Ann Quinlan-Colwell, PhD, RNC, AHNBC, DAAPM
In the last newsletter, compassion was discussed as the possible ghost of pain management. Intrinsic in that possible relationship is the potential ingredient known as compassion fatigue which is described by Sinclair and colleagues (2017) as “a work-related stress response in healthcare providers that is considered a ‘cost of caring’ and a key contributor to the loss of compassion in healthcare.” The stress response involved in compassion fatigue is believed to evolve while caring for patients, clinicians repeatedly experience, in a secondary manner, the traumatic events and/or suffering of patients. Although, there is no identified theoretical basis, empirical validation or measurement, there is general consensus that compassion fatigue is real and does clinically exist internationally (Sinclair et al, 2017). It is certain that for a clinician to experience compassion fatigue, the clinician must first have compassion and experience compassion with patients. Ironically, the terminal result of compassion fatigue is that such an originally compassionate caregiver, no longer feels empathic or nurturing toward others, and no longer feels energetic or enthusiastic about the profession once so loved.
The term was first used in 1992 by a nurse educator, C. Joinson, who coined the term compassion fatigue to describe the burnout she observed among healthcare providers. Today, although compassion fatigue is at times considered a branch of burnout (Sabo, 2011), it is generally considered different from burnout (Lanier, 2017). In 1995, Dr. Charles Figley (Tulane University) described compassion fatigue occurring as the result of secondary traumatic stress occurring among caregivers when caring for people who are suffering as a result of a traumatic event. He described the secondary traumatic stress/compassion fatigue as being similar to the post traumatic stress disorder (PTSD) experienced by the traumatized person. In fact, the symptoms attributed to PTSD and compassion fatigue are remarkably similar (See Table 1).
Table 1
|
Post Traumatic Stress Disorder Symptoms |
Compassion Fatigue Symptoms |
|
Upsetting thoughts |
Intrusive thoughts |
|
Irritable |
Irritability |
|
Flashbacks |
Traumatic memories |
|
Upset by memories |
Anger |
|
Trouble sleeping |
Insomnia or difficulty sleeping |
|
Nightmares |
Nightmares |
|
Concentration difficulties |
Difficulty concentrating or focusing |
|
Jumpy |
Startle reactions |
|
Overly careful |
Hypervigilant |
|
Emotional distance |
Patient/client avoidance |
|
Overly careful |
Self-doubt and questioning self |
|
Loss of interest |
Depressed mood |
|
Avoid activities |
Isolating self |
|
Memory difficulties |
|
|
Taken from: Foa, Johnson, Feeny, & Treadwell, (2001). |
Taken from: Fidley, 1995; Fidley, 2002; Sabo, 2011; Sinclair, et al, 2017 |
Figley defined compassion fatigue “as a state of tension and preoccupation with the traumatized patients by re-experiencing the traumatic events, avoidance/numbing of reminders persistent arousal (e.g. anxiety) associated with the patients … a function of bearing witness to the suffering of others” (Figley, 2002, p. 1435). The Compassion Fatigue Self Test of Psychotherapists was developed by Figley and later adapted by others with one version adapted with the permission of Figley available via http://www.community-networks.ca/wp-content/uploads/2015/07/Self-Assessment-Tools-Compassion-Fatigue-Feb-22-2010.pdf In his Compassion Stress and Fatigue Model, Figley (1995, 1997, 2002) described ten variables which combine to result in compassion fatigue and which can be modified to avoid or mediate the development or experience. The ten variables are listed in Table 2 along with a brief description of each one.
Table 2 Variables of Figley Compassion Stress and Fatigue Model
|
Model Variable |
Description of variable |
|
Empathic ability |
The ability to appreciate pain in another person. |
|
Empathic concern |
The impetus to respond to the pain of another person. |
|
Exposure to the patient |
Directly being exposed to and experiencing the emotional energy of the suffering person. |
|
Empathic Response |
Using insight to share the perspective of the suffering person in an effort to ease the pain and suffering of the person. |
|
Compassion Stress |
The effect of the energy expending during the empathic response which can result in negative effects on the well- being of the caregiver. |
|
Sense of Achievement |
The satisfaction with compassionate efforts that are experienced by the caregiver who has clear boundaries and concepts of responsibility. This variable is protective against compassion fatigue and promotes compassion satisfaction. |
|
Disengagement |
The ability, between encounters, to put space between self and the suffering patient and let go of the qualities associated with the suffering experience. It also involves the clinician in fully engaging in his or her own life. When utilized this variable also is protective against compassion fatigue. |
|
Prolonged Exposure |
Over time the persistent belief of responsibility for the person and the associated suffering. The more intense the exposure with limited interruptions the greater the compassion fatigue. |
|
Traumatic Recollections |
These are memories of other experiences or the experiences of other patients which trigger emotional and stressful reactions (i.e. anxiety or depression). |
|
Life Disruption |
The unanticipated events that necessitate change in routine or schedule which normally occur in life. However, when combined with the other variables, the likelihood of compassion fatigue developing increases. |
|
Taken from: Figley, 2002, pp. 1436 – 1438. |
|
Although the concept descriptor, compassion fatigue, was only coined 25 years ago, compassion fatigue is now considered an occupational hazard of health care workers (Mathieu, 2012). Estimates of prevalence range as high as 40% in Intensive Care Units (van Mol, Kompanje, Benoit, Bakker, & Nijkamp, 2015). Not only is it a general occupational hazard, but among clinicians who strive not only to do well, but to at all times to do their best, Figley noted it is a “disorder that affects those who do their work well” (Figley, 1995, p. 5). Traumatologist Eric Gentry proposed that many who enter caregiving professions suffer from compassion fatigued prior to even starting their profession because they previously learned to care for others rather than learning to care for self (Lanier, 2017).
Equipped with this knowledge, it seems reasonable to conclude there is an ethical responsibility to educate those who are at greatest risk (i.e. all clinicians) to be able to empathically and compassionately care for patients while promoting compassionate satisfaction and preventing compassion fatigue. As a first step in addressing this responsibility, the next segment of this series will address the concept of self-compassion and the final segment will discuss restoring compassion in the work of pain management. Now that you have read about the dilemma, hopefully, you will return to read about viable resolutions.
References
Abendroth, M., (Jan 31, 2011) “Overview and Summary: Compassion Fatigue: Caregivers at Risk” OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 1, Overview and Summary. DOI: 10.3912/OJIN.Vol16No01OS01
Figley, C. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Brunner-Routledge.
Figley, C.R. (1997). Burnout in families: The systemic costs of caring. Boca Raton: CRC Press
Figley, C. (2002). Compassion fatigue: Psychotherapists’ chronic lack of self care. Psychotherapy in Practice, 58(11), 1433-1441.
Foa, E. B., Johnson, K. M., Feeny, N. C., & Treadwell, K. R. (2001). The Child PTSD Symptom Scale: A preliminary examination of its psychometric properties. Journal of Clinical Child Psychology, 30(3), 376-384.
Gentry, J. E.. Baranowsky, A. & Dunning, (1997). Compassion Fatigue Article: Accelerated Recovery Program (ARP) for compassion fatigue. Traumatology Institute. Online Training for Trauma Professionals.
Joinson, C. (1992). Coping with compassion fatigue. Nursing 22(4), 116-122.
Lanier, J. (2017). Running on empty: Compassion fatigue in nurses and non-professional caregivers. The Bulletin Indiana State Nurses Association, 44(1), 10-14.
Mathieu, F. (2012). The Compassion Fatigue Workbook. NY, NY: Taylor and Francis Group.
Sabo, B., (Jan 31, 2011) “Reflecting on the Concept of Compassion Fatigue” OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 1, Manuscript 1. DOI: 10.3912/OJIN.Vol16No01Man01
Sinclair, S., Raffin-Bouchal, S., Venturato, L., Mijovic-Kondejewski, J., & Smith-MacDonald, L. (2017). Compassion fatigue: A meta-narrative review of the healthcare literature. International Journal of Nursing Studies, 69, 9-24.
Todaro-Franceschi V. (2013). Compassion Fatigue and Burnout in Nursing New York, NY: Springer Publishing Company. ISBN: 978-0826109774
van Mol, M. M., Kompanje, E. J., Benoit, D. D., Bakker, J., & Nijkamp, M. D. (2015). The prevalence of compassion fatigue and burnout among healthcare professionals in intensive care units: a systematic review. PloS one, 10(8), e0136955.