“I get of tired explaining the ‘whats and whys’, ‘dos and don’ts’ of diabetes to my patients.”
“My patients don’t listen. I am worn out by having to ask my patients to modify their lifestyle, take their medication, and engage with self-care.”
“If this keeps up, I’ll end up with diabetes and hypertension trying to control their sugars and blood pressure!”
Professional hazards in diabetes care
Such refrains can be common in informal conversations between diabetes care professionals. Irrespective of their specialty and type or place of work, diabetes care professionals complain of work-related stress, including mental and emotional exhaustion. This stress is one of several professional hazards that a diabetes caregiver must face [1]. As Charles Figley succinctly puts it, “There is a cost to caring for those with chronic illness.” In this case, the cost is termed compassion fatigue [2].
The difference between compassion fatigue and burnout
Compassion fatigue is a type of secondary traumatic stress disorder, which itself was defined by Figley as a state of tension and preoccupation with the traumatized patients by re-experiencing the traumatic events, avoidance/numbing of reminders persistent arousal (eg, anxiety) associated with the patient [2,3]. Simply put, compassion fatigue is the traumatization of caregivers through their efforts to help others [4].
Closely related to compassion fatigue is the concept of burnout [4]. Burnout is defined as “a state of physical, emotional and mental exhaustion caused by long-term involvement in emotionally demanding situations” [5]. As a term, burnout conveys a sense of irreparability or failure, while fatigue seems temporary. In the healthcare environment, burnout seems to be related to environmental stressors, while compassion fatigue is linked to interpersonal relationships [6]. Keeping these facts in mind, the term compassion fatigue will be used henceforth.
Etiology
Excessive demands
For diabetes care professionals, compassion fatigue is the result of unmanageable demands on energy and compassion while providing care to individuals living with diabetes. Compassion is needed throughout the care of people with diabetes, but especially so at times of diagnosis (more so with type 1 diabetes), when complications arise, and in situations where suggested diagnostic or therapeutic interventions may cause significant changes in lifestyle.
Compassion fatigue can be related to heavy patient loads. The diabetes care professional may be willing to have an empathic conversation with a particular patient, but may not have the time to do so because of other professional commitments. Efforts by the patient to clarify doubts or concerns are always time-consuming. Prolonged conversations with multiple patients, on a busy clinic day, may lead to a sense of fatigue on the part of the diabetes care professional.
Professional challenges
While it is assumed that compassion is a basic human quality, this is not always so. The diabetes care professional may feel overwhelmed by what they perceive as unreasonably demanding patients. Patients who refuse to get, or resist getting, appropriate investigations, do not agree to suggested lifestyle modification, and do not adhere to prescribed therapy, especially injectable therapy, create a sense of frustration and fatigue in the diabetes care provider.
The sense of fatigue may be accompanied by subclinical fear, as the diabetes care professional is trained to anticipate potential complications that could occur if appropriate therapy is not followed. This phenomenon may become more frequent as the profession tries to balance the complexity of providing complete biomedical care for a multifaceted syndrome with the diverse demands of patient-centered care philosophy. Such a balance is made more challenging by concerns related to accusations of medical negligence and possible litigation.
Clinical features
Psychological symptoms
Compassion fatigue can present with symptoms similar to normative stress reactions [7, 8]. However, the complaints are usually of greater severity and are more persistent. In diabetes clinics, healthcare professionals may find it difficult to separate their personal life from the professional domain. Affected personnel complain of feeling depressed and tired, and try to avoid handling patients. Even when at work, professionals who are compassion fatigued avoid raising health-related topics with their patients where there is a chance of resistance or cross questioning. Behavior which is fatigue-sparing, such as the avoidance of discussion on insulin initiation or intensification, can directly contribute to clinical inertia in diabetes care.
Physical symptoms
While compassion fatigue is defined as an emotional response, it also may lead to physical, mental, and social dysfunction. An affected individual may report that they tire easily, feel more irritable, and/or have a shorter temper. These attributes can impair a caregiver’s ability to perform optimally in both the professional and personal domains.
Without adequate management, compassion fatigue may result in complications. At the individual level, compassion fatigue may progress into an adjustment disorder or major depressive disorder. From an institutional point of view, a fatigued worker is prone to undesirable professional judgments, such as misdiagnosis, poor treatment planning, or abuse of clients [9]. Such a worker may progress to burnout, and this may in turn lead to employee attrition. There is also a cultural dimension to compassion fatigue, with certain cultures being more resilient to the condition [10].
Diagnosis
The diagnosis of compassion fatigue is done using validated psychometric instruments. The most popular diagnostic tool is the Professional Quality of Life Scale, developed by Stamm [11]. This 30-item questionnaire measures compassion fatigue, burnout, and secondary traumatic stress. Other screening tools include the Secondary Traumatic Stress Scale [12], the Impact of Event Scale [13] and the Impact of Event Scale-Revised [14], the Trauma and Attachment Belief Scale [15], and the World Assumptions Scale [16].
While these instruments are useful for screening compassion fatigue, they do not replace the need for diagnosis by a qualified healthcare professional. More often than not, compassion fatigue is suspected by colleagues at the workplace, who observe subtle changes in attitude and behavior toward patients. A diagnosis can be confirmed by taking a detailed history and assessment of the work environment [17].
Management
Timely diagnosis
The management of compassion fatigue is multifaceted (Fig. 1), but the first and most important step is timely diagnosis. This can be facilitated by sharing information with diabetes care professionals about the hazards of compassion fatigue, its precipitating factors, symptoms, and complications, and by providing a means to prevent and manage it.
Fig. 1 Management of compassion fatigue in clinical settings
Therapeutic patient education
Providing information on compassion fatigue to affected individuals can have a therapeutic effect, similar to the positive impact of therapeutic patient education, as seen in diabetes and other chronic diseases. Therapeutic patient education ensures timely diagnosis of compassion fatigue, and allows the affected professional (and their work system) to institute corrective measures. These measures can include reducing clinical workload, ensuring equitable workload distribution, creating stress-reducing breaks during busy clinic hours, taking help from colleagues to handle difficult patients, and utilizing referral systems for psychosocially refractory patients.
Coping skills enhancement
A professional’s capacity to handle compassion load can be enhanced through stress management training, coping skills training, meditation, physical toning, and yoga. In severe cases, assistance from qualified mental health professionals may be needed to limit and manage the effects of compassion fatigue.
Patient sensitization
It can be worthwhile to sensitize patients about the existence of compassion fatigue in diabetes care professionals, empowering them to improve the quality of their interaction with their care providers. This may reduce the compassion burden on diabetes care providers and allow them to experience greater professional satisfaction.
Summary
Compassion fatigue is a professional hazard for diabetes care professionals. However, it is not an inevitable or universal occurrence. Awareness and education about compassion fatigue can help to limit its incidence and severity. Having non-fatigued, healthy diabetes care professionals will benefit individuals living with diabetes in the long run, who will gain from the interaction with compassionate and happy care providers.