Motivation and emotion/Book/2020/Compassion fatigue

Overview
Have you ever met someone who works tirelessly to care for others, but seems exhausted, cold, or even detached? Does it make you question why they work in the caregiving profession? Compassion fatigue may be the answer. Compassion fatigue occurs when an individual has become emotionally, spiritually, and physically exhausted by the provision of care, leading them to become irritable, apathetic and withdrawn. Associated with those who tend to the sick, disabled, or incapacitated, compassion fatigue can have detrimental consequences for both the caregiver and the receiver of care (van Mol et al., 2015).

Focus questions:
 * Is there a universal definition of compassion fatigue?
 * Who is affected by compassion fatigue?
 * What are the implications of compassion fatigue?
 * Can compassion fatigue be prevented or treated?

Defining compassion fatigue
Compassion fatigue was first used in 1992 to describe the lack of charitable giving in America (Ledoux, 2015), however quickly evolved to a different meaning when Joinson used it to describe a form of burnout in nurses that caused forgetfulness, anger and apathy (Ledoux, 2015). Figley defined compassion fatigue as "a state of exhaustion and dysfunction - biologically, psychologically, and socially - as a result of prolonged exposure to compassion stress and all it evokes" (1995, p. 253). Figley stated that compassion fatigue was synonymous with secondary traumatic stress (Lynch & Lobo, 2012), whilst also clarifying that it can occur within one encounter (Figley, 1995).

The majority of the literature has equated compassion fatigue with secondary traumatic stress, vicarious trauma, and even burnout (Lynch & Lobo, 2012). It is important to distinguish these from each other, as seen in the table below.

 The cause of compassion fatigue lies in the empathic engagement caregivers have care receivers. Burnout results from external pressures that degrades an individual's feelings of competency in the workplace. Whilst compassion fatigue can be exacerbated by burnout, and individuals who are experiencing burnout may also struggle with compassion fatigue, the concepts are distinguished by cause. Compassion fatigue can be easily treated once identified, whereas burnout typically results in complete removal of oneself from the workplace (Lynch & Lobo, 2012).



Whilst a universal definition does not exist, compassion fatigue is best described as “a natural response that results from an inability to protect or heal a patient, creating stress and self-blaming" (Mattioli et al., 2018 p. 323). This response results in the caregiver’s detachment from a care receiver due to feelings of exhaustion. This inability to administer compassion can be described as “pouring from an empty glass” as depicted in Figure 1.

{What is the most distinguishing factor of compassion fatigue? + Empathy and inability to ease suffering - Empathy and workplace stresses - Experiencing another's trauma - Hearing about trauma from someone who is suffering
 * type=""}

Motivation and compassion fatigue
From a motivational viewpoint, compassion fatigue can be understood as a deficit of competence, autonomy, and relatedness. Autonomy is the psychological need to have a degree of control, investment and choice over one’s behaviour, which impacts an individual’s performance. Caregivers suffering from compassion fatigue may feel they have little autonomy over the care they provide. The inability to relieve suffering may lessen the amount of choices they have regrading treatment, also limiting their autonomy.

This can have an impact on the need for competence, which refers to one’s ability to complete a task or take on challenges. Caregivers who cannot resolve a patient’s pain may be at risk of internalising this as a ‘failure to perform’, consequently degrading their self-efficacy to a point where they may want to disengage from the caregiving process. This is often reflected in absenteeism (Houck, 2014) or the transition of family members from private care into nursing homes (Lynch et al., 2018).

Individuals with compassion fatigue may over exceed in terms of relatedness. Relatedness is described as the psychological need to form interpersonal connections with other people, and involves being responsive, warm and nurturing. Individuals suffering from compassion fatigue often form strong connections with patients and exhibit high levels of empathy and responsiveness to their pain. However, the care provider may not receive the same level of investment from the care receiver, particularly for those who are sick or in environments such as busy hospitals. Subsequently, care providers may become exhausted and withdraw from the emotionally taxing tasks of caregiving.

Emotion and compassion fatigue
Emotions are often short-lived responses to significant events that help individuals adapt and cope effectively. Individuals suffering from compassion fatigue may constantly experience significant life events, as providing care to the significantly ill or incapacitated is generally stressful in nature. Care providers may consistently experience negative emotions and high levels of physiological arousal. This is particularly important to the onset of compassion fatigue as caregivers may not engage in effective coping or emotion regulation strategies. These may include suppression of emotions, rumination, or negative secondary appraisals, which can promote and exacerbate compassion fatigue. Continual exposure to situations that provoke concern, anxiety, or sadness are often connected to the risk of compassion fatigue in health care workers (Bush, 2009). This is more likely for those without adequate coping strategies.

Who can suffer from compassion fatigue?
Compassion fatigue has been historically linked to the caregiving profession, focusing on nurses, social workers, and clinical psychologists (Ledoux, 2015). The most substantial research has occurred within the field of nursing. Increasing attention is being placed on filial caregivers such as spouses and adult relatives (Day et al., 2014). This has important implications for the broader community as home care has replaced hospital care in some cases for reasons such as financial cost (Lynch & Lobo, 2012).



Nurses
Nurses are among the most affected population group, mostly due to their frequent and prolonged exposure to individuals who require intensive medical care. Ledoux (2015) discusses the core tenet of nursing, compassion, as an archetype to the profession. As a vital part of self-identity in nurses, focus on compassion in practice was pioneered by Florence Nightingale (see Figure 2) who symbolised self-sacrifice and nurturing (Ledoux, 2015). The presence of compassion fatigue in nurses presents implications of its impact on the profession, particularly on the identity and competence of nurses.

Studies have found that nursing specialties such as oncology are associated with stronger risks of compassion fatigue (Wu et al., 2016). Hunt and colleagues (2019) found that 25% of cancer health care providers in Ireland were at a high risk of compassion fatigue, with high levels of personal distress, felt as part of the empathy process, having negative impacts on quality of life at work.

Filial caregivers
Lynch and Lobo (2012) suggest that compassion fatigue should be extended to include family caregiving, as compassion fatigue shares the same cause: "a care-giving relationship founded on empathy” that includes “an established relationship between the caregiver and patient, empathy, stress, shared experiences, and a psychological response” (Lynch & Lobo, 2012). Compassion fatigue in filial caregivers also produces similar psychological, social and emotional symptoms to healthcare workers (Day & Anderson, 2011).

Day and Anderson (2011) applied compassion fatigue to family caregivers of individuals living with dementia. Caregivers who are concerned, who engage empathically, who have competing life demands, and experience a lack of satisfaction with caregiving are at high risk of compassion fatigue. Day and colleagues (2014) studied adult daughter caregivers of parents with dementia and found that they were at risk of compassion fatigue due to similar factors. Interestingly, the risk of compassion fatigue may differ between spouses and adult children, with spouses having a more positive experience than adult children (Day et al., 2014).

Psychologists
Psychologists are also at risk of compassion fatigue. Dehlin and Lundh (2018) found that levels of compassion fatigue varied with differing characteristics of patient population. Harling and colleagues (2020) found that compassion fatigue had impacted psychologist’s personal lives and had been exacerbated by high expectations, emotional strain, and excessive workloads. Autonomy (Harling et al., 2020) and evidenced-based practice appear to buffer the ill effects of compassion fatigue (Harling et al., 2020).

Risk factors
"The capacity for compassion and empathy seems to be at the core of our ability to do the work and at the core of our ability to be wounded by the work." Charles Figley, 1999, p.15

Individuals who provide care for another person may be at risk of compassion fatigue (Badger, 2000 in Bush, 2009). Common risk factors include stressors, lack of support, and personal trauma (Bush, 2009). Burnout itself has been identified as a risk factor for compassion fatigue through excessive workloads and role ambiguity (Bush, 2009).

Figley's compassion fatigue process (2001)
Figure 3 describes the process in which compassion fatigue may occur, which involves an interplay of personal and external factors. One of the core features is the existence of empathic ability, which is channeled into an empathic response upon exposure to an individual's suffering and caregiver concern. If an empathic response is met with dissatisfaction (often from being unable to relieve the patient’s pain) and an inability to detach properly from the situation (Day & Anderson, 2011), compassion stress can occur. Compassion stress degrades into compassion fatigue if a caregiver continually observes the patient’s suffering, has other competing demands or has traumatic memories (Figley, 2001).



The role of coping in compassion fatigue
Ineffective coping strategies may play a role in causing or maintaining compassion fatigue (Bush, 2009). Emotion-focused coping strategies are designed to regulate emotional responses to a problem or threat. This differs from problem-focused strategies, which involve managing or resolving the problem directly (Lazarus & Folkman, 1984). Individuals suffering from compassion fatigue often adopt emotion-focused strategies of coping such as avoidance, minimisation, or distancing. When the suffering of the patient cannot be resolved, many caregivers adopt these coping strategies, which can be extended to include self-criticism and withdrawal (Khalaila, 2020). These may either impair one's sense of self, invoke negative moods or emotions, or shift attention away from the current threat. However, avoiding the situation may not be possible for caregivers, as the care receiver is dependent on them for assistance. Consequently, compassion fatigue may occur or become even further exacerbated.

Subsequent interactions with patients may be subconsciously interpreted as a threat to the caregiver, who recognises that their inability to help may impact their own stress levels, emotions, and self-identity (see Figure 2 for an archetype of caregiving). They may respond by emotionally withdrawing themselves from interacting with patients, which can negatively impact quality of care (Boyle, 2011). This cycle continues to a point where the caregiver cannot engage in the empathic process at all.

Finley and Sheppard (2017) identified several ineffective coping strategies used by oncology nurses, which included alcohol consumption, emotional eating, rumination, and self-loathing. These emotion-focused strategies also perpetuate negative beliefs about the caregiver's own abilities and deplete their physical and emotional resources. Detachment or excessive emotional distancing may then occur, depriving the patient of a responsive and empathetic caregiver in such a demanding environment.

A common dilemma for caregivers is the promotion of appropriate coping strategies, particularly where the patient cannot be cured. If problem-focused coping (such as information gathering and learning new skills) cannot be adopted, alternative options are needed to process the emotional difficulties associated with caregiving in an adaptive manner. This can include personal therapy (Finley & Sheppard, 2017) to promote positive coping strategies such as reframing, positive secondary reappraisals, seeking social support, and acceptance.

Sandra has just commenced her first nursing job in an oncology unit. She has been exhausted from the work so far, and spends most of her day trying to help patients manage their pain. At times, no matter what she does, some patients still suffer from considerable discomfort. She has formed close relationships with the majority of her patients. However, in the past week she has felt irritable, fatigued and overemotional. She now dreads going to work. When she does talk to patients, she can feel herself withdrawing from them as she ‘cannot deal with them anymore’. Sandra has resorted to binge eating and finds herself thinking about her patients when she is at home. She considers calling in sick for the next few days.

{What kind of emotion-focused coping strategy is Sandra using? - Exercise - Talking to patients - Going to work + Emotional eating
 * type=""}

{What kind of coping strategy is Sandra using by calling in sick? + Avoidance - Minimisation - Rumination - Suppression of feelings
 * type=""}

Signs and symptoms of compassion fatigue
According to Mattioli and colleagues (2018), signs and symptoms of compassion fatigue include:


 * feelings of anxiety, irritation, and impulsivity
 * fear and insecurity
 * distancing oneself from patients and support networks
 * feelings of depression

Additional symptoms include cynicism and avoidance (Lachman, 2016), increased emotional sensitivity or outbursts (Smith, 2017), and hopelessness, apathy, and emotional disengagement (Day & Anderson, 2011).

The cost of caring? Consequences of compassion fatigue
Compassion fatigue may affect the caregiver, care receiver and the organisation where care may occur (Ledoux, 2015). The most defining hallmark of compassion fatigue is the inability of the caregiver to enter into a responsive and empathic relationship with the care receiver. This may occur through the caregiver's detachment from a care receiver as a means of self-protection (Ledoux, 2015).

For informal caregivers, this may result in the cessation of care and the movement of the care receiver to institutions such as nursing homes (Day & Anderson, 2011). This may result in a larger cost to society due to this transition (AARP Outreach and Services, 2009 in Day & Anderson, 2011).

Nurses who experience the symptoms of compassion fatigue may fail to deliver quality patient care as there may be an increased risk of making errors, poor judgment, and the forming of poor professional relationships (Alkema et al., 2008).

Research into compassion fatigue in psychologists has mainly focused on prevalence and risk factors. As compassion fatigue has been observed in the psychologist population, and affect psychologists in similar ways to other health professionals (Harling et al., 2020), it can be assumed that quality of patient care may also be affected.

Prevention and management
Compassion fatigue can be prevented and treated in a number of ways. A common cross over in areas such as self-care and social support demonstrates its significance in managing compassion fatigue.

Prevention
Education and awareness remain the strongest forms of prevention. Whilst references to compassion fatigue are becoming more common, the signs, symptoms, and causes of compassion fatigue are not emphasised in caregiving environments (Boyle, 2011). Educational seminars in the nursing profession are being recommended to stimulate awareness of compassion fatigue (Wu et al., 2016) whereas communication between nurses and family caregivers is suggested to provide support and a sense of control to the caregiver (Day et al., 2014).



Other forms of prevention include social support (see Figure 4), debriefing, and self-care (Bush, 2009). Social support has been reported to have a mediating effect on compassion fatigue in filial caregivers in an Arabian community sample (Khalaila, 2020), and enhanced resilience of nurses when coupled with peer support (Yoder, 2010).

Debriefing has been a primary focus in the healthcare field, with Mattioli and colleagues promoting the use of Schwartz Rounds® and the Watson Room as methods to debrief or relax with colleagues. Schwartz Rounds® enable staff to discuss their experiences without judgment, whilst the Watson room is a dedicated area designed to promote relaxation (Mendes, 2017 cited in Mattioli et al., 2018), allowing nurses to de-stress and process negative emotions in a calm area.

Self-care is the common method of prevention, with many researchers highlighting the importance of exercise, nutrition, sleep, and relaxation (Sinclair et al., 2017) in promoting resiliency. An emerging focus of prevention is centred on the spiritual needs of the caregiver (Bush, 2009), as well as a focus on setting boundaries and self-compassion (Delaney, 2018). An eight-week pilot study conducted by Delaney in 2018 used Mindful Self-Compassion (MSC) training to enhance self-compassion. It increased self-compassion, mindfulness, compassion satisfaction, and resilience in nurses. Interviews of participants also revealed that they gained better coping skills during this process (Delaney, 2016). Another MSC pilot program in clinical psychologists in 2019 also improved self-compassion, mindfulness and well-being levels when participants highly adhered to the eight-week program (Yela et al., 2019). Growing focus on MSC should be extended to family caregivers due to its current positive implications on the prevention of compassion fatigue.

Compassion satisfaction, defined as personal fulfillment through feeling competent at work (Stamm, 2012) has also been identified as a protective factor for compassion fatigue (Yoder, 2010; Harling et al., 2020). Compassion satisfaction as a concept has not been studied extensively in filial caregivers.

Treatment
Treatment for compassion fatigue focuses on empowering individuals to adopt positive coping strategies and increase their resilience (Smith, 2017). This includes the regular use of debriefing, self-care, and access to social support as adaptive forms of emotion-focused coping. Mindfulness and relaxation exercises are also recommended. Focus on the present is thought to prevent rumination, emotion suppression, and avoidance, preventing negative lasting impacts on the caregiver (Smith, 2017).

Another form of treatment for compassion fatigue is the Accelerated Recovery Program (ARP). It is a five-step therapy program which includes education on symptoms and causes of compassion fatigue, accessing resources, boundary setting, self-soothing, and learning grounding and containment skills to control situations and symptoms which may cause compassion fatigue (Sinclair et al., 2017). ARP was successful in improving compassion fatigue symptoms in a sample of emergency nurses (Flarity et al., 2013 in Sinclair et al, 2017).

Conclusion
Compassion fatigue occurs when caregivers are unable to relieve the pain of their patients. Continual exposure to suffering, lack of personal boundaries, and ineffective coping strategies place individuals at an increased risk. Serious consequences for caregivers and care receivers, such as decreased quality of care, absenteeism, and detachment highlight the necessity of compassion fatigue awareness. Positive coping strategies such as self-care and social support are key factors in preventing and treating compassion fatigue. Relaxation and mindfulness techniques also play a role through the promotion of acceptance and emotion regulation in processing the difficulties of caregiving. Reminding caregivers that they must first take care of themselves first lies at the very core of preventing and treating compassion fatigue.