful events can help to explain why two individuals who experience the same trauma will have different emotional responses. The higher one’s resilience score, the better their ability to cope, grieve, justify and accept difficult situations and therefore, it is felt individuals with higher resilience scores are less likely to succumb from compassion fatigue.

Self-assessment tools help an individual to remain honest and true to one’s self. They can provide insight into the current work balance, or imbalance, that an individual is experiencing. They allow individuals to learn their strengths and weaknesses; identify their security and risk factors. These scores are not constant. They improve and decline based on the internal and external variables, but more importantly, they can be a good identifier for when an individual may need to consider changes to improve their quality of life.

Finding work/personal life balance is extremely important. As previously stated, the veterinary field attracts highly motivated and self-critical individuals who have a strong desire to help suffering pets, sometimes at the expense of one’s own needs. It’s no wonder why compassion fatigue is such a struggle in the field of veterinary medicine! Maintaining a balance between the time spent focused on work and the time spent doing enjoyable extracurricular activities is essential. Engaging in activities outside of work which one finds fulfilling has rejuvenating powers. Spending time with family and friends, reading, journaling, and spending time outdoors are all examples of positive outlets to rejuvenate the soul. Activities will differ from person to person, but whatever activity is chosen, the purpose should be focused on one’s own needs and interests.

Establishing and committing to healthy self-care practices can help an individual stay balanced physically and emotionally. Practices such as getting a good night’s sleep and eating breakfast every day (table 2) may seem so basic, but it’s these practices that get overlooked when stresses run high. An individual is more likely to handle an abnormally stressful/traumatic day in stride when they are well-cared for themselves.

Creating Healthy Teams

The responsibility to identify and prevent compassion fatigue should be one for the whole team. Showing compassion and understanding for one another is the first step. Strong teams are self-regulating. They offer quick, unsolicited support at the first sign of struggle. Teams that implement coping strategies, such as debriefing sessions after a code or moments of silence after a euthanasia to honor a lost patient, maintain their strength by learning from and leaning on one another.

Establishing a buddy system among the hospital can be helpful as well. The goal of the buddy system is to provide employees with committed partners who are looking out for each other during their workday. This may be done by checking in with each other regularly to discuss the current state of wellbeing after a long week or by alerting one another to take a break when they see the other fatiguing.

Management has more control than they realize over how compassion fatigue affects their hospital. Studies have been done on emergency nurses, and researchers have found that the nurses who score the highest compassion satisfaction scores all work in emergency departments where management support is very present. Hospital managers and supervisors can intervene at the first sign of poor performance to coach those employees who may be struggling. Interventions should never be disciplinary, rather a simple acknowledgment of the stressors affecting them and a discussion of observed responses. In most cases, early intervention provides an employee with a safe forum to reflect and discuss how they may be struggling. It may be enough to jolt them back into good self-care practices. If early intervention is not effective, it at least establishes a platform to assist an employee in getting the help they need.

Appendix

About the author

Patty Pate, CVT, VTS (ECC), CFE has nearly 20 years’ experience in the veterinary field with the last 16 years focused on emergency and critical care working at Massachusetts Veterinary Referral Hospital, Bulger Veterinary Hospital and Port City Veterinary Referral Hospital. In her current role of Technician Clinical Educator for Ethos Veterinary Health (East Region) Patty provides educational opportunities to 400 veterinary technicians, was instrumental in the development of the Ethos AVA Program and is a primary instructor for the program. Patty is the Secretary of the NHVTA and lectures frequently on emergency, critical care, and compassion fatigue.