Working in veterinary practice can be both rewarding and satisfying and has been recognised as one the most caring of all professions (Mitchener and Ogilvie, 2002). Seeing an animal get better and receiving gratitude from a client can have a positive impact on the veterinary team and individuals. The positive aspects received through the veterinary caregiving role are known as ‘compassion satisfiers’. They are integral to achieving job satisfaction and helping to mitigate the negative aspects of this role (Yaxley, 2013; Dobbs, 2015).
Dealing with end-of-life care and facing euthanasia on a regular basis can be a very stressful aspect of working in practice. One survey, performed by Robert Roop in 2003-2004, listed euthanasia as one of the top stressors for veterinary technicians, front office and practice management staff (Dobbs, 2012). Providing emotional support to bereft and distressed pet owners is also a source of stress for the whole veterinary team (Williams and Mills, 2000). This already intense situation may be exacerbated by many veterinary surgeons and veterinary nurses coming out of their training feeling unprepared to deal with conversations surrounding end-of-life care and euthanasia (Tinga et al, 2001; Shaw and Lagoni, 2007). Further, individuals working in caregiving environments like a veterinary practice, will witness suffering and emotional situations daily, which can cause cognitive, emotional, behavioural and physical signs of distress (Moga, 2015) (Figure 1).
Compassion is defined as ‘a deep awareness of the suffering of another, coupled with the wish to relieve it (Figley and Roop, 2006). Sadly, as euthanasia and end-of-life care are all part of everyday practice life, those working in practice are required to show compassion on a regular basis. This, combined with the naturally caring, giving and compassionate natures of individuals that professions like veterinary medicine and nursing attract, means it is not uncommon for veterinary professionals to give so much that they become drained both physically and emotionally (Rose, 2015).
A recent survey of veterinary surgeons by the RCVS (2014) revealed that less than 30% of respondents had ‘energy to spare’. This is worryingly low and reflects the excessive amounts of energy that veterinary professionals are injecting into their working role. Over time this can leave team members feeling both physically and emotionally drained and at risk of suffering from ‘compassion fatigue’ and ‘burnout’, especially if this is not balanced with ‘compassion satisfiers’. This is often referred to as the ‘cost to caring’ (Dobbs, 2015) or the ‘hurt of the heart’ (Dobbs, 2015).
This article will discuss how practices can help to prevent compassion fatigue by taking steps to maintain a balance between compassion satisfiers and compassion fatigue, both as teams and as individuals.
Why is compassion fatigue experienced in veterinary practice?
One study revealed that between 16–85% of healthcare workers based in various fields experience compassion fatigue (IAAHPC, 2014). More specifically, the results of a survey conducted in the United States of America across 200 veterinary practices demonstrated that over 50% of veterinary technicians (veterinary nurses) were classified as being at between moderate and extremely high risk of experiencing compassion fatigue (Figley and Roop, 2006). Interestingly, burnout amongst veterinary professionals is comparatively low (Dobbs, 2015). This is speculated to be due to the prevalence of compassion satisfiers such as gratitude from clients and the pleasure gained from working with animals (Figure 2). However, when veterinary medicine is compared with other allied caring professions, it has some unique qualities. One perspective is that as well as being able to heal patients and save lives, veterinary professionals also have the power to take lives away (Buisson, 2013a; Yaxley, 2014). This ability to take away a pet's life can place the individual in a painful place and a specific anguish is associated with it (Hart and Hart, 1987).
The lifespan of pets is on average only one fifth of that of humans, meaning those in veterinary practice will be exposed to death five times more than those in human health professions (Hart and Hart, 1987). Further, out of all health care professions, veterinary practice members are five times more likely to be present at the death of their patients (Hart and Hart, 1987).
Any impact needs to be acknowledged and managed from both the team and individual perspective. Roop's ‘Compassion Satisfaction and Fatigue Survey’ in 2003–2004 revealed that practices that see very ill patients, or those that perform a high volume of euthanasias, are at greater risk of compassion fatigue (Dobbs, 2012). An oft-quoted phrase by Remen (1996) commented that ‘the expectation that we can be immersed in suffering and loss daily and not be touched by it, is as unrealistic as expecting to be able to walk through water without getting wet’.
The impact of dealing with loss regularly may be considerable.
The difference between compassion fatigue and burnout
The term ‘compassion fatigue’ was first used in 1990 in a New Zealand medical journal (New Zealand General Practice) (Huggard and Huggard, 2008). However, nurse Carla Joinson is often credited with the term, first using it in 1992 to describe the negative feelings that arose while caring for patients who were suffering (Abendroth, 2011).
A subsequent definition refers to compassion fatigue as ‘progressive loss of idealism, energy and purpose, experienced by people in the helping professions’ (Dobbs, 2013). Mathieu (2007) describes compassion fatigue as being characterised by deep physical and emotional exhaustion, and a pronounced change in the helper's ability to feel empathy for their patients, their loved ones and their co-workers.
Anyone who works in veterinary practice can be susceptible to experiencing compassion fatigue (Huggard and Huggard, 2008; Dobbs, 2012). Dobbs (2012) commented that at any one time, there would be a number of team members working in practice suffering from it. Further, team members may not be aware of the impact that responsibility for the ending of a life, as well as dealing with owners' distress is having on them (Dawson, 2007).
Compassion fatigue may affect all members of the veterinary team, including those in management or administrative positions, and especially those that had a previous veterinary background prior to management. Those individuals, on moving into management, may lack previous sources of satisfiers such as the contact with animals, which puts them at risk (Dobbs, 2012).
In a recent UK study, veterinary nurses were identified as being at risk from compassion fatigue (Smith, 2016). Out of 992 eligible responses, 68% of respondents were identified at being at moderate/high risk of secondary traumatic stress (a subset of compassion fatigue). The presence of compassion satisfiers was statistically significant in having a preventative effect.
Individuals that are most at risk of compassion fatigue will be those who are highly compassionate, empathetic and emotionally driven (Figure 3) (Dobbs, 2015; Bishop et al, 2016). In addition, Dobbs identified that these are also the people who make fantastic veterinary nurses and veterinary surgeons and who may be lost from the industry because of compassion fatigue, making it imperative to deal with this situation. Many veterinary nurses will have been attracted to the profession because of their caring and compassionate natures and love of animals (personal observation). It is known that any work involving end-of-life care increases your risk of compassion fatigue (Bishop et al, 2016).
For some veterinary professionals, euthanasia and the delivering of end-of-life care is sometimes perceived as a form of ‘failure’ at doing their job (Buisson, 2013b). The sense that they have failed to heal their patient is coupled with the guilt of feeling that they have let the animal and their owner down (Scherk, 2015). A lot of time and energy will have been invested in caring for a patient and it can feel that this has all been lost when the animal then dies or is euthanased (Durrance, 2005). An example of this might be where a trauma or spinal patient has been hospitalised for a prolonged period, requiring one-to-one daily nursing, and then the patient is euthanased. This can be emotionally impactful on the veterinary nurse who has cared so much for the patient throughout its illness.
Veterinary medicine is a profession that attracts ‘perfectionism’ and many individuals will be prone to negative thought processes and negative self-appraisals (Stoewen, 2015). This in turn can lead to a sense of inadequacy and self-doubt, resulting in tasks feeling overwhelming. Loss of compassion satisfaction from work ensues, leaving them exposed to compassion fatigue instead.
Burnout is described as ‘physical or emotional exhaustion, especially because of long-term stress or dissipation’ (Dobbs, 2013). To distinguish between burnout and compassion fatigue, it is helpful to think of burnout as caused by problems specific to the workplace, for example, poor management, lack of support, or lack of trained staff. It can lead to individuals feeling generally fatigued, frustrated and with an unbalanced work load. Burnout may be cured by changing the place of work and moving to a practice that is well managed and supported (Dobbs, 2012).
Conversely, compassion fatigue is associated with the actual work that is done and the person's relationships with patients and clients. Changing practice will not alleviate this condition and it may follow the individual to their next practice and throughout their career (Faulkner, 2016). It is not uncommon in practice for a colleague or manager to dismiss a colleague who is emotional, angry or negative as simply experiencing ‘burnout’, when in fact they are expressing symptoms of compassion fatigue (Dobbs, 2015; Bishop et al, 2016). It is vital to recognise that burnout and compassion fatigue are different and require very different treatments (Cohen, 2007).
Traumatic stress
Compassion fatigue is a recognised form of secondary traumatic stress. Individuals working in caring professions can be indirectly traumatised by the suffering and traumatic events faced by their patients and their patients' families (Buisson, 2013a; Huggard & Huggard, 2008; Kearney, 2009). This may happen at any time during the veterinary career, though those that are new to practice are particularly vulnerable (Lovell and Lee, 2013). This may be because communication with clients is often stressful due to the intense emotions involved — many clients regard their pets as cherished family members. Where the pet is ill, or where euthanasia is an outcome, emotions will be heightened. Engaging with the client and managing these sensitive situations requires practice, time and patience (Lovell and Lee, 2013).
The onset of compassion fatigue is often insidious and those suffering may not even realise it (Faulkner, 2016). Smith (2009) postulated that once an individual has compassion fatigue, it will always stay with them while they continue to work in practice or any other caring role. The implication is that it is something that can be managed rather than cured. It is also possible to have both compassion fatigue and burnout at the same time and compassion fatigue can also trigger burnout (Faulkner, 2016).
Experts, such as Yaxley from Michigan State University and Dobbs from interFace Veterinary HR Systems LLC, have placed great importance on raising the awareness of compassion fatigue and the symptoms associated with it. They believe that if individuals are better placed to spot the symptoms, they will be better prepared to cope with it and manage it (Dobbs, 2012). Table 1 outlines some recognisable symptoms of compassion fatigue. Those suffering may exhibit some or all of the symptoms.
| Physical |
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| Emotional |
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| Behavioural |
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The consequences of compassion fatigue on the veterinary profession
Because of the occupational stressors associated with the veterinary environment, depression, burnout and compassion fatigue are prevalent amongst those in practice (Rose, 2015; Bishop et al, 2016). Faulkner (2016) highlighted that the veterinary profession is experiencing increased attrition and compassion fatigue is a valid contributor to this. A recent survey conducted by the RCVS (2014) revealed that only 46% of respondents would choose to follow a career in the veterinary profession again, exposing the level of disharmony felt amongst veterinary surgeons in practice.
One survey conducted in the US also revealed that the veterinary community had a turnover of 29%. This was nearly double that of the other industries surveyed, at 13–15% (Rose, 2015). However, there are also certain buffers in veterinary practice which have been identified as helping to reduce compassion fatigue and these include: working as a team; working with grateful clients; and helping animals (Moga, 2015).
The consequences of compassion fatigue on the practice
Individuals that are affected by compassion fatigue tend to become less efficient and have reduced productivity (Yaxley, 2013; Faulkner, 2016). They are also more likely to make mistakes and incur increased numbers of compensation claims (Yaxley, 2013; Dobbs, 2015). Compassion fatigue has also been associated with increased sick leave from work due to some individuals feeling unable to face doing their job (Hooper et al, 2010; Dobbs, 2015). From a patient's perspective, in the field of human nursing, compassion fatigue also compromises the individual's ability to deliver quality care (Yaxley, 2013).
This quality care may also include the inability to feel empathy. One pet owner respondent in Compassion Understood research (2015a) commented:
‘Vets need to be more sympathetic and less robotic. I understand they have to do this often, but it's not every day it happens to you and your family.’
It may be that in situations such as the one highlighted by the pet owner above, the veterinarian involved may be suffering from compassion fatigue, and either be blunted in their emotional responses or emotionally protecting themselves from this stressful situation.
From a practice owner's perspective, having members of the team suffering from compassion fatigue may have a significant impact on the practice's ability to thrive and prosper. Hewson (2014a) describes how suffering excessive stress and risking compassion fatigue can create turnover losses. In Hewson's model, of the 12-estimated euthanasiarelated clients lost per year per full time small animal veterinary surgeon, she attributed a loss of seven of these as a result of dissatisfaction arising from the veterinary surgeons' emotional depletion; four because they were affected by errors in communication or clinical judgement, and three because of high veterinary surgeon turnover. Together with losses of potential new clients because of lack of referrals or negative word of mouth, and practice publicity not indicating understanding of clients' grief, as well as costs of rehiring veterinary surgeon and veterinary nurse positions vacated due to burnout, the cumulative costs per full time veterinary surgeon over a 3-year period may amount to Euro 51 000 (Hewson, 2014b).
Working with individuals suffering from compassion fatigue can also affect the morale of the practice team (Yaxley, 2013; Bishop et al, 2016) and if several individuals are employed who are affected by compassion fatigue, then ‘organisational compassion fatigue’ may result (Buisson, 2013a).
Therefore, preventing and managing compassion fatigue in practice is important for both the individual's wellbeing and health, as well as for the veterinary business.
Protective strategies against compassion fatigue
Table 2 includes suggestions on how to protect against compassion fatigue through self care.
| Speak to colleagues about worries |
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| Seek help |
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| Self care |
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| Disconnect from work |
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| Socialise |
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| Relax |
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| Mind-set |
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| Reassess boundaries |
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| Traveling home |
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| Maintain your values |
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Recommendations for veterinary nurses in practice
It is important that veterinary nurses in practice protect themselves against the impact of the sadness and traumas that they absorb through dealing with end-of-life care and euthanasia on a regular basis. In the human field, nurses are singled out as being especially vulnerable to compassion fatigue, due to both empathy and compassion being core values (Melvin, 2015).
There are, thankfully, lots of ways to help prevent, manage and treat compassion fatigue. The overriding principle is to maintain a balance between compassion fatigue and compassion satisfaction and to ensure a balance of ‘feelgood’ neurotransmitters, for example, dopamine, endorphins and serotonin, against those associated with stress, including increased cortisol and insulin (Faulkner, 2016).
This care needs to include physical, emotional and spiritual wellbeing. Each of these will be placed under pressure through the daily work of the veterinary nurse and the sad tasks that they witness and perform. The first step is to look at one's own ‘self care’ routine, ensuring there is a healthy baseline. The mantra, ‘take care of yourself before helping others’ is pertinent here.
Eating well and drinking
Healthy nutritional practices should be adopted by ensuring that regular, healthy meals are eaten during both the working day and outside of work. Skipping or missing meals should be avoided, together with the mistaken habit of grabbing high fat or high sugar snacks to give a burst of energy in the attempt to revive a tired body. This quick fix approach may be at the expense of long-term health.
Individuals should ensure that they stay hydrated and drink plenty of water. This will not only help with feeling better, but will also ensure better functioning in the job at hand.
Sleeping well
Adopting good sleep patterns will be beneficial; working in veterinary practice is both physically and emotionally demanding. Mind and body need time out to rest and regenerate.
Compassion fatigue can be very disruptive to sleep patterns and individuals often struggle with insomnia, finding themselves lying awake thinking about sad cases from that day or worrying about patients currently under treatment for end-of-life care. Another symptom of compassion fatigue is having recurring bad dreams that are often centred on the work place. To help prevent this, at the end of the working day, the development of a set routine that signifies that the working day is over is recommended, such as the removal of one's stethoscope or changing out of one's uniform. It is important to have a clean break and maintain clear boundaries between working life and personal life.
If, at the end of a shift, there is something playing on one's mind concerning a case, it is advisable to ring a trusted colleague and talk it through with them (Huggard and Huggard, 2008). Sharing a problematic case can help to process worries and prevent over thinking.
Regular relaxation
Effort should be made to incorporate relaxation into the daily routine. Examples include yoga or pilates, or simply walking the dog. Even short periods of yoga, such as 10 minutes before work or at the end of the day, can be of benefit in helping to unwind and re-centre. Reflective exercises like meditation and mindfulness have also been shown to help improve self regulation by actively stimulating the prefrontal cortex (Moga, 2015). Due to neuroplasticity, neural pathway altered by stress and trauma can be rewired, helping individuals recover and develop resilience (Moga, 2015). Mindfulness meditation is also reported to ‘enhance a person's capacity to feel both self compassion and empathy for others' (Kearney et al, 2009).
There are also opportunities for relaxation within the working day. Doing some deep breathing exercises between consultations can help in re-centring oneself. Scheduling time for breaks into the working day and sticking to them is beneficial; it is recommended to take the opportunity to step away from the practice and walk the dog or volunteer to go to the shop to get the staff milk. Some proactivity and assertiveness may be necessary; ensure that the current work schedule includes breaks. Disconnecting oneself from all technology can benefit chronically stressed individuals, allowing a healthy break from the bombardment of any electronic demands (Moga, 2015).
Regular exercise
Exercise is important for not only the body, but also the mind. The release of hormones during exercise will help with managing stress and promoting relaxation. Embrace hobbies, and activities that drive happiness; these will release endorphins and serotonin which will help with the necessary switching off from work and from a stressful day. Make time for oneself and ensure that holiday allowance is used.
Build resilience
Higher levels of both resilience and emotional ability in individuals are associated with lower levels of compassion fatigue (Huggard and Huggard, 2008). Resilience is the ability to persistently bounce back when something bad happens, to accept it and to put it down to experience and learn from it. Individuals with high resilience have an innate ability to adapt, cope and remain optimistic in the face of adversity (Hart et al, 2014; Melvin, 2015). The outcome of increased resilience is a sense of much greater job satisfaction and career longevity (Melvin, 2015). This is an important trait to have in veterinary practice and one that, fortunately, can be learned. Every person has a degree of innate resilience that can be built on by changing mental attitude and thought processes (Melvin, 2015). This will have a powerful impact on the way in which one can handle and process the stressors that veterinary professionals are exposed to in practice, including euthanasia and end-of-life care.
Being able to feel gratitude for the minor ‘wins’ that happen during the day and to think positively is associated with enhanced resilience to stress (Figley and Roop, 2006). Thinking positively and rejoicing at positive outcomes has been associated with lower levels of compassion fatigue and increased levels of compassion satisfaction (Fredrickson and Losada, 2005).
The ability to learn from adverse events and to put them down to experience, can provide a way to cope with the sad times in practice when a long-term patient is euthanased or a case that an individual has invested a lot of time and energy in, fails to respond to treatment and is euthanased. These should be viewed not as failures but as experiences that can be learned from. It is helpful to balance any negative thoughts by acknowledging that the animal is no longer suffering.
Many individuals in practice fail to acknowledge their own grief and it is important to allow time to grieve for the loss of a patient, even saying a private good bye to them. Afterwards, taking time to debrief and support any other team members that need it is beneficial. Talking is helpful; showing emotion is normal and should not be viewed in a negative light. Writing a reflective journal can help to express some of the thoughts and feelings that can otherwise end up getting bottled up. This can be especially helpful for individuals that struggle to communicate their emotions.
Be realistic with personal needs
In general, veterinary professionals are hard working, committed people. The temptation can be to take on too much and not prioritise one's own needs. Knowing one's limits and asking for help is something that one should strive to become comfortable with; be realistic about what can be achieved in a day. It is those that are the most selfless that will be the most vulnerable to compassion fatigue, due to their inability to put themselves first (Smith, 2009). Nurses should feel empowered to say ‘no’ to overtime and extra shifts without feeling guilty (Dobbs, 2012; Melvin, 2015).
It is important to keep a healthy life–work balance including socialising away from the practice, and developing friendships that are positive and supportive (Stoewen, 2016). Having people around who will listen without any judgement to worries and daily experiences can help to alleviate the symptoms of burnout and compassion fatigue (Moga, 2015).
Team care by managers
Creating a culture in practice that supports and endorses both self care and team care is essential to creating a healthy working environment designed to protect its employees from developing burnout and compassion fatigue. Practices can promote self care by providing healthy snacks such as fruits and nuts and the inclusion of herbal teas as an alternative to caffeinated options such as coffee and tea. The provision of a drinking bottle to each team member will help to encourage individuals to drink more water during their working day. Making even these small changes to the working environment can help to transform a practice into a supportive environment conducive to self care. Developing a culture where employees are encouraged to express emotions and talk about their experiences with traumatic and sad cases will also help to reduce compassion fatigue.
Compassion fatigue can affect anyone in practice at any time during their career (Huggard and Huggard, 2008; Yaxley, 2014). However, personal characteristics and situations that can make individuals more vulnerable, include: those new to practice; young; female and being unmarried and without dependents (Lovell and Lee, 2013; Yaxley, 2013). Extra attention is therefore needed on the training of new graduates with the communication skills around end-of-life care and euthanasia.
Practices should include training for all new members of the team regarding euthanasia and end-of-life care. A practice mentoring system can also help to ensure that new graduates and trainee nurses are supported and guided. This can help to reduce the stressors that new graduates can be exposed to. Spreading euthanasia consults between the team (respecting existing client relationships, of course) can also help to reduce the compassion load on any individual.
For many in practice there is a strong sense of unease and even anxiety surrounding end-of-life care, euthanasia and compassion fatigue. This can be attributed to lack of training at veterinary school, combined with feelings of failure, a sense of letting the patient down and enduring time restrictions (Shaw and Lagoni, 2007). Research reveals that many veterinary practitioners have not received formal training at veterinary school on how to handle these conversations (Shaw and Lagoni, 2007). A skills gap has been identified between what is taught and the real skills that are needed to survive in practice (Shaw and Lagoni, 2007).
One survey showed that 80% of respondents would want information on compassion fatigue to be included in end-of-life training (Compassion Understood, 2015b). One respondent commented,
‘[I] feel quite strongly that more support should be avail(sic) for staff, it can be very emotionally draining to experience loss and distress so frequently.’
It is never too late to learn and this can be corrected by offering in-house team training in the communication skills centred on how to approach end-of-life conversations with clients. This will help the practice team to conduct compassionate end-of-life discussions, which has been proven to increase professional satisfaction as well as lowering the risk of compassion fatigue and burnout (Shaw and Lagoni, 2007). Training is available in end-of-life matters and in compassionate communications (see Article 2 in this series for a list of end-of-life resources, including CPD that veterinary professionals can undertake).
Addressing compassion fatigue in practice is important. Helping the team to recognise the signs and spot it within themselves and their colleagues, can assist with getting treatment and support sooner rather than later.
Conclusion
To ensure sustainability of the veterinary and veterinary nursing profession, ‘self care’ and ‘team care’ must be a priority for all those in practice. For some, this will take time and discipline to reverse some of the ingrained thought processes and mind-sets that have been established. However, taking positive and proactive steps to address and minimise any negative effects of regular exposure to end-of-life situations is something that all practices can do.
Compassion fatigue cannot be cured; preventing it is a lot easier and worth investing time and energy in from both an individual and team perspective.