Compassion fatigue is a topic of increasing interest in health care as organizations struggle to find ways to improve outcomes and decrease costs. Compassion fatigue is defined as the combination of secondary traumatic stress and burnout experienced by health care providers and other helping professionals (Figley, 1995; Stamm, 1995). Compassion fatigue occurs when health care providers exercise high levels of energy and compassion to care for patients or victims of trauma who are suffering, often without seeing improvement (McHolm, 2006). Secondary traumatic stress is a traumatic reaction to witnessing the suffering of others (Gentry, Baranowsky, & Dunning, 1997) and is characterized by symptoms of intrusion, arousal, and anxiety (Coetzee & Klopper, 2010). Burnout is a state of chronic exhaustion when caregivers’ perceived demands outweigh perceived resources (Gentry et al., 1997).
Compassion fatigue is a common and well-documented problem affecting health care providers around the world. In the United States, the prevalence of compassion fatigue among RNs ranges from 16% to 39%, with burnout ranging from 8% to 38% (Hooper, Craig, Janvrin, Wetsel, & Reimels, 2010; Potter et al., 2010; Robins, Meltzer, & Zelikovsky, 2009; Yoder, 2010). Compassion fatigue takes a toll on health care providers and the organizations they work for. It has been associated with increased employee turnover, absenteeism, poor coworker support, depersonalization, increased mistakes, decreased performance, decreased patient and staff satisfaction, and substance abuse problems (Garman, Corrigan, & Morris, 2002; Leiter, Harvie, & Frizzell, 1998; Perry, Toffner, Merrick, & Dalton, 2011; Pfifferling & Gilley, 2000; Schwam, 1998; Stamm, 2002; Sundin, Hochwälder, & Lisspers, 2011; Vahey, Aiken, Sloane, Clarke, & Vargas, 2004).
An intervention in the form of an educational program for supporting staff to better understand and manage compassion fatigue was developed at Barnes Jewish Hospital, a 1,200-bed tertiary academic medical center in the midwestern United States. This article describes the outcomes experienced by the professionals who presented the program.
The compassion fatigue resiliency program was conceived after concerns had been expressed by nurse managers of the hospital’s outpatient chemotherapy infusion center. Staff working in the center were showing signs of compassion fatigue. The project team conducted a survey of the oncology staff (including nurses, medical assistants, and technicians) and found more than one third of the staff were at high risk for burnout (Potter et al., 2010). Survey findings motivated the project team to develop a program to assist staff in understanding and managing compassion fatigue. Financial support from the hospital’s internal funding program was obtained to find a resource who could develop a relevant and comprehensive compassion fatigue program. The project team enlisted the help of a clinical psychologist and traumatologist as a consultant to customize a program that would address the needs of the oncology nursing staff. The hospital’s primary objective was to support staff with the aim of improving patient satisfaction.
The compassion fatigue resiliency program was designed to educate participants about the contributing factors for compassion fatigue and the deleterious effects of chronic stress. A typical health care provider who suffers compassion fatigue is fatigued, often nervous and irritable, has relational problems with coworkers and patients, and directs anger at coworkers. A thorough discussion about the effects of chronic sympathetic stimulation on cognitive and behavioral function provides the groundwork to the resiliency program for participants to understand the importance of stress management in a health care role. Research has shown that the continued effects of chronic stress influence neurocognitive functions including problem solving and decision making, the ability to communicate clearly, emotional regulation, and memory (Goldberg, 2001; Mackenzie, Smith, Hasher, Leach, & Behl, 2007; Takahashi et al., 2005). The implications are significant for the potential chronic stress has on clinical decision making and the occurrence of adverse medical events.
Components of the compassion fatigue resiliency program are designed to help staff achieve resiliency by adopting five key strategies:
- Perceptual maturation.
The program combines didactic with numerous small group activities and discussions. Through self-regulation, participants learn how to achieve relaxation and reduce negative (sympathetic) arousal during times of perceived threat, such as encountering difficult patients or health care colleagues, managing multiple patient priorities, or dealing with emergency situations. Learning to relax while engaged in caregiving activities helps individuals to relieve sympathetic nervous system dominance. Engaging self-regulatory skills immediately restores comfort to the body and better motor and cognitive functioning, regardless of the external context. Living intentionally emphasizes the importance of developing and following one’s professional covenant by doing one’s very best each day, acknowledging best efforts, and living by one’s professional values. Perceptual maturation emphasizes the importance of aiming to live and work with integrity rather than pursuing the acceptance and acknowledgment of others. Connection emphasizes the importance of cultivating social support in the workplace to have someone who can appreciate and share stories of stressful caregiving. Finally, self-care interventions are used to underscore the importance of refueling and restoring one’s energy and passion for professional caregiving.
The project team conducted a feasibility test of the compassion fatigue program to determine staff receptivity and the potential for adopting the program throughout the hospital. The initial program was developed for staff nurses working in the outpatient chemotherapy infusion centers. Input from managers and staff led to the decision to offer the program immediately after the end of shifts, in the evening. The resultant 5-week program developed for oncology staff consisted of four 90-minute evening sessions offering content on stress management and resiliency skills, and one 4-hour retreat that allowed for a final refresher of content and a focus on self-help activities.
The pilot program involved 13 oncology nurses (Potter et al., 2013). The study showed that the program had long-term benefits. Both burnout and secondary traumatic stress levels decreased during the 6 months following the program, although only the change in secondary traumatic stress levels was found to be statistically significant (p < 0.05). Three key symptoms of compassion fatigue (i.e., avoidance, hyperarousal, and intrusions) also decreased significantly in the 6 months following the program (p ⩽ 0.01).
The promising results from the feasibility study led the project team to seek additional funding for the development of a compassion fatigue resiliency program for all hospital employees. The decision was made to revise the class so that a full 8-hour session could be provided, increasing the likelihood of greater staff participation. The hospital’s charitable organization funded training of select staff to become course facilitators. Facilitators were recommended by their managers as excellent communicators and proficient in group work and education.
Twenty-five staff members participated in a 2-day facilitator training program during the fall of 2011. The facilitators who underwent training included nurse clinicians and managers, pastoral care staff, social workers, human resource trainers, a psychologist, physician’s assistant, and staff from the cultural diversity program. Facilitators became immersed in the resiliency concepts that would be integrated into the training program. The aim was to create a resiliency program that incorporated lessons learned from the oncology pilot program as well as issues pertinent to nonclinical staff. In addition, the intent was to create a program that could be delivered during the course of a single day. Many of the participants later acknowledged that they were interested in the program as a result of their own struggles with compassion fatigue.
This article describes the facilitators’ perceptions of the effects of participating in a compassion fatigue resiliency training program. Their narratives served as a means of program evaluation and to determine whether further facilitator training was needed.
This program evaluation involved the collection of narratives from the training program facilitators. The facilitators were participating in a 9-month program review conducted by the compassion fatigue consultant and were asked to write a short narrative describing how the program had affected them. The narratives were submitted anonymously with no identifying information.
Narratives were analyzed using a phenomenological method to reveal the essential structure of the facilitator experience (Boyd, 1993). The narratives were read and re-read to gain understanding of the facilitator experience. Participants’ core feelings, perceptions, and experiences were identified. Common feelings, perceptions, and experiences found across multiple narratives were clustered together and labeled as themes, such as change in perception or intentionality. Statements that exemplified themes were identified and used to illustrate, explain, and deepen understanding of the facilitator experience.
This program evaluation was reviewed by the hospital’s Human Research Protection Office and was determined to be exempt from institutional review board oversight because the data were de-identified and not collected for research purposes.
Fifteen of the 25 staff members who completed the facilitator training program submitted narratives. Two main themes were identified among the responses. The first theme, self-improvement, encompasses the many ways the facilitators benefited from the program. The second theme, application of resiliency, addresses how the facilitators applied the program’s strategies and techniques to their daily lives.
Many of the facilitators’ responses described how the program helped them achieve self-improvement, particularly regarding improvements in their emotional lives. Facilitators reported experiencing improvements professionally and personally.
Emotional Health. The facilitators who noticed general improvements in their emotional health described having more positive feelings about themselves and others. The most common improvements reported were feeling happier and enjoying themselves more (n = 6), and feeling energized or less fatigued (n = 4). Participants noticed an increase in positive emotions including feeling calmer (n = 4), more confident (n = 2), and more present (n = 2). Three facilitators noted improved self-esteem. Participants also noticed a decrease in negative emotions, including feeling less judgmental of themselves and others (n = 4), less fear and anxiety (n = 4), and less cynicism (n = 1). One respondent wrote, “[I am] enjoying life in a way I hadn’t.” Another participant commented, “I feel more at ease before, during, and after work.”
Seven facilitators noticed a change in their perceptions that resulted in more positive feelings and behaviors. One individual described it as a new ability to “separate reality from perception.” Several facilitators commented on their new awareness of the perceptions that preceded feelings and how those perceptions may be false. One respondent described a “decreased perceived threat in relationships,” and another participant reported, “I am less afraid of everybody.” What typically triggered a perceived threat and resultant stress was no longer formidable or unmanageable.
Two respondents noted a new recognition that their need to control was based on the false perception that control was possible and that their new insight allowed them to let go of the need to control. One respondent summarized the change in perception she experienced by writing:
I have different perspectives regarding all things since first taking the workshop. I understand the impact of illusion on mind and body, and [I] became more aware of situations where my feelings, emotions, or perceptions were derived from those illusions. Actually, I started to see things more objectively; therefore, more right decisions were made.
Six facilitators felt that they had greater empathy as a result of their compassion fatigue training. As one facilitator explained, “I have become more sensitive to compassion fatigue in my staff. I am more proactive about encouraging staff to address this and take care of themselves.” She added that she no longer tried to get staff to be “stoic/self-sacrificing at work.”
Professional Life. Nine facilitators noted an improvement in their work life, with three respondents reporting that they enjoyed work more and two participants reporting that they were more productive. A few facilitators elaborated on their responses. Comments included, “It has made me a better professional,” “I can more healthily embrace caregiving as a profession,” and “I am more productive on my job, more proactive than reactive to issues that arise in the office.”
Personal Life. Six facilitators cited improvements in their life outside of work. One reported improved sleep, another reported a better relationship with her husband, and a third reported, “My energy level is higher…for activities outside of work.”
Application of Resiliency Skills
At the core of the compassion fatigue program is the concept of resiliency. The facilitators described how they used the five strategies for increasing resiliency in their everyday lives to help them overcome compassion fatigue.
Self-Regulation. Self-regulation is the ability to immediately shift from sympathetic to parasympathetic dominance when perceiving a stressful threat by becoming aware of muscle tension and consciously relaxing the body (Gentry, 2011). Nine of 15 facilitators (60%) described practicing self-regulation routinely and six facilitators (40%) described handling stress better. Other facilitators reported increased awareness of body tension (n = 4) and stress (n = 3). Several facilitators described how such awareness helped them modify their behavior. For example, one facilitator wrote, “I am now able to notice the effects of stress on my body and can utilize more than one way to prevent a full-blown fight or flight response.” Similarly, another facilitator commented:
I have noticed my ability to stop stressful situations from affecting me in negative ways, to be aware of stress in my body, and even be able to feel where the stress is, and dissipate the stress through self-regulation.
Intentionality. Intentionality involves developing and following a set of principles or a personal mission statement to live by (Gentry, 2011). Intentionality is a buffer to guide reflection during a time of stress so that a person is less reactive (Gentry, 2011). During the resiliency class, facilitators participated in self-reflection and small group discussion regarding the reasons they entered health care and the values they wished to inculcate into their practices. Eight facilitators (53%) wrote about a sense of increased intentionality. One facilitator described it as having a “greater awareness of my mission,” and another facilitator described it as revisiting “who I want to be.” The experience of learning intentionality was profound for one facilitator, who wrote, “I have been transformed, with increased awareness of and reconnection with my state of mission. I appreciate more why I do this work and what it means to me.”
Self-Care. Self-care involves any activity that “refuels” an individual who suffers from compassion fatigue (Gentry, 2011). The work of caregiving uses energy, and it is important to refuel the body so as to be able to assume caregiving responsibilities the next day (Gentry, 2011). Seven facilitators described how they had started to make more time for self-care (46%). They reported a variety of self-care activities, including “using my support network” (n = 3), “practicing relaxation” (n = 2), “playing guitar” (n = 1), “reading for enjoyment” (n = 1), and “making a healthy lifestyle a priority” (n = 1). One facilitator explained how her perception of self-care changed, stating, “I have gotten more intentional and purposeful in my self-care. I no longer view it as optional or even just desirable, but see this as more crucial, more elemental.” Another facilitator wrote, “The training gave me a much needed push to [begin] therapy. I could see it as an important part of the antibodies versus luxury.”
Connection. Connection involves developing and using a support network of fellow professionals (Gentry, 2011). Five facilitators (33%) wrote about finding ways to connect more with others. For three facilitators, connection meant sharing the lessons they had learned about compassion fatigue with others, through role modeling new behaviors, talking about their personal experience with compassion fatigue, or sharing information. One person elaborated on her experience:
The greatest part for me is that I can help others get through their own stressful situations by using. . .my experience in compassion fatigue and the antibodies/techniques I used to help me become more resilient. People at work are inquiring about this class because of my testimonies.
Perceptual Maturation. Perceptual maturation emphasizes the importance of being true to oneself rather than seeking validation from others (Gentry, 2011). Two facilitators (11%) mentioned “pausing to put integrity first” and “moving away from reputation” as being important. One facilitator mentioned trying to teach others about perceptual maturation, stating, “Though I have developed a dislike for those that put reputation first, I am trying to greatly move them away from what other people think.”
The results of this program demonstrate the powerful impact participating in a compassion fatigue facilitator training program has on hospital staff. The facilitators of the hospital compassion resiliency program teach a minimum of two classes per year. Even with such minimal time commitment, the experience of becoming a facilitator is empowering. Facilitators described many ways they had benefited from the program. The most common benefit cited was improved emotional health, including feeling happier and calmer, as well as being more energetic, empathetic, and confident.
The facilitator training program included the core curriculum of the compassion fatigue resiliency program. Many of the benefits cited by the facilitators paralleled the objectives of the hospital program. A previous study describing the results of the compassion resiliency program cited staff who experienced the same increased confidence, empathy, and ability to relax (Flarity, Gentry, & Mesnikoff, 2013).
For most of the facilitators, the resiliency skills had become a part of their day-to-day approach for coping with stress. The most commonly used skill was self-regulation, reported by 60% of facilitators, followed by intentionality (53%), self-care (46%), connection (33%), and perceptual maturation (11%). These percentages reflect only what the facilitators chose to comment on, yet these skills were likely practiced more widely than indicated.
Other compassion resiliency programs have found similar increases in application of resiliency skills. Flarity et al., (2013) noted that participants evaluated the program positively, particularly with respect to their ability to apply and benefit from resiliency techniques in the future. Potter et al. (2013) reported increases in the areas of self-care, connection, and perceptual maturation.
Two of the facilitators noted that combating compassion fatigue was a continuous process. Although the skills of resiliency are not difficult to learn, maintaining the skill set is difficult when one continues to work within a stressful environment. As one facilitator noted:
Initially after CF [compassion fatigue] training, I noticed a dramatic improvement in my personal and professional life. However, in the past several months, I seem to have lost my way…CF is a never-ending problem for those of us in health care. Resiliency is paramount to maintain your ability to stay healthy and give your optimal contribution.
It is clear that the facilitators internalized the lessons from the program and applied them to their lives to great benefit. In addition, many seemed to have been somewhat transformed by the experience into more confident, energetic, calm, and empathetic individuals. The experience of using these lessons and skills, and even being transformed by them, is critical for prospective facilitators. This training program helped the facilitators achieve a deep and personal understanding of the compassion resiliency program necessary for them to be effective teachers.
The compassion fatigue facilitator training program had many positive perceived effects on the program participants, particularly on their emotional health and use of resiliency skills. This resiliency training program seems to be a viable method for increasing employee satisfaction and hardiness. This program offers many indirect benefits to large health care organizations, including increased employee retention, greater patient satisfaction, fewer medical errors, and improved staff morale. Further exploration into this and other programs is indicated by the results of this program evaluation.
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