Compassion Fatigue and Vicarious Trauma

Here is an excerpt from the last chapter of my coursebook, Grief, Loss, and Bereavement: Helping Individuals Cope sold through Western Schools.

Introduction

With an understanding that mostly everyone experiences stress in the workplace, I begin the last chapter of my coursebook for nurses and healthcare professionals by identifying contributors to compassion fatigue, including job burnout and secondary traumatic stress. Next, the focus moves to vicarious trauma, including various negative symptoms that may mirror the effects seen in trauma victims, which can occur when helping patients cope. Finally, the chapter explores the FABULOUS Principle, a framework that identifies eight protective factors that build resilience and mitigate the impact of compassion fatigue and vicarious trauma. This chapter explores how bereavement research can be adapted and applied to nurses and other healthcare clinicians to mitigate the impact of compassion fatigue and vicarious trauma.

Compassion Fatigue

“At the time of the World Trade Center terrorist attack in September 2001, I was employed as a hospice bereavement coordinator and supported those who were terminally ill and those who loved them; I also facilitated a bereavement support group and taught a master’s-level crisis intervention course at Brooklyn College in New York City. It was during the car ride back from teaching that I felt compassion fatigue and vicarious trauma. As I reflected on my feelings, I knew that I needed self-care strategies to replenish myself, not only in the days following the events of September 11th, but every day thereafter.”

                       – Barbara Rubel

Symptoms

Compassion fatigue is defined as the depletion of emotional energy from the empathetic response in health professionals when the expectation is to relieve the suffering of others. Some of the contributors to compassion fatigue are feelings of inadequacy, personal trauma and past losses that have not been worked through, inadequate job training, an excessive workload, or patients whose cases are difficult.

Symptoms of compassion fatigue in clinicians include boredom, detachment, irritability, sleeplessness, forgetfulness, and exhaustion (Sheppard, 2016). Compassion fatigue includes compassion strain, anguish, guilt, and distress associated with the perception of not having done enough to avert suffering (Figley, 2002). Symptoms will increase negative outcomes and rob clinicians of their passion and energy. Symptoms usually appear without warning, creating a sense of helplessness, shock, and confusion, along with a sense of isolation (Figley, 2002).

Those at Risk

Those at risk for compassion fatigue include family caregivers, volunteers, and professionals. Professionals at risk include nurses, doctors, chaplains, correctional and police officers, first responders, disaster team members, therapists who work with sexual abuse victims, social workers, psychiatric technicians, marriage and family therapists, child protective services workers, counselors with high domestic violence caseloads, and animal care workers.

Patricia C. Mazzotta, a nurse, maintains,

“I can’t recall the number of times human suffering, violence, and death touched me when I was an emergency/trauma nurse. I now understand that the emotional and psychological ailments I experienced were indicative of compassion fatigue, a form of secondary traumatic stress experienced by health care workers. I often withdrew, emotionally detaching myself from patients as a way to get through a shift. Sometimes I relived a traumatic event for weeks or months, even when I thought I had dealt with my feelings” (2015, par. 1).

Compassion Stress

Compassion is defined as “sympathetic consciousness of other’s distress together with a desire to alleviate it” (Merriam-Webster, n.d.). Wanting to alleviate the distress can bring about compassion stress, which is described as “the natural behaviors and emotions that arise from knowing about a traumatizing event experienced by a significant other and the stress resulting from helping or wanting to help the traumatized person” (Figley, 2015, pg. xiv).

Empathy is the intellectual identification with or vicarious experiencing of the feelings, thoughts, or attitudes of another (Empathy, 2015). According to Salmond, Ames, Kamienski, Watkins, & Holly, C. (2017), when clinicians are exposed to suffering while empathetically connecting with and caring for patients, psychological distress and compassion fatigue can occur. Accordingly, clinicians with an immense capacity for “expressing empathy” are at a greater risk for compassion stress (Figley, 2015).

TWO ELEMENTS OF COMPASSION FATIGUE

In contrast, where compassion stress focuses on stress, compassion fatigue focuses on energy, or the lack thereof. When combined, burnout and secondary traumatic stress create a state of tension and preoccupation with the individual or the cumulative trauma of patients, thus producing compassion fatigue (Figley, as cited in Figley, 2002).

Burnout

The first element of compassion fatigue is burnout. Primarily, burnout stems from job stress that progressively overcomes individuals, frustrating them and hindering their ability to reach their professional goals. According to Maslach & Leiter (2016), burnout is a prolonged response to chronic interpersonal job stressors characterized by three dimensions: exhaustion (depletion) that feels overwhelming, becoming cynical, and being detached from the job while not feeling a sense of accomplishment. Decreased professional efficacy, increased role conflicts, low morale, impaired competence, feelings of powerlessness, and encounters with difficult personalities, can lead to burnout. In a national survey, Kronos (2017) found that unfair salary, “unreasonable workload” and excessive overtime are the leading contributors to burnout.

Job stress is the response of cumulative work pressure. According to the American Institute of Stress (n.d.), burnout develops over time when a clinician is emotionally exhausted and withdraws because of a heavy workload and job stress that is not related to traumatized individuals. Also, personality traits can contribute to burnout such as being a high-achiever, perfectionist, pessimist, or having to be in control and being unwilling to delegate (Smith, Segal, Robinson & Segal, 2018).

Burnout can affect those who do not have job resources. Job resources are factors that help clinicians feel less stress, such as having a good relationship with supervisors and coworkers, and having tools to do one’s job well. Stressors may include time pressures, deadlines, or the occurrence of several emergencies at once. In particular, job stressors or contributors to burnout in nurses consist of:

·        stressful, even dangerous, work environments;

·        lack of support;

·        lack of respectful relationships within the health care team;

·        low pay scales compared with physicians’ salaries;

·        shift changes and long work hours;

·        understaffing of hospitals;

·        pressure from the responsibility of providing continuous high levels of care over long periods; and

·        frustration and disillusionment resulting from the difference between job realities and job expectations (Mosby's Medical Dictionary, 2009, Burnout).

Wigert & Agrawal (2018) maintain that to reduce burnout, leaders need to focus on treating employees fairly, offering a controlled workload with clear roles and expectations, managers who offer support, and reasonable time pressures. Furthermore, Finlayson, & Simmonds (2017) reported that in order to prevent burnout in clinicians after patient suicide, organizations need to recognize the impact of the death on the clinician, the value of debriefing, the need for supervision and colleague support, offer workload flexibility, and the ability to be present at the funeral.

Secondary Traumatic Stress

The second element of compassion fatigue is secondary traumatic stress, which is associated with vicarious trauma and occurs when a clinician is subjected to a very stressful event (The Center for Victims of Torture, 2018). When clinicians listen to or hear about a patient’s primary trauma, secondary traumatic stress can occur which brings about a struggle to function in the workplace and a reduced “quality of life” (National Child Traumatic Stress Network, n.d.).  The quick onset of symptoms can include being fearful, having sleep issues, and picturing the terrible scene in one’s mind (The Center for Victims of Torture, 2018). Secondary traumatic stress symptoms include intrusion, avoidance, and arousal symptoms (see Table 13-2)

When a clinician’s functioning is decreased, workplace challenges are created (Administration for Children and Families (n.d.). These challenges include the way one thinks about and responds to one’s role. In contrast, compassion satisfaction is the sense of pleasure or fulfillment that clinicians derive from their work. Compassion fatigue is most commonly measured using the Professional Quality of Life (ProQoL) scale with a focus on burnout, secondary traumatic stress, and compassion satisfaction/compassion fatigue. According to Harris (2015), there are other measuring instruments to assess compassion fatigue such as the Compassion Fatigue Self Test (CFST) and the Compassion Satisfaction and Fatigue Test (CSFT).

VICARIOUS TRAUMA

Although compassion fatigue and vicarious trauma are distinct experiences, people often interchange these terms. Vicarious trauma is a transformation in the clinician’s cognitive, physical, psychological, emotional, and spiritual health that results from using controlled empathy when listening to a patient’s trauma-content narrative (Vicarious Trauma Institute, n.d.). According to Pearlman & Saakvitne (2015), vicarious trauma profoundly changes the clinician’s sense of self and world view as they struggle with “intrusive imagery” from their patient’s experience. Vicarious trauma can occur when a clinician is exposed to a primary (e.g., emergency department) or secondary (e.g., counseling) traumatic circumstance.

Symptoms of vicarious trauma are “increased aggression, decreased sex drive, sexual dysfunction, difficulty with boundaries, sleep problems, intrusive imagery, sudden increase in cynical outlook, depression, issues around trust and intimacy and greater sensitivity to violence” (HumanServices EDU.org, 2018, Trauma, Vicarious Trauma and Post-Traumatic Stress Disorder). Moreover, being a professional who is either new to trauma work or who has experienced personal trauma him/herself can contribute to vicarious trauma (Iqbal, 2015).

GRIEF

Ceyhan, et al. (2018) maintain that nurses experience grief as they worry and are angry when unable to provide adequate care to terminally ill patients and their loved ones. Bereavement and loss-exposed workplaces influence the likelihood that a clinician will experience burnout, secondary traumatic stress, compassion fatigue or vicarious trauma.

Generally, workplace wellness programs are created to ensure the wellbeing of health workers (Ledikwe, et al., 2017). In recent years, more focus has been on managing compassion fatigue. By reducing compassion fatigue and vicarious trauma in those at risk, the associated mental health and economic costs will also be reduced (Cocker & Joss, 2016). However, these programs also need to focus on grief because clinicians can experience grief after a patient’s death. For instance, in a study of nurses’ experiences of grief following patient death, one nurse noted, “increasing the death cases make us like a stone; sometimes I deal with five death cases during the same shift” (Khalaf, et al. 2017, p. 6).

Although nurses report that they experience more grief responses when their patients who die are young or died suddenly and less grief responses when patients are terminally ill and had suffered for a long time, they are still grieving (Khalaf et al., 2017). Accordingly, they need resilience building strategies to cope with loss in the workplace. Ghesquiere and Bagaajav (2018) found that home health aides who felt shock, sad, numb, “grief, and relief” after the death of their patients, coped by accepting that death is a part of life; making meaning out of the loss experience; and utilizing peer support.

Barbara Rubel is a keynote speaker and trainer on building personal resilience in professionals. The third edition of her book, But I Didn't Say Goodbye: Helping FAMILIES After a Suicide (2020) just launched on Amazon.com. Here is the link: https://amzn.to/2FwS6JI Barbara's website is www.griefworkcenter.com