Compassion fatigue, compassion satisfaction and burnout during a pandemic

Compassion is defined as the awareness of the suffering of others and the desire to act to relieve it (Sinclair et al, 2017). Compassion is at the centre of many care-related fields, be it human or animal, and there is an expectation that workers within these fields will provide their clients with care that is compassionate (Smith, 2016). A paradox lies in how the provision of these empathetic services can render individuals more vulnerable to the effects of ‘compassion fatigue’. A term first used by Joinson (1992) described a specific type of stress known as ‘burnout’, typically experienced by emergency department nurses. In later studies, it was also referred to as ‘vicarious trauma’ or ‘secondary traumatic stress’ (Bride et al, 2007), and as the loss of the ability to ‘nurture’ (Coetzee and Klopper, 2010). Recognition of compassion fatigue within healthcare related fields is of particular importance as it can impact the care received by the most vulnerable in our communities, and can lead to clinical mistakes in judgment (Jackson, 2004). Other symptoms can include, but are not limited to, generalised depression, disordered sleep, hypertension, feelings of helplessness, anger, anxiety, and intrusive thoughts (Bride et al, 2007; Kashani et al, 2010).

Burnout

Although burnout is an aspect of compassion fatigue, the concepts are distinct. Both compassion fatigue and burnout fall under the umbrella term of secondary traumatic stress (Huggard and Huggard, 2008). At its core, burnout is an overpowering, invasive stress which can interfere with an individual's ability to function (Joinson, 1992), which reflects environment-induced employment stress. In comparison, compassion fatigue reflects the interaction between an individual and the nature of the work that they do. While burnout may lead to some of the same consequences as compassion fatigue, it is exemplified by three components: emotional exhaustion from exposure to prolonged stress, pessimism, and detachment from employment role with reduced personal accomplishment and feelings of inadequacy (Maslach and Jackson, 1981). However, burnout can be expressed in a wide variety of ways affecting cognition, affective state, and behavioural expression, and is often a result of employment role conflict, lack of expectations, or overload (Rizzo et al, 1970; Truzzi et al, 2012). Those most susceptible to burnout tend to work in emotionally intense roles involved with distressed and traumatised individuals (Scotney et al, 2019).

Compassion satisfaction

On the other end of the spectrum, compassion satisfaction is the extent to which an individual can find pleasure or joy in their work (Rank et al, 2009). It is a positive aspect of care-giving work and a reflection of the emotionally rewarding nature of helping others and alleviating suffering (Stamm, 2010). Compassion satisfaction is most frequently garnered from contributing to the employment environment, maintaining meaningful relationships with colleagues, and feeling accomplished in an employment role (Smith, 2016). It is considered to increase a person's ability to endure the effects of compassion fatigue and burnout as a protective measure (Stamm, 2002). Burnout, compassion fatigue, and compassion satisfaction are not mutually exclusive, rather they help paint a more informed picture of the mental health of caregivers.

The Professional Quality of Life scale and human studies

To produce a measure of the mental health of care workers, the Professional Quality of Life scale (ProQOL) assesses both the negative and positive effects of working within a caring role (Stamm, 2019). It is a measure of the risk of compassion fatigue, burnout, and compassion satisfaction occurring in the form of a self-scored Likert scale (Stamm, 2019). During data analysis descriptive statistics for each dimension are scored. Based on high alpha reliability scores that reflect how well the survey questions relate to either compassion fatigue, burnout and compassion satisfaction, an individual's scores can be classed as either low (scores <23), moderate (between 23 and 41) or high (scores >41; Stamm, 2010). The ProQOL scale has seen several iterations since its initial development in 1995, and up until 2016 there have been more than 667 studies recorded to have used the ProQOL (Stamm, 2016). The fifth and current version was released in 2012 after revisions to the wording on several questions for brevity, specificity, and application (Stamm, 2019). In utilising this measure for compassion fatigue, burnout and compassion satisfaction, researchers have a common measure for comparisons and correlations within their respective fields involving the care of humans and animals.

Human studies

Compassion fatigue, burnout, and compassion satisfaction have been quantified using the ProQOL scale in global populations of human nurses, carers, and physicians. These populations include hospice care (Abendroth and Flannery, 2006), emergency medicine (Crowe, 2016), neonatal intensive care (Amin et al, 2015), oncology (Potter et al, 2010) and general practice (Zhang et al, 2018). Investigating reports on compassion fatigue and burnout in these areas can provide an understanding of how different specialities are affected, with application to veterinary medicine. Despite their specific definitions, the rates of compassion fatigue, burnout, and compassion satisfaction between populations can be compared because of their consistent ProQOL methodology. High compassion fatigue scores (indicating high risk of compassion fatigue) across medical professions varied from 23% of survey respondents (Amin et al, 2015) to 78% of survey respondents (Abendroth and Flannery, 2006). These results are important when extrapolated to the population of nurses globally numbering 20.7 million (World Health Organization (WHO), 2021). Burnout was also prevalent in these populations with moderate to severe scores varying from 23% of respondents (Amin et al, 2015) and 61% of respondents (Abendroth and Flannery, 2006). While these scores show a large range, they indicate that compassion fatigue and burnout are contemporary issues human nurses face on a global scale. Understanding that these issues are prevalent in human nurses is reason to consider the impact that compassion fatigue, burnout, and compassion satisfaction have on care professionals in the veterinary industry.

Veterinary industry studies

The veterinary industry, as in human nursing, has studies dedicated to assessments of various iterations of stress, burnout, and satisfaction. However, few of these use the ProQOL scale to quantitatively measure the scores for each dimension of the ProQOL, opting instead for self-reported surveys (Smith, 2016; McArthur et al, 2017; Harvey and Cameron, 2020). Of those studies that did utilise the ProQOL scale, very few measured veterinary nurses as an independent subgroup (Smith, 2016; Scotney et al, 2019). While these studies assessed veterinary nurses working in general practice clinics, it is of note that many of these clinics perform a wide range of services, so are less often defined into the specialities typical of the studies in human medicine, or the type of practice remained unspecified. In studies that utilised the ProQOL scale, scores for compassion fatigue and burnout are comparable to those reported in human nurses (Smith, 2016; McArthur et al, 2017; Scotney et al, 2019).

Despite this, the incidence of compassion fatigue, burnout, and compassion satisfaction in veterinary nurses is still largely lacking in research. Use of the ProQOL scale could enable compassion fatigue, burnout, and compassion satisfaction results to be compared with rates within veterinarians and human healthcare practitioners (Dobbs, 2014). These studies could also provide assessments into the efficacy of resilience programmes used to promote wellbeing and good mental health in the face of compassion fatigue and burnout (Brannick et al, 2015).

Coronavirus 2019 (COVID-19) pandemic

The numbers of New Zealanders experiencing mental distress are increasing (Health Promotion Agency, 2020). Work-related stress (such as compassion fatigue and burnout) and mental health issues are especially prevalent during times of great stress, such as global disasters, particularly within fields deemed essential services (Ruiz-Fernández et al, 2020), including that of the veterinary industry. In response to global crises, elevated scores for compassion fatigue and burnout within veterinary nurses are expected to be consistent with reports of affected mental health during the H1N1 pandemic in 2009 (Pfefferbaum et al, 2012), and severe acute respiratory syndrome (SARS) outbreak in 2003 (Leung et al, 2003). Increased rates of compassion fatigue and burnout during natural disasters have been credited to increased hours and unusually strenuous conditions (Frank and Adkinson, 2007). Additionally, essential veterinary practitioners during the COVID-19 pandemic have been faced with resource scarcity, the burden of constant personal protective equipment, and the fear of contracting and transmitting a potentially fatal virus (Ruiz-Fernández et al, 2020). In addition, animal euthanasia is being conducted under conditions of isolation, where both veterinary personnel and owners are lacking the familiar support and care necessary to emotionally cope with animal death (Hurn et al, 2020). Feelings of support and work-place community are important contributors to feelings of compassion satisfaction (Smith, 2016). Many veterinary practices are also experiencing a drop of up to 75% of financial weekly turnover, which may cause nurses to feel insecure in their roles, or stressed about their income (Hurn et al, 2020). Job security is also a key factor in compassion satisfaction and the significant changes to nurses' workplace environment may cause additional stress (Bianchi et al, 2015).

There are also reports from members of the British Veterinary Association, of ‘abuse and undue pressure from clients,’ which could be in part a result of veterinary practices only admitting emergency cases in combination with clients’ own internal pressure to provide care for their animals (Hurn et al, 2020). Companion animal surrender (e.g. animals taken to rehoming charities and shelters) has also been reported to increase during COVID-19 (World Small Animal Veterinary Association, 2020). This is in part because of owners being concerned about virus transmission from their pets; but also factors of financial concern (Hurn et al, 2020).

The effects of COVID-19 on rates of compassion fatigue, burnout and compassion satisfaction in veterinary nurses remains largely unstudied. Use of the ProQOL scale could accurately identify the rates of compassion fatigue and burnout during the COVID-19 pandemic. It is expected that more respondents will have high scores on the ProQOL test indicating increased compassion fatigue and burnout because of the stressors of working during a global pandemic in an essential worker role. This project will provide an indication of the mental health status of veterinary nurses for comparison for future studies and help to prepare the veterinary industry for future global crises through trigger mitigation and management.

Methods

An online self-report survey, designed to be answered in less than 15 minutes, was disseminated to veterinary nurses across multiple platforms including social media (Face-book) and email (via the New Zealand Veterinary Nursing Association (NZVNA)). Social media was utilised to target a more accurate population sample and to maximise the number of respondents considering evidence that surveys are recognised to amass poor response rates (Cartlidge, 2012). The NZVNA email was sent to all current members, with a hyperlink to the survey hosted by Zoho, which was selected as the host website for this survey because of its robust measures of confidentiality and ease of use (Zoho Corporation Pvt. Ltd, 2020). It enabled respondents to be completely anonymous (because of no IP data being collected) and made for easy data transfer to an analysis program (Denscombe, 2017). Prior to admittance to the survey, respondents were shown a consent page, which outlined the purpose of the research project, the survey instructions and provided resources for mental health support from the NZVNA website and the 1737 national telehealth service. Respondents were also required to answer an eligibility question (‘Did you work as a veterinary nurse during the COVID-19 pandemic?’). A multiple choice answer of either ‘Yes’ or ‘No’ was offered. If the participant selected a ‘No’ answer they were redirected to the final survey screen with mental health resources and a thank you message. An offer to proceed or opt out was also offered for the ‘yes’ option.

Professional Quality of Life scale

The survey was a combination of the well-validated Pro-QOL scale (Stamm, 2019), followed by a series of additional demographic, open-ended and multiple choice questions. Respondents were asked to rate on a 5-point Likert scale the frequency that they had experienced symptoms of burnout, compassion fatigue and compassion satisfaction in the past 30 days. A preamble outlining the concept of compassion fatigue was adapted to reflect the nature of the participants. ‘Helper’ was changed to ‘veterinary nurse’ and ‘helps/help’ was changed to ‘nurses/nurse’. The ProQOL is a Likert scale which consists of 30 questions pertaining to compassion fatigue, burnout, and compassion satisfaction. The Likert scale values were described in the preamble. They ranged from 1 to 5 and their weightings were: (1 = never; 2 = rarely; 3 = sometimes; 4 = often; 5 = very often). The individual subscales are summed to give individual scores for risks for compassion fatigue and burnout, and amount of compassion satisfaction. The Likert scale scores are calculated as either low (≤22 points), moderate (23–41 points), or high (≥42 points). The lowest possible score per category is 10 (10 counts of scores of one) and highest is 50 (10 counts of scores of five). The ProQOL uses both positively and negatively framed questions to increase the psychometric properties of the scale (Stamm, 2010). The self-score was omitted from this survey to reduce completion time and encourage completion of the survey. The newest version and latest information about the ProQol survey can be found at ProQol.org.

The second section of the survey included eight additional demographic and descriptive questions, intended to inform about the participant sample. The questions were either multiple choice, open-ended, or a combination of both, allowing for elaboration and expansion. The demographic and descriptive questions were not compulsory.

The survey was hosted online on the Zoho program for 6 weeks. Zoho allows simple and rapid export of data as a CSV file, which was analysed using Microsoft Office Excel. The ProQOL responses were each sorted categorically between compassion fatigue, burnout, and compassion satisfaction and summed after transformation from rank to count data. Burnout required inverse scoring against questions (i.e. 1 transforms to 5, 2 transforms to 4 and 3 remains the same as it is the median, etc.). The questions requiring inverse scoring were: 1 (‘I am Happy’), 4 (‘I feel connected to others’), 15 (‘I have beliefs that sustain me’), 17 (‘I am the person I always wanted to be’) and 29 (‘I am a very caring person’). All other data analyses (including graphs, demographic, and descriptive questions) were also performed on Microsoft Office Excel. A diagnosis of the risks of compassion fatigue, burnout and compassion satisfaction in New Zealand veterinary nurses was calculated via the ProQOL scoring system and using means (M), standard deviations from the mean (SD) and standard error (SE).

This research was approved by the Unitec Research Ethics Committee, Auckland, New Zealand (UREC Registration Number: 2020-1030).

Results

A total of 166 (n=166) usable responses were received for the ProQOL section of the survey, and 163 (n=163) for the demographic and descriptive questions. Based on census 2018 figures of New Zealand's population of veterinary nurses (2145), the response rates were 7.74% and 7.60%, respectively (Statistics NZ, 2018).

Professional Quality of Life scores

The number of scores, mean, standard deviation standard error, and range were calculated for all the respondents across each dimension of the ProQOL (Table 1). The sub-scores for each dimension were also categorised into low, moderate, and high levels for comparison as per the Pro-QOL guidelines (Stamm, 2010), with the mean scores for all dimensions across the sample falling into the moderate category. The mean score for compassion fatigue was the lowest of all the dimensions at 26.74 (SD=6.28), although it had the largest range between individual scores (19–50). The percentage of low scorers was 0.60% (n=1), moderate 76.51% (n=127), and high 22.89% (n=38). This means that the majority of veterinary nurses are satisfied in their job and nearly a quarter of respondents are highly satisfied and reflect a greater ability to be an effective care person (Stamm, 2010). In addition, the alpha value (measuring how well the questions in the survey measure compassion satisfaction was 0.88 on a continuum of 0–1 with 1 being perfect consistency) indicating high reliability of the scores reflecting a measure of satisfaction.

The mean score for burnout was 28.94 (SD=5.83) and the smallest range between individual scores of all the Pro-QOL dimensions (14–43). The percentage of low scorers was 15.06% (n=25), moderate 84.34% (n=140), and high 0.60% (n=1). This means that most of the veterinary nurses surveyed are coping in their job with neither positive nor negative feelings about their workload at their job with 15% of respondents feeling effective in their work (Stamm, 2010). The alpha score was 0.79 indicating high internal consistency of the questions in measuring burnout. The mean score for compassion satisfaction was the highest of all the dimensions at 36.88 (SD=5.76) and a range between individual scores of 12–47. The percentage of low scorers was 26.51% (n=44), moderate 72.29% (n=120), and high 1.20% (n=2). This means that most of the veterinary nurses surveyed were not experiencing trauma in their job that is negatively affecting them (Stamm, 2010). The alpha score was 0.83 indicating high internal consistency of the questions in measuring compassion fatigue or secondary traumatic stress.

Demographic and descriptive questions

Within our sample of New Zealand veterinary nurses, 98% answered the demographic and descriptive questions (163/166 respondents; Table 2). Of those responses, 96.32% (n=157) of the participants were female. The average age of participants was 32.22 years (SD=10.33 years). The tenure of the participants was wide with 4.91% of participants working as a veterinary nurse for less than 1 year (n=8), 17.79% for 1–2 years (n=29), 29.45% for 3–5 years (n=48), 20.86% for 6–10 years (n=34), 11.66% for 11–15 years (n=19) and 15.34% for 16+ years (n=25). Most of the participants (51.53%, n=84) worked in companion animal practice, followed by mixed companion animal and large animal or equine practices (23.83%, n=47).

Few participants reported a lack of change in role during the COVID-19 pandemic (7.36%, n=12), whereas 43.56% (n=71) worked fewer hours than usual and 25.77% (n=42) worked more hours than usual. Nearly a fifth of respondents, 23.31%, reported a change in role (n=38) including changes to usual rosters (less days but longer hours on those days), working from home, changes in protocols around use of personal protective equipment and consulting outside the building.

Interestingly, 63.19% (n=103) of participants reported that their ability to do their job well was unaffected by the COVID-19 pandemic and 53.99% (n=88) of participants reported that their job satisfaction as a veterinary nurse had not been affected by the pandemic. Whereas 36.81% (n=60) of respondents reported that their ability to do their job well was affected by the pandemic and 46.01% (n=75) of respondents reported that their job satisfaction as a veterinary nurse had been affected by the COVID-19 pandemic.

Discussion

This research was intended to investigate the levels of compassion fatigue, burnout, and compassion satisfaction within the veterinary nurse population in New Zealand during a global pandemic. While this objective was met, the results were somewhat unexpected. Across all the Pro-QOL dimensions, moderate levels of risk were discovered. It is difficult to fully understand the implications of these results because of the lack of a baseline ProQOL measure specific to the veterinary nurse population outside of this global crisis. A descriptive study carried out by Harvey and Cameron (2020) suggested that 33.5% of the population surveyed (n=189) responded with experiencing compassion fatigue more than half of the time ‘pre-COVID-19’, providing baseline indications that a portion of the New Zealand veterinary nursing population believed they were suffering from some form of compassion fatigue prior to the COVID-19 pandemic because of the nature of the job. It is for this reason that the authors are surprised by most veterinary nurses in this study reporting moderate scores in terms of burnout and compassion fatigue, but also in terms of compassion satisfaction.

With a view to a global scale, there is still a paucity of studies that reflected on compassion fatigue, burnout and compassion satisfaction in veterinary nurses using the ProQOL scale. An Australian study (pre-COVID-19), undertaken by Scotney et al (2019), sampled the veterinary industry that included a small proportion of veterinary nurses. While that study may not have focused on veterinary nurses, the mean scores across the three dimensions provided a comparison measure between a pre-COVID-19 veterinary nurse population and our sample of veterinary nurses that worked through a pandemic. The Australian ProQOL scores all fell into the category of ‘moderate risk’ and were only negligibly more ‘positive’ than the current study. For example, Scotney et al's (2019) study reported level of compassion fatigue was the lowest scoring of the three dimensions averaging a score of 24.6, while the current study reported an average score of 26.74. The Australian average score for burnout was 24.8, and the current study reported an average score of 28.94. Scotney et al (2019) reported their highest average scores for the compassion satisfaction dimension of 39.2, while the current study reported an average score of 36.88. Although indicative of similar population dynamics, the Australian sample had varied sample demographics and limited sample size of veterinary nurses. Taking the data at face value and because of the lack of comparative data of the same population, the Scotney et al (2019) study and the current results provide an indication of only very slight change in reports of compassion fatigue, burnout and compassion satisfaction in veterinary nurses pre- and post-COVID-19 pandemic (and in line with similar descriptive results from Harvey and Cameron (2020)), suggesting that New Zealand nurses performed remarkably well considering the societal upheaval. Further investigation of these coping mechanisms deserves investigation to provide continued professional development to manage events of stress and mitigate development of compassion fatigue and burnout.

In another study using the ProQOL as a measure for veterinary nurses, the UK population was sampled (Smith, 2016). Again, the mean findings within this study are consistent with the previous Australian sample and the current study, and the three dimensions of the ProQOL fell into the moderate risk category. Smith (2016)'s results indicated that compassion fatigue scored lowest of the three dimensions averaging 25.52, burnout was reported at 28.84, and compassion satisfaction scored the highest at 37.89. In comparing the current results to these international studies there are clearly trends of moderate risk for veterinary nurses to experience burnout and compassion fatigue, and similarly high levels of compassion satisfaction across the board. This begs the question of whether the use of the ProQOL measure failed to capture the true levels of compassion fatigue, burnout, and compassion satisfaction present during a pandemic, possibly lacking the sensitivity to isolate the nuanced effects of unprecedented stress responses. Alternatively, it could be that there is something unexpectedly positive and endearing about the New Zealand veterinary nurse that is maintaining low levels of compassion fatigue and burnout and high levels of compassion satisfaction. These authors suspect the former but are optimistic there are aspects of the latter reason too.

Geographic influences

Despite New Zealand's elimination of COVID-19 and low burden of disease (Jefferies et al, 2020), COVID-19 has become the most significant global health crisis in recent history (Rothan and Byrareddy, 2020), and essential workers (such as veterinary nurses) are greatly affected by COVID-19. Among many of the stress-inducing factors of being a front-line worker, the general public is urged to self-isolate and socially distance themselves, while veterinary nurses are encouraged to keep working closely within their work places, all while interacting with clients who may potentially expose them to the virus (Ruiz-Fernández et al, 2020). New Zealand is not only geographically distanced from the epicentre of the COVID-19 disease outbreak, but also separate from other land masses unlike many parts of Europe, South America, and Asia. Alongside the rapid implementation of ‘lockdown’ procedures and border closures, and united compliance with the national emergency measures put in place, New Zealand's veterinary nurses may not feel as though COVID-19 is as much of a threat as in other countries.

The effect of work role on compassion satisfaction

Human studies during the COVID-19 pandemic have also discovered higher rates of compassion satisfaction in nurses than in physicians (Ruiz-Fernández et al, 2020). This has been credited to the nature of the role, as physicians hold more responsibility regarding decision making on cases and how workplaces will functionally operate (Greenberg et al, 2020). Within the veterinary industry in New Zealand, this is particularly applicable to veterinarians, upper management, and practice owners who were faced with having to rapidly implement new standard operating procedures, while prioritising which cases are necessary enough to risk exposure to themselves and staff. The mental strain of ‘breaking bad news’ to clients has also increased during the COVID-19 pandemic, an aspect that largely does not fall on veterinary nurses (Rimmer, 2020). The elevated levels of compassion satisfaction observed in the current study may in fact be reflective of veterinary nurses' ability to make a positive change in their patients' lives, during an otherwise anxious and pessimistic episode of world history. This sentiment was echoed in a study of Spanish nurses who worked during the COVID-19 pandemic. Ruiz-Fernández et al (2020) postulated that nurses have been able to better connect with their motivation for working within caregiving roles, and their compassion satisfaction has in turn improved from their active dedication to their patients. It may well be that veterinary nurses are resilient as a profession, and as dictated by the hedonic treadmill theory, humans are adaptive in the face of overwhelming positive or negative life experiences, lending to wellbeing eventually returning to its pre-event levels. In fact, Daly and Robinson (2020), found that a sample of the US population had returned to their base-line physiological stress levels by June of 2020, which could mean that the present study is in fact more representative of normal levels of compassion fatigue, burnout, and compassion satisfaction within the veterinary nurse population.

Study improvements and limitations

The current study faced the challenge of collecting data during a busy and unprecedented era within the veterinary industry. This study would have more power and significance if the sample collected had been larger, however, the alignment of the results with other studies gives this study weight. The survey asked open-ended questions, but low response to these has precluded further analysis. Furthermore, the ProQOL tool is iterative in that it continues to improve in terms of statistical power as a result of the growing number of healthcare-related groups using the tool. The dimensions of compassion satisfaction, burnout and compassion fatigue are obviously related (as shown by Cameron and Harvey, 2020), but this survey tool measures each dimension well, with high internal reliability allowing researchers a method to elucidate the mechanisms that build to compassion fatigue and job change to provide recommendations for managing burnout and compassion fatigue within professional development. This provides researchers with scope to compare their studies with similar populations, thus as future populations of veterinary nurses normalise to a post-COVID-19 world, this tool can be used to measure the effects of compassion satisfaction, burnout, and compassion fatigue.

Conclusion

This study indicates that New Zealand's veterinary nurses are coping remarkably well with the challenges they are faced with during the COVID-19 pandemic. Moderate levels of compassion fatigue, burnout and compassion satisfaction have been found across the sample, which reflects levels measured in other populations prior to the pandemic. This may lend itself to the resiliency of veterinary nurses as a profession or the well-managed strategy to mitigate the effect of the COVID-19 pandemic in New Zealand. Even so, implementing resilience programmes as part of the compulsory continuing professional development requisite in New Zealand may aid in lowering the overall average scores of compassion fatigue and burnout within this population, and promote positive wellbeing that remains through stressful global events.

KEY POINTS

• Mental health challenges are expected to increase during times of heightened stress.
• New Zealand veterinary nurses coped remarkably well with the challenges of COVID-19.
• Moderate levels of compassion fatigue, burnout and compassion satisfaction were found.
• Levels across the three scores of the ProQOL measure were similar to prepandemic levels.
• Resilience programmes and mental health support for veterinary nurses may help support ongoing coping during a crisis.