Though new technological advancements occur almost daily in the world of modern medicine, one of the most powerful tools a healthcare practitioner (HCP) can use remains something far more fundamental: empathy.
Empathy – the ability to understand and share the feelings of another – a skill vital in healthcare, and one that can significantly improve patient outcomes and satisfaction, as well as practitioner wellbeing.
Empathy is displayed through both verbal and non-verbal gestures and may be facilitated by sharing common experiences and emotional reactions, allowing HCPs to feel more connected to their patient, improve HCP job satisfaction and reduce stress. For patients, experiencing empathy from their HCP helps to reduce anxiety, improve adherence to treatment plans, and empowers them to be more involved in decision-making regarding their care.
Compassion is an emotional response to empathy; it’s the desire to act and help a person to alleviate their suffering.
But does empathy come at a cost?
The answer is yes, it very much can. This is known as compassion fatigue.
What Is Compassion Fatigue?
Compassion fatigue is a silent epidemic amongst HCPs. It is a term used to describe the physical, emotional, and psychological cost of caring for other people, resulting from taking on the suffering of patients who have experienced stress or trauma. In other words, it is the result of long-term use of empathy, which can leave HCPs feeling less able to care for others.
For HCPs, it can become a problem when it starts to affect them outside of work too.
Long-term use of empathy can lead to compassion fatigue for several reasons, including:
- Emotional contagion theory – when emotions and behaviours can effect the emotions and behaviours of others. For example, if a patient feels sad, their HCP feels sad too.
- Difficulty maintaining emotional boundaries, especially when HCPs are under significant stress, are strongly empathic as people and may not have sufficient emotional support networks.
- Suppression of self-care – high empathy can lead to HCPs prioritising the needs of others over their own.
- Vicarious trauma – HCPs experience trauma through indirect exposure to other people’s trauma. HCPs are more at risk of this is they have had a previous traumatic experience themselves, or if exposed over a prolonged period.
It is commonly mistaken for burnout – there is a difference between the two, though the symptoms can be very similar. Burnout, as defined by the World Health Organisation, is “a syndrome conceptualised as resulting from chronic workplace stress that has not been successfully managed.” It typically presents with exhaustion, feelings of dissatisfaction or negativism about the job, and reduced efficacy. We will touch more on this another time.
How Common Is Compassion Fatigue, and Why Do Healthcare Practitioners Experience It?
One study published in 2020 found that just under a third of UK Doctors had low compassion satisfaction – the satisfaction derived from helping others – with the highest proportion being within Doctors working in Emergency Medicine and General Practice[1]. The figure has been reported in another two studies as being up to 40%[2], and this is likely to have significantly increased since the Covid-19 pandemic.
These figures aren’t altogether a surprise to me; working in A&E has shed light on the long waiting times (which can be upwards of 10 hours), scarcity of beds for patients, significant staffing shortages, and growing numbers of patients attending the department including for non-urgent conditions, all of which influence overall wellbeing.
It isn’t just A&E experiencing these challenges though – staff in all departments are subject to long hours, shift work, lack of resources, stressful work environments and exposure to traumatic events.
These factors take an emotional toll on staff members, which can subsequently affect the quality of patient care and overall health outcomes, too. Addressing these issues will ultimately require a system-wide approach, from improving staffing levels to the continuous assessment of resource allocation, as well as awareness on an individual level to create a more sustainable and compassionate healthcare environment.
My Experience With Compassion Fatigue
My last job as a Foundation Year 2 (FY2) Doctor was working in General Surgery. I loved this rotation, but after 4 months of carrying the On-Call Surgical bleep often I needed a break for my own wellbeing too.
On my first day On-Call I was part of the trauma team, and the call went out twice for two traumatic cardiac arrests; one a road-traffic collision (RTC) patient and the other a burns patient. I have seen and been involved in cardiac arrests before, but these were particularly difficult for me emotionally, and combined with the stress of it being my first On-Call in General Surgery I really struggled that week (and I still had 4 more 12.5-hour On-Call days to go!).
It was commonplace when On-Call too to be referred around 20-30 patients in one shift, and the high patient turnover and acuity* of patients would leave me feeling emotionally exhausted by the end of the day.
*Higher acuity patients = more unwell.
I also noticed as time went on that I would have to remind myself to “hit reset” before reviewing the next person, because otherwise I’d be less aware of and less responsive to their emotions and feelings in amidst the pressure of trying to review as many people as I could, so that I didn’t have to handover too much to the night team.
Being aware of compassion fatigue and how it presents helped me though. I was aware towards the end of the rotation I was starting to feel it, albeit alongside burnout too, so planned to take a break right after finishing FY2. This meant when I came back to A+E two weeks later, I felt refreshed and better prepared to cope with work again.
How Does Compassion Fatigue Present?
Physically, it can present with symptoms such as exhaustion, irritability, sleep disturbances, headaches, nausea. Emotionally, it can also leave healthcare workers feeling helpless, emotionally disconnected, anxious or depressed, angry, and overwhelmed.
At work, HCPs may use sick days frequently, find it hard to concentrate, have memory issues, show reduced performance, and have a reduced ability to feel empathy.
It can also start to affect personal life, leading to increased conflict in relationships, withdrawal from friends and family, or using substances like alcohol to self-medicate.
How Can We Prevent and Manage Compassion Fatigue?
System-wide strategies:
Healthcare services could look to implement regular debriefing sessions – something that is done quite regularly following traumatic events in A&E through “hot” and “cold” debriefs – but looking to expand on this to make it more prevalent throughout all healthcare settings.
*Hot debrief = a short process that takes place immediately after a traumatic event involving HCPs that took part in patient care, where the event is discussed. The aim is to aid learning, identify any improvements that can be made, and to identify the need for further support. Cold debrief = similar to a hot debrief, but it takes place days to weeks after the traumatic event.
Creating quiet spaces for HCPs to use on their breaks, allowing them to decompress and “switch off” from the busy working environment.
Look to develop a mentorship program, where experienced staff are paired with newer staff, or even through a peer support program. The aim with this being to create a safe space to discuss any challenges HCPs may be facing, and to help signpost to other services that may be beneficial to them.
Aim to make services like Occupational Health more accessible to HCPs (as often the waiting times can be long), so that any extra support that may be needed at work can be implemented early, thus safeguarding HCP mental health.
Endeavour to improve patient support services, such as through employing more patient navigators or care coordinators and making them more readily available in all departments, helping guide patients through their healthcare journey. This will help to reduce anxiety, manage expectations (e.g., expected wait times), and improve patient feedback systems so that services can be continuously improved, and any concerns acted on promptly.
Individual strategies:
Optimise work-life balance and prioritise self-care:
Instead of picking up that extra shift, HCPs should think carefully before taking extra shifts, book annual leave early and use it all, and make time for activities they enjoy.
Mindfulness:
A practice stemming from the early teachings of the Buddha, defined in the Merriam-Webster Dictionary as “the practice of maintaining a non-judgmental state of heightened or complete awareness of one’s thoughts, emotions, or experiences on a moment-to-moment basis”.
In recent years there has been increasing interest into the effects of mindfulness on our psychological wellbeing; it is felt to have an overall positive effect on psychological wellbeing, as well as on emotional reactivity[3]. This may, in turn, help combat compassion fatigue.
Mindfulness resources:
Headspace app – for guided meditations and mindfulness exercises. Free for NHS workers.
Every Mind Matters – for tips on meditation, guided meditation videos.
https://www.nhs.uk/every-mind-matters/mental-wellbeing-tips/how-to-meditate-for-beginners/
Exercise:
One study looking at compassion fatigue in Oncology nurses showed that increasing levels of physical activity was associated with lower levels of emotional exhaustion[4].
It is advised that adults should aim to do strengthening activities at least twice per week, and at least 150 minutes of moderate intensity exercise (e.g., fast walking, cycling, hiking) or 75 minutes of vigorous intensity exercise (e.g., running, swimming, football) per week, spread evenly over 4-5 days.
Exercise resources:
Couch to 5K – a free, 9-week running plan for beginners.
https://www.nhs.uk/live-well/exercise/get-running-with-couch-to-5k/
Strava – track your workouts, see suggested routes, connect with friends and monitor progress.
The Body Coach TV by Joe Wicks – a lockdown favourite; Youtube videos of varying lengths that are easy to follow, with a mix of bodyweight and equipment-based workouts.
https://www.youtube.com/@TheBodyCoachTV
Caliber – a free strength training app, where you can customise your workouts, with videos showing correct technique.
Gym Possible – aim to make exercise accessible to people with disabilities. Their Youtube has lots of different videos of different lengths, designed specifically for wheelchair users.
https://www.youtube.com/@gympossibleUK
Pregnancy and Postpartum TV – Youtube videos created by a certified Pregnancy and Postpartum Exercise specialist, designed to help you keep fit during pregnancy and postpartum.
https://www.youtube.com/@PregnancyandPostpartumTV
Talk to others:
Talk to friends, family, colleagues – they will help provide perspective and support.
Healthcare practitioners can speak to their Occupational Health Department through work, as they will be able to offer further support that is tailored to the needs of the individual.
Professional services are also available, including:
- NHS talking therapies for anxiety and depression. No referral needed, you can self-refer using he following link:
https://www.nhs.uk/service-search/mental-health/find-an-nhs-talking-therapies-service
2. Practitioner Health – a free and confidential mental health and addiction service with expertise in treating healthcare practitioners.
https://www.practitionerhealth.nhs.uk
To Summarise:
Empathy is imperative to working in the healthcare profession and the impact it has on overall healthcare outcomes is undeniable; however, it can come at the expense of practitioners’ mental wellbeing.
Understanding what compassion fatigue is and how it can impact HCPs is important for everyone to be aware of. As patients ourselves, or as family and friends of patients, we all interact with the healthcare system in different ways; recognising this can help us better support the people that care for us, too.
If you’re a HCP and you recognise the signs of compassion fatigue in yourself, please remember that you are not alone, and that it doesn’t mean you are bad at your job. It’s a sign the balance isn’t quite right, and that maybe you need a “reset”, whatever this may mean for you. Please make sure to reach out to those around you.
If you would like to share your own experiences with compassion fatigue or have any other tips for HCPs that may be experiencing it right now, please leave a comment below.
Response
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Such a brilliant, thought-provoking piece Charlotte! I definitely feel compassion fatigue playing a part in my practice, particularly with the current pressures to see as many patients as possible in the Emergency Department. Empathy is so important as a tool to gain patients’ trust and to help advocate for their care.
references/citations
[1] McKinley N, McCain RS, Convie L, et al
Resilience, burnout and coping mechanisms in UK doctors: a cross-sectional study
BMJ Open 2020;10:e031765. doi: 10.1136/bmjopen-2019-031765
[2] van Mol MM, Kompanje EJ, Benoit DD, Bakker J, Nijkamp MD.
The Prevalence of Compassion Fatigue and Burnout among Healthcare Professionals in Intensive Care Units: A Systematic Review.
PLoS One. 2015 Aug 31;10(8):e0136955. doi: 10.1371/journal.pone.0136955. PMID: 26322644; PMCID: PMC4554995.
[3] Keng SL, Smoski MJ, Robins CJ.
Effects of mindfulness on psychological health: a review of empirical studies.
Clin Psychol Rev. 2011 Aug;31(6):1041-56. doi: 10.1016/j.cpr.2011.04.006. Epub 2011 May 13. PMID: 21802619; PMCID: PMC3679190.
[4] Murphy CA, Staffileno BA, Hand M, Bruen CP, Hermsen M, Johnson L, et al.
Feasibility and impact of physical activity on Compassion fatigue and Burnout among Ambulatory Care Oncology nurses.
Clin J Oncol Nurs. 2022;26(5):519–27. doi: 10.1188/22.Cjon.519-527. – DOI –PubMed
https://www.webmd.com/mental-health/signs-compassion-fatigue
https://www.keepingwellnwl.nhs.uk/self-help-resources/common-problems/compassion-fatigue
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