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Moving from compassion fatigue to compassion resilience Part 3: Causes of compassion fatigue

March 17, 2020

Having previously focused on the significance of compassion (1) and understanding compassion fatigue (2), this article focuses on the causes of compassion fatigue, specifically
the many realities of life in clinical practice that can make veterinary caregivers so susceptible. For those who work in clinical practice, these realities will come as no surprise. What may come as a surprise, however, is the range of stressors that can culminate as compassion fatigue. Interwoven within any one scenario may be an intricate variety of stressors, making what may seem on the surface as simple and straightforward, actually quite complex. When caught up in the moment, or busily moving through the day, we may not realize the extent to which we are challenged — physically, intellectually, emotionally, and socially, and even morally. To engage in veterinary caregiving is, quite simply, to engage with complexity. We attend to imperatives from countless directions, some obvious and many less so, but all of which can be sources of stress — stress that can culminate
as compassion fatigue.

There has been a great deal of research on stress in veterinary clinical practice (3–7). The rate of stress is thought to be moderately high to high, and, by all accounts, rising (8). The very nature of what we do, contending with the prevention, diagnosis, and treatment of disease, disorder, and injury, exposes us to the suffering of patients and distress of clients, which inherently gives rise to compassion stress, the central precursor to compassion fatigue (9). Beyond this, certain other realities of life in practice — and how we respond to them — can contribute to compassion fatigue. In exploring the causes, keep in mind that
they are often intricately interwoven, not easily separable or identifiable unless we were to intentionally pause, reflect, and take a mindful approach to what we do and how it affects you.

Caring for clients and patients

Most clients are highly bonded to their pets; they consider them as members of the family (10). Devoted and resourceful, and with the best of intentions, clients sometimes arrive at our doorsteps with unrealistically high expectations, having sought information from online resources, family, and friends. This can place undue pressure upon us and set the stage for differences as we work towards helping them understand the feasibilities. They may also arrive with diverse psychosocial and emotional needs, requiring support as they navigate the health concerns or crisis their pet (and family) is facing. Today’s role as veterinary caregivers is demanding: we are not just health care providers for our patients, but also emotional support workers (i.e., ad hoc counsellors) for our clients (11). Veterinary services have increasingly shifted from providing care solely to animals to caring for both the animals and their owners (12). The honoring of the human-animal bond is a necessary and positive shift in the profession, yet it can increase the risk of psychological stress (7,13). Despite this shift, and consequent risk, veterinary curricula have not devoted much time to the study of the human-animal bond (11,14), including how to break bad news or support the guilt and grief of euthanasia (10,15). This gap in veterinary education can have serious consequences as caregivers become enmeshed in intense emotional scenarios for which they have little to no training (16).

Most clients are appreciative of, and amenable to, veterinary recommendations, but there are always exceptions, often related to the specifics of the circumstances. At these times, clients may be found to be difficult. They may dispute the findings, diagnostic and treatment options, and fees and billing, or refuse payment. Conflictual conversations about health care and the cost of care can become emotionally charged, and the stress from these interactions tends to linger long afterwards. Added to this is the risk of cyberbullying, now a real concern in the veterinary profession (17). The most common impacts of cyberbullying are workplace tension and mental health problems, both of which increase the risk of compassion fatigue.

As pets are legally recognized as property, clients have the right to determine the type and extent of care their pet receives. This places veterinary caregivers, dedicated to acting in the best interests of animals (18), in a place of relative powerlessness (12). They may be faced with extremes, from requests to prolong pet’s lives beyond what is in their best interest to ending their lives when care could easily make them healthy and well again (15,19). When it comes to patient care, the decisions that are made are strongly influenced by factors unrelated to the patient. When clients make decisions that collide with the veterinarians’ supposed advocatory role, it can create ethical or moral dilemmas with resultant distress. Moral distress, as coined by Andrew Jameton (20), is “the experience of knowing the right thing to do while being in a situation in which it is nearly impossible to do it” (20,21). Recent research has identified that veterinarians face ethical conflict and moral distress regularly in the normal course of practice (22). Furthermore, it appears that most veterinarians have little to no training on how to navigate these dilemmas and resolve the conflict to reduce the impact of these problems (22). Any situation that causes moral distress is, quite simply, a stressor, and although moral distress is different from compassion fatigue, it definitely contributes to it. When we cannot follow our own moral compass and need to engage in actions that are inconsistent with it, the painful feelings
and psychological disequilibrium increase our vulnerability to compassion fatigue (20).

Moral distress can especially be felt in relation to performing and/or witnessing euthanasia (15). Euthanasia can create a sense of having failed the animal or of having betrayed the contract of care, especially when we have come to know the patient well (23). Beyond being a source of moral distress, euthanasia is a source of grief, which can deeply affect veterinary caregivers (19). As well as being unable to “solve” the client’s grief, we ourselves grieve, and typically have very little time to debrief, reflect, or process this grief, having to resume regular duties immediately afterwards. All of this has a toll on caregivers (24), and it is a repeated toll. Veterinarians experience death five times more often than physicians (13). Exposure to death incurs both short- and long-term emotional impacts (19).

Managing workload, finances, administration, and co-worker relationships

Outside of the many sources of compassion stress and moral distress, anything that contributes to burnout can contribute to compassion fatigue. This includes long work hours, excessive workload, emergency on-call, work-home interference, under-staffing, lack of resources, low remuneration, low profit margins, financial pressures (e.g., individual or practice loans), and administrative duties (12,25,26) — all of which can wear us down, reducing our resilience. These circumstances are made worse when there are difficult relationships with co-workers or conflict in the workplace (12). Any and all of these factors
reduce job satisfaction, and the less satisfied a veterinary caregiver is with their employment, the greater the risk of compassion fatigue (27).

Job complexity, isolation, and medical errors

As veterinary medicine continues to advance, becoming increasingly sophisticated and specialized, and the bar for professional standards set at ever greater heights, there is an increasing need — and pressure — to keep up with new skills and technology. High levels of job complexity and concern about maintaining skills and expertise have been directly linked to the risk of compassion fatigue (9,27). Compounding the necessity to keep up is the relative social and professional isolation that is experienced in veterinary medicine (28). In human medicine, physicians routinely collaborate with other physicians — peer-to-peer or
peer-to-specialist — openly reviewing cases and sharing ideas within a multitiered medical system. Veterinarians, on the other hand, tend to work within independent, fully operationalized hospitals with little supervision, mentorship, or access to assistance from colleagues. Not only is isolation a source of stress, it is ripe with the potential for medical errors. Medical errors and unexpected outcomes can have considerable emotional impact
and incur the risk of complaints and litigation (29), with further emotional impact.

Who we are and how we carry ourselves

This article would not be complete without mentioning that it is not just the nature of veterinary medicine and stressors of clinical practice — altogether the veterinary environment — that makes us vulnerable to compassion fatigue, but also who we are
and how we carry ourselves in this environment. It depends on our values, mindsets, and ability to tolerate stress and distress. It depends on our coping skills and strategies, and the choices we make as we respond to our environment. The degree to which we are resilient in the face of challenges — able to bounce back from difficult experiences — influences vulnerability (30). Key to resilience is knowledge, having awareness of the issues and
how they can be managed. The more we learn about compassion fatigue, the greater the opportunity to remain resilient — and thrive, despite the challenges! Having focused on the causes of compassion fatigue, the next article will focus on the signs and consequences, specifically the changes that occur and how they impact health and well-being, professional efficacy, organizational success, and career trajectory.

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Dr. Debbie Stoewen is the Director of Veterinary Affairs for LifeLearn Animal Health, Guelph, Ontario. With a passion for lifelong learning, she contributes to designing innovative continuing education to help veterinarians and their teams address the challenges of modern veterinary practice.