American College of Physicians: Internal Medicine — Doctors for Adults ®

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Caring is hard work

Programs seek to address ‘compassion fatigue’

From the May ACP Hospitalist, copyright © 2012 by the American College of Physicians

By Stacey Butterfield

When someone first suggested to Patricia Potter, RN, PhD, that the clinicians at Barnes-Jewish Hospital in St. Louis might be suffering from compassion fatigue, she didn't know what they were talking about. “I had never heard of compassion fatigue,” said Dr. Potter, who is the hospital's director of research for patient care services.

Many physicians are equally unaware of this condition, despite their risk of developing it. Compassion fatigue shares symptoms and some causes with burnout, a more commonly discussed peril of medicine, but it's not quite the same thing, according to Mimi Alvarez, RN, MSN, a psychiatric clinical nurse specialist with the Comprehensive Cancer Support Program at the University of North Carolina at Chapel Hill (UNC).

Photo by Thinkstock.

Photo by Thinkstock.



“Compassion fatigue originates from the cost of deeply caring for your patients. It costs you something emotionally. Burnout is more of a system problem. It's short-staffing or physicians that are overworked,” said Ms. Alvarez.

Dr. Potter believes burnout is less systemic and more personal, however: It occurs when a person perceives his or her demands outweigh the resources available. “A person's perception and the ability to deal with that perception is key,” she said.

Physicians who aren't affected by burnout can still find themselves compassion fatigued, she added. The condition can be triggered by one particularly upsetting case or the general nature of the job. “Seeing somebody with chronic lung disease or heart disease who is just getting more and more debilitated, that wears on you, and no one prepares caregivers for this,” said Dr. Potter.

She and others are currently working to prepare clinicians by teaching them strategies to prevent compassion fatigue—or recognize and treat it when it occurs.

Compassion training

At Barnes-Jewish, the effort has involved a training program developed for the hospital by a psychologist with expertise in treating trauma. Starting with an intensive pilot group of a few nurses, the hospital offered training in how to avoid compassion fatigue. Now full-day classes are offered to anyone in the hospital twice a month.

Because it was a research project, the Barnes-Jewish program used a specific instrument to measure compassion fatigue among oncology staff (the ProQOL survey, available free online. But the symptoms of the condition are often readily apparent to both sufferers and their colleagues.

“When somebody is truly experiencing compassion fatigue, they are fatigued, irritable, avoid interactions with others, and often become very reactive,” said Dr. Potter. Any change in behavior can be a sign, but especially withdrawal, according to Ms. Alvarez.

When a physician with compassion fatigue does communicate, it may go badly. “There's not openness to another perspective, and there's often a great deal of irritability,” said Kathleen Beck-Coon, MD, adjunct associate professor at the Indiana University School of Nursing in Indianapolis.

Sufferers may try to dull these feelings with substance abuse, overeating or activities like shopping or gambling. “They're feeling stress. They're feeling like they're inadequate, but also feeling kind of frustrated because they feel like no one's listening. They begin to follow self-soothing behaviors,” said Dr. Potter.

Not surprisingly, one solution to this frustration is to listen to the person. “Especially if you've got a good relationship with a colleague, you can tell that a certain case may have really had more of an emotional toll on them than other cases,” said Ms. Alvarez. “Notice when they're struggling and reach out to them: ‘Let's go out and get some dinner or coffee or lunch.’”

Listening works best as a long-term solution to compassion fatigue if it's mutual. “You need to have people who are going to be equally sharing, so it's not just that ‘Joe's the one with all the problems, and I'm perfect,’” said Mary Vachon, RN, PhD, a professor in the Department of Psychiatry and Dalla Lana School of Public Health at the University of Toronto.

At UNC, this kind of sharing has been formalized as “Breakfast with Mimi,” held on the bone marrow transplant unit of the oncology service. The service's nurse manager arranges a breakfast during the shift turnover and Ms. Alvarez meets with anyone who wants to come.

“I listen and I support them and I try to help them make sense and find meaning in their experience,” she said. “It's not sitting there pathologizing the experience but… normalizing and not making them feel like there's something inherently wrong with them if they feel.” Often there are several people sharing experiences: The most recent breakfast was standing-room only, she said.

The classes at Barnes-Jewish also offer clinicians the chance to communicate. At the start, participants write down and share three negative effects of caregiving that they have experienced. “It connects everyone,” said Dr. Potter.

Beyond sharing

Of course, sharing and connection are not an appealing solution for every fatigued clinician. “Sometimes people are afraid to share their feelings with one another,” said Dr. Vachon. For people who prefer to treat their compassion fatigue individually, the experts offered a number of tips.

“What we do in this class is teach people how to manage stress in their daily work activities when they perceive a threat,” said Dr. Potter.

Some of the recommended strategies are typical, well-known stress reducers. “Making sure you sleep, eating well, exercising, having a life outside the hospital,” listed Ms. Alvarez.

Separating life inside and outside of the hospital is an important component, and clinicians who engage in spiritual and mindfulness practices may be better able to avoid compassion fatigue, the experts said. “Something simple is having a ritual when they walk into the hospital of finding a way to ground themselves, either saying some kind of mantra or some kind of prayer or setting the intention for the day, and the reverse when they leave work to release it,” said Ms. Alvarez.

Inability to release the stress of work after hours is a sign of compassion fatigue, noted Dr. Potter. “You have to learn that you can only do so much,” she said. “You have to be focused on ‘I'm going to do my best today. I can make a difference.’”

Risk factors

Being a perfectionist (or not settling for just doing your best) is both a risk factor for compassion fatigue and a common trait among physicians, according to Dr. Vachon. “Part of what we need to work towards is a non-attachment to outcome in difficult situations,” she said. “We can do our best, but we cannot necessarily control the outcome.”

Clinicians may be at highest risk for compassion fatigue during certain parts of their careers. “I think the people who are most vulnerable are the ones who are early in their careers,” said Ms. Alvarez.

Dr. Vachon agreed, adding, “That's where mentoring could be helpful. Then sometimes at mid-career, people begin to question, ‘What's the purpose of everything I'm doing?’”

Certain specialties of medicine, with closer patient interactions and worse outcomes, may increase the risk of such feelings. “When you're in the OR, and the patient's asleep, it's not quite the same interchange as opposed to somebody in oncology, the palliative care team, the ICU team, the ER teams,” said Ms. Alvarez.

Although research on compassion fatigue is quite limited overall, the existing literature might give the impression that the condition is mostly a problem of nurses. “Compassion fatigue as a phenomenon has been studied much more in nurses. That's probably because it feels more acceptable in nurses to have these soft feelings,” said Dr. Vachon.

“Trust me, (physicians) suffer it, too,” said Dr. Potter.

The systemic solution to compassion fatigue would be to make it more acceptable for all clinicians to acknowledge and deal with their negative feelings, by thinking and talking about them or even taking some time off. “In the past we thought it was an either/or proposition: You either take care of yourself or you take care of your job,” said Dr. Beck-Coon.

Now it's becoming apparent that the former is a step to achieving the latter, she added. “Suppressing grief, fear and sadness actually increase these states,” Dr. Beck-Coon said. “It is impossible to truly aid another in the midst of their suffering when we do not know how to address our own.”

She and other compassion fatigue experts are optimistic that hospitals and medical education are moving toward a greater understanding of this situation, which will benefit all clinicians.

“The flip side of compassion fatigue is compassion satisfaction. Whereas we may get drained helping people, we also get sustained in helping people and we can derive a great deal of satisfaction,” said Dr. Vachon.

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