
The opioid epidemic is taking its toll on today’s healthcare worker. Overdose rates have never been higher, and in many areas, death from overdose has taken the place of trauma and cancer as the most frequent killer.1 Frontline healthcare workers – including nurses, firefighters, EMS and police officers – experience the crisis as they provide care for increased numbers of patients suffering from substance abuse disorder, specifically opioid overdose. The treatment that frontline healthcare workers deliver can feel futile, because they revive the patient and treat the immediate concern, but then the patient returns to the same environment where the pattern of substance abuse may repeat itself. First responders usually do not have the opportunity to treat the underlying cause of the addiction. This leaves many frontline healthcare workers feeling helpless which can lead to compassion fatigue.2
Compassion fatigue is a term coined by a nurse manager who worked with emergency department nurses and observed that many nurses lost the ability to nurture patients.3 Compassion fatigue is “the natural predictable, treatable, and preventable, and unwanted consequence of working with suffering people.”4 Compassion fatigue can have a rapid onset and often is the precursor to burnout.5 Symptoms of compassion fatigue include difficulty sleeping, difficulty concentrating, emotional exhaustion, irritability, headaches, depression, sadness, anxiety, intrusive images, flashbacks, numbness, avoidance behaviors, cynicism, and poor self-esteem.2,6 Compassion fatigue has been shown lead to decreased patient satisfaction, under performance, job dissatisfaction, increased turnover and increased sick days.2
Related
- Psychological Health for First Responders: Behavioral Health Basics, Suicide Awareness, and Self Care
- Psychological Trauma: The Silent Stalker
- Compassion Fatigue: A Hidden Stress in Providers of Mobile-Integrated Healthcare
- Recognizing and Supporting EMS Providers with Mental Health and Substance Use Disorders
In one study, all frontline healthcare workers reported some degree of burnout, mostly in the moderate range.7 Specifically in Ohio, frontline healthcare workers have reported suffering from compassion fatigue.8 While there has been research establishing the prevalence of compassion fatigue among frontline healthcare workers, there is much less literature on effective interventions to decrease compassion fatigue in this population. The purpose of the current study was to discover if a sample of frontline healthcare workers in the Midwest were suffering from compassion fatigue and whether a trauma informed care training program could decrease compassion fatigue.
Methods
This quality improvement project using a pretest/posttest intervention design involved providing education on trauma informed care to frontline healthcare workers and comparing compassion fatigue scores before and after the training. This project was reviewed by the institution’s Institutional Review Board (IRB) and deemed to be non-human subjects research and did not require IRB oversight.
Participants included firefighters, nurses, and police officers recruited from Southwestern Ohio. All participants were volunteers and not compensated for involvement in the project. Participants were instructed to provide a generic email address created for this project so anonymity would be maintained.
Compassion fatigue was measured using the Professional Quality of Life (ProQOL) tool.9 The ProQOL is a 30-item validated tool that measures compassion fatigue, burnout and compassion satisfaction. Participants completed the ProQOL (pretest), received a two-hour training on trauma informed care, and then completed a program evaluation immediately after the education session, which included an open text box for comments. One month later, participants again completed the ProQOL (posttest).
The primary author, who is a certified trauma informed care instructor, provided the training. The author obtained certification by completing a two-day training provided by the Ohio Board of Mental Health using the train-the-trainer model where the author was expected to offer the training in the community. The training focused on adverse childhood events (ACEs) and the effects they can have on neurobiology. Often, ACEs can lead patients to substance abuse-related coping skills. A male child with a high ACEs score has a 4,600% increase in the likelihood of using intravenous drugs and 78% of drug injection by women can be attributed to ACEs.10 The course provided helpful tips in providing care to patients who may have a high ACEs’ score and helpful self-care behaviors for frontline healthcare workers. Examples of client behaviors were given for many of the neurobiological changes that happen to clients who have high ACEs’ scores. The presentation included information on how ACEs lead to chronic disease and early death, and the need for an authentic healing relationship and empathy in the front line healthcare workers.
Descriptive statistics were used to describe the study sample. Percentages were calculated to describe the pretest and posttest prevalence of compassion satisfaction, burnout, and compassion fatigue in the study sample. A paired samples t-test was computed to compare changes in compassion satisfaction, burnout, and compassion fatigue from the pretest to posttest periods for participants (n=52) who completed the posttest ProQoL. Alpha was set at 0.05.
Results
A total of 186 frontline healthcare workers participated in the project: 68 firefighters, 10 nurses, and 108 police officers. The local police and fire departments included this training as part of their continuing education at their stations. Classes were offered at local emergency departments for nurses to voluntarily attend.
The ProQOL survey results were evaluated to obtain scores for compassion satisfaction, burnout and compassion fatigue. Before receiving the education, 3.2% of respondents reported their compassion satisfaction as low, 77.4% as average, and 19.4% as high. Over half (51.6%) of respondents scored feelings of burnout as low, 47.3% scored as average, and 1.1% as high. The baseline measure of compassion fatigue showed that 60.8% of frontline healthcare workers had low levels of compassion fatigue, 38.7% had average levels, and 0.5% had high levels of compassion fatigue.
All 186 frontline healthcare workers received the training and completed an evaluation immediately after the education session. The free-text feedback received in the evaluation survey reinforced the numeric scores as evidenced by one participant who said: “This information has relevance to our role and population. Trauma is so prevalent and this education was very helpful.” Another participant said: “I sometimes forget there are reasons for peoples’ behavior and the way I question them may be triggering them,” and “I needed a reminder to meet people where they are.”
Approximately 28% (n=52) of participants completed the one-month survey: 23 firefighters, five nurses and 24 police officers. On the one-month ProQOL, 3.8% of frontline healthcare workers reported low compassion satisfaction, 73.1% reported average compassion satisfaction, and 23.1% reported high compassion satisfaction. Respondents reported a 46.2% prevalence of low burnout, 53.8% of average burnout, and no participants scored in the high burnout range. The majority of participants (61.5%) scored low in compassion fatigue, 38.5% scored average, and none scored in the high range for compassion fatigue.
The three subscale scores, compassion satisfaction, burnout, and compassion fatigue, were compared using a paired samples t-test. Compassion satisfaction did not significantly differ before the training compared to after the training, t(51) = -1.63, p=0.109. However, there was a significant decrease in burnout after the training (M=22.48, SD=5.98) compared to before the training (M=23.79, 5.35), t(51) = 2.15, p=0.037. Additionally, there was a significant decrease in compassion fatigue after the training (M= 21.35, SD=5.25) compared to before the training (M=22.90, SD=5.84), t(51) = 2.14, p=0.037 (See Table 1).
Discussion
Frontline healthcare workers who participated in a two-hour training on trauma informed care reported significantly decreased burnout and compassion fatigue one month after the training. This project provides some insight into the prevalence of compassion fatigue in frontline healthcare workers in Southwestern Ohio, but more work needs to be done to nationally recognize this secondary trauma in frontline healthcare workers. Additionally, there needs to be more research focusing on interventions to decrease compassion fatigue among frontline healthcare workers. Knowing that frontline healthcare workers are experiencing compassion fatigue and burnout can compel employers to prioritize the issue due to the potential financial and emotional consequences. The study showed that a relatively low-cost education on trauma informed care had a statistically significant impact on burnout and compassion fatigue.
Limitations
The posttest was administered electronically one month after the training. Only 28% of participants completed the post-education survey. An in-person postsurvey may have yielded more participation and provided more data. The small number of frontline nurses who participated in the project is also a limitation. An incentive to participate may have increased the number of participants. Because these symptoms evolve over time, a survey administered monthly over a few months may provide more information on the sustainability of the effects.
Conclusion
Compassion fatigue is a problem among frontline healthcare workers, which can increase turnover and cost for employers. Education on trauma informed care is one intervention that can reduce compassion fatigue. More work needs to be done in this area to see if the results of this study are replicable.
Funding Acknowledgement
The first author was supported by the National Institute for Occupational Safety and Health though the University of Cincinnati Education and Research Center (No. T42OH008432).
References
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3. Coetzee SK & Klopper HC. Compassion fatigue within nursing practice: A concept analysis. Nursing & Health Sciences. 2010; 12(2): 235-243. doi:10.1111/j.1442-2018.2010.00526.x.
4. Stamm BH & Figley CR. Treating compassion fatigue. New York: Brunner Routledge. 1996: 123-138.
5. Hooper C, Craig J, Janvrin D, Wetsel MA, Reimels E, Greenville A. Compassion satisfaction, burnout, and compassion fatigue among emergency nurses compared with nurses in other selected inpatient specialties. Journal of Emergency Nursing. 2010; 36(5): 420-427. http://dx.doi.org/10.1016/j.jen2009.11.027.
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7. Smith JI. (2014). A study of first responders and burnout as governed by the Occupational Safety and Health Act of 1970 (OSHA) in metropolitan Atlanta, Georgia Digital Commons Publishing. 2014: 1-160.
8. More victims of ODs: first responders suffering from compassion fatigue. 2017. Retrieved from https://www.cincinnati.com/.
9. Stamm, B.H. (2016, January). Comprehensive Bibliography of Documents Specifically Using the ProQOL Measure.
10. Ohio Mental Health and Addiction Services. 2017 Trauma curriculum instructor’s guidance. Trauma informed approach: key assumptions and principles. 2017.Columbus, OH.