I walked into my supervisor’s office and sat down when I realized I had tears streaming down my face. This was definitely not like me at all and I began to wonder how I had reached this point.
If a patient called me, regardless of the time, I felt that I had to be there for them because I felt like I was their only source of support and comfort. I felt like I had to be the parent, child, friend and savior to every patient.
I’d been carrying their burdens as well as my own. The incident that set me over the edge was a patient who had severe behavioral health and substance abuse issues who accused me of violating his HIPAA rights, which I hadn’t done.
I felt like I had been putting my whole heart and soul into all of my patients for a long time and at the expense of my own health. To have a patient make this accusation for his own personal gain was the ultimate betrayal and more than I could take.
THE COST OF CARING
Charles Figley, a pioneer in compassion fatigue research, first coined the phrase “the cost of caring.” In his landmark book, he describes compassion fatigue as “the stress resulting from helping or wanting to help a traumatized or suffering person.”1
Compassion fatigue, also known as secondary traumatic stress disorder (STSD), is similar to post-traumatic stress disorder (PTSD) and is usually found in caregivers for populations like pediatric,2,3 veteran4 and cancer patients.5
The difference between PTSD and STSD is that PTSD is caused by direct exposure to a traumatic experience, whereas STSD “applies to those emotionally affected by the trauma of another.”6
We believe community paramedics (CPs) are more likely to be at risk for compassion fatigue than traditional EMS providers because they develop a longer and deeper relationship with a patient, during which they learn much more about the patient’s traumatic physical and emotional history.
If left untreated, both PTSD and STSD can have a devastating effect on the provider. These stress disorders are associated with an increased risk for depression,7 heart disease,8 increased healthcare utilization and premature death.9,10
Figley described several factors that can increase the risk a CP will suffer from compassion fatigue and that may guide EMS systems on how to protect their workforce. When applied to mobile integrated healthcare (MIH) work, Figley’s model describes a combination of provider and patient attributes that increase the risk of compassion fatigue. The following are just a few of the characteristics that can place the CP at risk.
Empathy and concern: Put simply, the more empathic you are, the more likely you’ll experience compassion fatigue. EMS providers are compassionate, empathic people, as evidenced by their willingness to help strangers at any time in any location, and by often placing themselves in harm’s way to do so.
CPs tend to be highly motivated to work with their patients as long as necessary to resolve chronic and complex problems. Unfortunately, that caring comes with an emotional cost that can precipitate compassion fatigue.
CPs are at the greatest risk for empathy-based stressors when they over-identify with the patient’s problems based on the patient’s extraordinary circumstances or a shared experience with the patient. The patient’s current plight often begins with abuse and neglect suffered in childhood, which precipitates a series of mental and physical health issues.
Listening to those horror stories often evokes our strongest desire to make up for the past sins of others. Unfortunately, that response also makes the CP more vulnerable to fatigue when that commitment becomes too taxing.
Provider mental health: Mental health issues are commonplace in patients served by CPs, but we’d be foolish to think EMS providers are immune to those same diagnoses. Depression, anxiety disorders and substance abuse can be just as prevalent in EMS providers as they are in the general population.
Figure 1: Characteristics likely to increase risk of compassion fatigue
While there’s no reason to exclude providers who are able to function despite these challenges, their illness may place the CP at higher risk for experiencing compassion fatigue.
Overwhelmed coping mechanisms: Regardless of whether a CP has a mental health disorder, nearly everyone will experience periods in their career where stress overwhelms their usual coping strategies. Techniques used to manage stress may be overcome by physical fatigue or emotional exhaustion from other aspects of the CP’s life.
CPs carrying a high caseload of patients and those who are managing many complex patients are at higher risk of compassion fatigue. Other work factors like long shifts or troublesome coworker interactions can also be detrimental.
In addition to the personal traits that place the CP in jeopardy, certain characteristics of the patient may exacerbate the risk of compassion fatigue as well.
Cling-ons: The ability to develop a therapeutic relationship with the patient is critical for the CP. That relationship requires the CP to be both nonjudgmental and to display “unconditional positive regard” for the patient, often using the counseling style known as motivational interviewing.11 However, that relationship may differ drastically from the patient’s experience with the rest of their providers. It’s not unusual for doctors and nurses in clinics and hospitals to lecture the patient about how their poor choices have led to their poor health.
So when a CP sitting in the familiar surroundings of the patient’s home neither judges nor lectures, the difference can evoke powerful emotions from the patient. CPs have reported that at the end of their initial assessments, patients have hugged the medics while crying that the CP was the first person who actually listened.
It’s no wonder, then, that these patients, whose lives are often a complex mix of medical, psychological, social, economic and other issues, “cling” to the paramedic as a lifeline. They may call the CP on a frequent basis regardless of the time of day to talk through whatever problem is occurring at the moment, seek their advice or just to socialize. The compassion the CP feels for the patient can quickly wear thin when the patient calls incessantly. Similarly, patients who don’t call frequently, but only call when they’re in the middle of another crisis, can increase the risk of compassion fatigue for the CP.
Patients you can’t help: MIH programs regularly help patients navigate to the resources they need to help them better manage their diseases. However, that help requires two critical components to be in place. The first is that there are resources available to help the patient. Patients who are needy but who don’t meet the eligibility requirements of potential programs are a significant source of stress for CPs.
The second component is that the patient has to provide the information necessary to enroll in those programs. Patients who fail to produce the documentation needed to complete an application or those who fail to follow through with appointments the CP helped to schedule are in essence failing to help themselves. When either or both barriers are encountered there’s little that can be done for the patient. That frustration increases the likelihood that the CP will experience compassion fatigue.
Patients who have no “future story”: The goal of most CP programs is to help patients enjoy a higher-quality and longer life. However, given their complex issues, many patients feel hopeless and suicidal. Many others are near the end of their life. CPs are much more likely to struggle with compassion fatigue when trying to provide hope to someone who has none.
CHRISTIE’S CASE CONTINUED
Looking back on my experience now, I realize that I was carrying too heavy of a patient load. I, like many others, have the mindset that we’re capable of handling “just one more patient.”
I also had several very complex patients who were extremely demanding of my time. Because I never set sufficient boundaries with my patients initially, they also had unrealistic expectations of what I was capable of handling.
In the weeks leading up to my breakdown, I had become exhausted and overwhelmed. I found that my emotional responses weren’t proportional to the situations I encountered. I would become extremely irritated or start crying over difficulties at work and in my personal life that I normally would have handled well.
The most noticeable change I began to see in myself throughout this ordeal was the inability to sleep well and focus throughout the day. I became extremely forgetful and had a difficult time achieving my daily goals because I just had so many things on my mind. I felt like I was being pulled in a million different directions.
SIGNS & SYMPTOMS OF COMPASSION FATIGUE
While any of the risk factors listed before can increase the likelihood of compassion fatigue, most providers will be able to manage the stressors using their normal coping strategies. However, administrators and co-workers should be aware of CPs who are beginning to show the following signs or symptoms relative to their usual actions, as they could signal the onset of compassion fatigue.12
· Moody or increased irritability: Emotional reactions that are unusually strong when compared to the CP’s historical responses.
· Avoidance: CPs who avoid engaging new clients or don’t follow up with existing clients.
· Intrusive thoughts or dreams: CPs who report they can’t stop worrying about a patient or those who talk about their patients more frequently than usual.
· Apathy: CPs who seems unusually detached from their work or loved ones.
· Reduced productivity: CPs who are normally productive who struggle to complete assignments.
SYSTEMATIC STRATEGIES FOR WORKFORCE PROTECTION
Administrators planning to develop programs can mitigate compassion fatigue by implementing policies to protect their new workforce. Below are several suggestions on how managers can help their EMTs, paramedics and CPs by implementing safety policies for their program.
Establish professional boundaries: During the first patient visit, the CP should make clear to the patient the support they’re about to provide will eventually end. If the timeframe for the patient’s engagement with the program is predetermined, the patient should be told during the first visit.
The discussion should also set realistic expectations about what will occur when the patient needs to speak to the CP. The CP should explain realistic timeframes for return calls and how best to reach them. While it sounds obvious, patients should never receive the personal cell phone number of their CP.
In Pittsburgh, patients are given a number to access a 24-hour answering service, but the CP may not call them back until their schedule permits. Regardless of how your system operates, it’s important to set the patients’ expectations appropriately.
Use a team approach: To protect CPs from becoming overwhelmed, managers should assess the complexity and caseload of their CPs on a regular basis. If a CP’s caseload is high or a CP has several complex patients, consider partnering the CP with another team member. Assigning high-risk patients to two CPs will reduce the burden placed on just one provider.
At times a CP can be stymied on how to help a particular patient. In addition to discussing operations and hearing from local social service agencies, we have a monthly staff meeting and open the floor to CPs who would like help resolving an issue for their clients. These meetings are in addition to the frequent impromptu “cube-side” consults that occur when CPs work together in the same cubicle and share ideas.
Offer counseling services: Other professions at high risk for compassion fatigue mandate periodic counseling for their employees. While we haven’t yet mandated its use, we do offer services through our employee assistance program. Regardless of whether your organization currently has similar resources, making professional therapy available to your CPs is sound advice for protecting their mental health.
Provide resiliency training: In addition to watching for the signs and symptoms of compassion fatigue, managers should schedule training opportunities for CPs to learn coping strategies to increase their resilience. A few examples of helpful strategies include employing relaxation techniques during highrisk moments, nurturing a strong social support network, using healthy self-care strategies and learning to say no to patients who have become overly dependent on the services of the CP.
Establishing boundaries with patients can help prevent compassion fatigue.
As the tears decreased, so did the burdens and frustration I’d been carrying for months. I was able to articulate the feelings I had been oblivious to until that moment. I was able to purge all of the feelings of being overwhelmed and of being inadequate in my performance as a CP.
My supervisor helped me devise a plan to maintain a more manageable workload and to set realistic boundaries for myself and my patients in the future. We then discussed what coping strategies would help me deal with my feelings and recover from my compassion fatigue. This experience helped me realize I’m not superwoman and I can only do so much. I’ve found that I can give my patients a better “me” if I give myself the love and attention that I require as well.
YOU’RE NOT ALONE
While compassion fatigue is widely known in other caregiving settings, it’s a relatively new form of a stress disorder for EMS providers working in MIH programs. If ignored, the stressors can lead to STSD.
We hope this article has raised awareness of the issue and will help administrators develop policies and procedures to help protect their CPs. More importantly, we want those helping patients in this new role to recognize the risk factors and signs and symptoms of the disorder in their colleagues and in themselves.
Compassion fatigue can be managed with personal coping strategies, social support and professional counseling. While EMS providers tend to be heroically stoic in these matters, we can’t allow those attributes to enable a culture of silence around compassion fatigue. If you’re suffering from these signs and symptoms, understand you’re not alone. While compassion fatigue may be the cost of caring, it’s a not a cost you have to pay on your own.
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