Veterinary professionals are becoming increasingly concerned about compassion fatigue and burn-out. The incidence of burn-out is on the rise among veterinary professionals, and negatively affects personal and professional wellbeing, and the provision of care to patients. There is evidence that the emotional exhaustion component of burn-out correlates with physical and mental health (Lovell and Lee, 2013). Several studies have shown that emotional exhaustion and mental health illnesses are significantly higher among veterinary surgeons (VS) and registered veterinary nurses (RVNs), with the rate of suicide in the veterinary profession four times the rate of the general public (Halliwell and Hoskin, 2005; Bartram and Baldwin, 2008). In order to source timely help for mental wellbeing, it is helpful to establish what the causes of burn-out and compassion fatigue are to help understand them.
The veterinary environment can be inherently stressful and demanding, as veterinary professionals often deal with euthanasia and end-of-life care, economics, staff shortages, and even bullying in the workplace. Veterinary professionals are known to have perfectionist personality traits that can lead to working long hours, poor sleep patterns and as a consequence, lack of supportive relationships in the work and home environment (Crane et al, 2015; Armitage-Chan et al, 2016). Burn-out is a gradual process but it can sometimes feel unexpected or sudden should the person fail to recognise the signs and symptoms.
Veterinary professionals frequently encounter ethical dilemmas or situations where the course of action is not clear: situations involving euthanasia, end-of-life care, economics and inadequate health and welfare standards can create ethical dilemmas. These dilemmas often become difficult to manage when professional obligations conflict with the clients' and veterinary professional's own moral standards (Morgan, 2007). Because of this complex ethical structure and veterinary professional obligations, many VS and RVNs may consider moral distress an unavoidable part of veterinary practice (Moses et al, 2018).
Compassion stress is unavoidable stress experienced when helping patients in distress; the stress is expected and unavoidable in the veterinary field as it is derived from a sense of responsibility and desire to alleviate suffering. Compassion stress can sometimes be viewed as a ‘positive stressor’ as it catalyses productivity, potentially deepening the employee's personal growth and job satisfaction. However, without the correct understanding of compassion stress, as with any work-related stressor, mental health illnesses including burn-out and compassion fatigue can occur.
Burn-out, compassion fatigue and moral distress are terms that are recognised but not necessarily understood among veterinary professionals, and are often used inter-changeably (Table 1). Although it is difficult to identify a specific definition of compassion fatigue across the veterinary profession, in healthcare professions it can be described as the reduced capacity in being empathetic and the consequent behaviours and emotions resulting from knowing about a traumatising event experienced or suffered by a person (Scotney et al, 2015). Compassion fatigue is characterised by emotional and physical exhaustion leading to an inability to empathise or feel compassion for others (Cocker and Joss, 2016). In veterinary practice, veterinary professionals may have a reduced empathy for co-workers, which can lead to a reduced quality of medical care being delivered to patients.
Table 1. Definitions of conditions related to wellbeing in veterinary professionals
| Condition | Definition |
|---|---|
| Compassion stress | Compassion stress is unavoidable stress experience when helping others or pets in distress; the stress is expected and unavoidable in the veterinary field as it is derived from a sense of responsibility and desire to alleviate suffering |
| Compassion fatigue | Compassion fatigue is characterised by emotional and physical exhaustion leading to an inability to empathise or feel compassion for others; often after consistent exposure to compassion stress |
| Moral distress | Moral distress is an emotional state that arises where a person feels that their ethical principles are different from the external factors which they must undertake (such as company policies or procedures). This can include euthanasia stress, which is the concept of being phychologically challeged when faced with the task of euthanising animals |
| Compassion satisfaction | Compassion satisfaction is a degree of fulfillment, sense of purpose and satisfaction derived from working as a care provider. This state can involve positive feelings toward colleagues, contributions to the work environment, or gratification |
The term compassion fatigue is sometimes used inter-changeably with the term burn-out, but there are variations in their meaning. Burn-out is a state in which a person feels emotionally, physically and mentally exhausted because of work-related stressors (Hall et al, 2016). The Health and Safety Executive's (HSE's) formal definition of work-related stress is: ‘The adverse reaction people have to excessive pressures or other types of demand placed on them at work’ (HSE, 2020). Burn-out is a cumulative process associated with increased workload and work-related stress, but not necessarily trauma. Notably, compassion fatigue is usually secondary to burn-out if the person does not have the training, coping mechanism or support to identify and counteract these effects.
Physically, a person with burn-out may have changes in their sleeping pattern and will feel tired as simple tasks become exhausting. Burn-out can also change appetite habits and the person may feel sick more often than usual. Emotionally, burn-out can make a person feel increasingly negative, helpless, dissatisfied and therefore, demotivated and detached from others. Staff with burn-out may have attendance issues, difficulty concentrating and undertaking their usual responsibilities, and may be isolating themselves from others. As with many other mental health illnesses, it is common for those suffering with burn-out to turn to alcohol, drugs and self-medication as a coping mechanism.
Although a person with compassion fatigue has similar physical symptoms to burn-out, such as sleep withdrawal, hypervigilance and resultant self-medication, the emotional symptoms are slightly different in that compassion fatigue is a complete inability to empathise. This lack of empathy can be both with their patients, owners, co-workers and even family members and friends. Factors that may place someone at an increased risk for experiencing compassion fatigue include high empathy, low emotional resilience, a history of traumatic experience, and the existence of unresolved trauma. However, any veterinary professional can experience compassion fatigue; the severity of compassion fatigue can be increased by the duration of the experience, the potential for recurrence, exposure to death and euthanasia, and the presence of moral dilemmas.
The practice of veterinary medicine has a complex ethical structure that consists of professional obligations to the patient, the owner, other veterinary professionals and society (Royal College of Veterinary Surgeons, 2020). Ethical dilemmas occur when these obligations conflict with one another, with the veterinary professional's own moral standards, or both. These conflicts are ethical in nature and can cause moral distress, an emotional state that arises from a situation where a person feels that the ethically correct action to take is different from the policies or procedures which they must undertake. Moral distress can happen in any profession, however, a common example in the veterinary industry is euthanasia (Manette, 2004). Euthanasia against one's own morals is regarded as one of the most significant contributors to the development of compassion fatigue (Newsome et al, 2019). A study by Moses et al (2018), showed that not being able to do what they believed to be the correct option for a patient caused them moderate to severe stress, and respondents said their empathy for their patients and their owners had waned over time showing a direct link between moral distress and compassion fatigue. Dow et al's (2019) study showed that veterinarians were experiencing mild to severe psychological distress and compassion fatigue; a significant proportion of these veterinarians felt that their mental health was affected by dealing with clients grieving the loss of a companion animal.
Promoting veterinary professionals' wellbeing
Veterinary professionals who neglect their physical, emotional and physiological needs often find themselves suffering with burn-out, compassion fatigue and moral distress; it has been estimated that 67% of veterinarians are at high risk of burn-out (Brannick et al, 2015). In Dow et al's (2019) study, no participants reported seeking professional mental health support despite suffering with the symptoms of burn-out and compassion fatigue. Many veterinary professionals consider moral distress and compassion fatigue an unavoidable part of veterinary practice; it is essential that employers actively encourage staff wellbeing (Moses et al, 2018). Strategies for reducing the incidence of burn-out and compassion fatigue can include encouraging meaning-ful breaks from practice, such as holidays without email or phone access to the veterinary practice, regular exercise, colleague support meetings and opportunities for mindfulness and meditation. There are a number of mental health support materials, samaritans and charities available for veterinary professionals including the Vetlife organisation and the Mind Matters Initiative (see Support Links below).
As well as providing methods to cope with stress, efforts should also be made to reduce stress to its lowest possible levels. Coetzee and Laschinger (2018) explored the use of a compassion fatigue model among human nurses. Interestingly, the study showed that it is not the natural empathy that nurses have that puts them at risk of developing compassion fatigue, but rather a lack of resources, inadequate positive feedback, and the nurse's response to personal distress. By addressing these three aspects, the risk of developing compassion fatigue could be reduced, improving the retention of compassionate and committed veterinary professionals (Endenburg and Johnston, 2019). Monaghan et al (2020) concluded that job demands for people caring for animals are an important risk factor for compassion fatigue. Reducing and equally distributing job demands among the veterinary team may be an effective intervention for employers seeking to promote staff wellbeing.
Furthermore, it has been clearly established that the decision of and the action of euthanising animals is stressful for veterinary professionals (Manette, 2004). As euthanasia against one's own morals is regarded as a significant factor to developing compassion fatigue, a carefully developed euthanasia policy can remove the need for veterinary professionals to engage in a stressful and divisive decision-making process. Although euthanasia serves as a method to end suffering in animals, the decision, inevitably, is difficult and highly bonded owners require support from veterinary professionals during this time. Both the owner and veterinarian have the ability to refuse euthanasia, which may lead to the veterinarian feeling guilty and responsible for the patient's suffering. Owners wishing to continue treatment despite poor animal welfare has also been shown to contribute to burn-out and compassion fatigue (Batchelor and McKeegan, 2012).
There are a number of tools that can encourage communication and agreement between owners and veterinarians, reducing the incidence of moral dilemmas. These tools include, but are not limited to: an ethical decision-making framework; a good communication system; quality of life (QoL) assessments; and consent tools. Two valuable frameworks are provided by Morgan (2005) and van Herten (2015), these frameworks focus on holistic patient care and active communication between owners and veterinary professionals. Training veterinary professionals in effective communication will assist them in providing the support required to make ethical decisions, understand ethical frameworks and reduce feelings of guilt. QoL assessments can be used during the patient's end-of-life period to help owners appreciate the severity of the health problems their animals are experiencing; QoL tools such as the HHHHHMM scale can be used to track the progression of the patient's condition and help the veterinarian and owner agree on a point where euthanasia should occur (Table 2). As there is a direct link between moral distress and compassion fatigue, these frameworks can encourage healthy veterinary–client relationships, and reduce the guilt and stress associated with end-of-life care and euthanasia.
Table 2. HHHHHMM quality of life scale
| Quality of life scale: The HHHHHMM Scale. Adapted from: Villalobos (2011) | |
|---|---|
| Criterion | Score (1 – 10, 10 being the highest quality of life) |
| Hurt: Adequate pain control, including breathing ability, is first and foremost on the scale. Is the pet's pain successfully managed? Is oxygen necessary? | |
| Hunger: Is the pet eating enough? Does hand feeding help? Does the patient require a feeding tube? | |
| Hydration: Is the patient dehydrated? For patients not drinking enough, use subcutaneous fluids once or twice daily to supplement fluid intake. | |
| Hygiene: The patient should be brushed and cleaned, particularly after elimination. Avoid pressure sores and keep all wounds clean. | |
| Happiness: Does the pet express joy and interest? Is the pet responsive to things around him or her (family, toys, etc.)? Is the pet depressed, lonely, anxious, bored or afraid? Can the pet's bed be close to the family activities and not be isolated? | |
| Mobility: Can the patient get up without assistance? Does the pet need human or mechanical help (e.g. a cart)? Does the pet feel like going for a walk? Is the pet having seizures or stumbling? (Some caregivers feel euthanasia is preferable to amputation, yet an animal that has limited mobility but is still alert and responsive can have a good quality of life as long as caregivers are committed to helping the pet.) | |
| More good days than bad: When bad days outnumber good days, quality of life might be compromised. When a healthy human–animal bond is no longer possible, the caregiver must be made aware the end is near. The decision needs to be made if the pet is suffering. If death comes peacefully and painlessly, that is okay. | |
| *A total over 35 points represents acceptable life quality | |
Conclusion
The veterinary environment can be inherently stressful and demanding, and veterinary professionals often deal with moral dilemmas, euthanasia and end-of-life care. The incidence of burn-out and compassion fatigue is becoming increasingly relevant among veterinary professionals as are the negative effects they can have on personal and professional wellbeing. Promoting veterinary wellbeing by reducing work-load, encouraging mental health initiatives, and implementing frameworks to reduce moral dilemmas and aid the euthanasia process, will ensure retention of compassionate and committed veterinary professionals.
KEY POINTS
- Mental wellbeing has become a prevalent and necessary part of the veterinary industry as veterinary professionals are exposed to a number of work-related stressors.
- Veterinary professionals should be aware of the signs of compassion fatigue and burn-out in order to find timely help for such conditions.
- Veterinary professionals are exposed to complex ethical dilemmas; ethical decision-making frameworks, a good communication system, quality of life assessments and consent tools can all assist in reducing the incidence of moral distress.