Gary has been a military occupational therapist for seven years. He has many duties beyond what civilian OTs typically absorb. He has always been enthusiastic about his work and cause, eager to be the man “on call.” Yet the last several months have been difficult for Gary. He has been out in the field, setting fractures, treating amputees, and trying to stay well. Getting in his vehicle everyday is overwhelming; he recalls the discussions with his wife regarding his absence and contemplates what awaits him. Headaches interrupt his entire day. His caseload for the week is high, emotionally draining, and constraining. In his thoughts, Gary excessively identifies with his patients, and he finds himself saying, “It could have been me.” He used to perceive his skills as effective, but now he wonders.

Cindy is a five–year, veteran OT working in a high–demand, acute care setting. She was once eager to get to work, devoting extra time to her employer and setting a high standard for the care she provided. However, the last two years have been disheartening. She feels that several physicians don’t understand her role on the team or respect her clinical recommendations. Colleagues constantly rearrange her treatment plans without consult, patients are unappreciative, and insurance companies undermine her efforts. She wonders why she ever became an OT. Since she is emotionally and physically exhausted when she arrives home, it’s not surprising that she feels she has no energy to give to her family.

Gary and Cindy are not alone. Many OTs and assistants, internationally across all practice areas, experience compassion fatigue and burnout.¹ Healthcare personnel are all at risk for such conditions because constant engagement with pathology tests OTs’ personal constructs every day. The intricate principles of burnout and compassion fatigue have similarities, and depending upon the discipline examining them, one can be the precursor to the other.^2–4

Compassion Fatigue and Burnout

We display empathy when we care for our patients. Empathy is defined as understanding another individual’s circumstances, emotions, or goals. The ability to empathize with our patients is a critical skill. Patients know that we assimilate their information and derive potential solutions to apply to their diagnostic situation. This ability to understand, assimilate, and yet keep often–disturbing information separate from our core being is a skill that therapists develop.³ However, when a practitioner is weakened or has gained or learned poor coping strategies personally or professionally, protection against the distressing information can collapse. The practitioner then enters the patients’ world, empathizing with them to the point that he or she has now taken on their complex emotional state.^2–4 A sense of powerlessness seeps in, undermining the therapist’s sense of competence. In addition, the practitioner may also experience the effects of the healthcare work environment itself — high demands, low staffing, lack of supervision or excessive supervision, and blurred authority.^3–6 At this juncture, the practitioner can be stressed by both over–identification with the patient and the environmental challenges of the workplace, creating compassion fatigue, the stress of caring too much.

Burnout is a triad condition of psychological, physical, and cognitive depletion.⁷ Key contributors to burnout include conflicting professional boundaries and externally derived stress factors that conflict with the inner values of the therapist, his or her work ethic, and perceived role definition — both as a multidisciplinary team member and as an individual.^5–7 Likewise, personal goals and skills that do not match the organization or the practice environment can contribute to a state of burnout.^3,5–7 All of the latter factors, not necessarily exclusive, act upon the practitioner to create a sense of utter emotive collapse. Burnout does not develop over a short period of time; rather, it develops cumulatively with repeated exposure to what may appear to the practitioner as unrealistic or unattainable demands of an environment.^4,5,7 Adding patient care and complexities to these environmental difficulties, it is no wonder that compassion fatigue and burnout are sometimes difficult to distinguish and define, and they are often antecedents to one another.^2,4,8,9 Both conditions and their root causes lie within a complex web of environmental factors and have consequences.⁹

A Unique Factor: The Ambiguity of Occupational Therapy

A majority of OTs and assistants are passionate about the underlying theories and definition of occupational therapy. Most therapists know that it is essential to articulate our purpose in the multidisciplinary team so that we’re fulfilling our role within our given environment. To most therapists this makes perfect sense. Yet, the field of occupational therapy continues to struggle with distilling what we do to a crisp soundbite.^6,9 This struggle is not unique to the U.S. but rather an international difficulty.^6,9 When we are unable to effectively define what we do in all settings to all patients, physicians, reimbursers, and other professionals, our role in healthcare can begin to feel ambiguous or unimportant.

When OTs feel unsure of their role and their unique contribution to a team, they can become frustrated, feel undervalued, and experience a loss of professional identity. Having an identity is important in both individuals and professionals. This can result in turnover and weak role delineations^1,6,9 and ultimately contribute to compassion fatigue and burnout in retained staff.

Consequences

The consequences of compassion fatigue and burnout are far reaching for OTs and others in caring professions. Physicians, nurses, psychological counselors, and teachers are also vulnerable to these difficulties. The consequences seem to have a domino effect, involving practitioners, patients, organizations, and the healthcare system in general.

Compassion fatigue and burnout can affect practitioners either positively or negatively. A positive effect can occur if the practitioners are able to use disturbing information from their patients as a growth experience, one that can be assimilated and used as a catalyst for professional and personal development.^8,10 Positive psychologists study how people in adverse or negative situations overcome those situations by focusing on the positive. One positive psychology researcher suggests that the bond between therapist and client allows the clinician to process client trauma positively.⁸ The researcher refers to the bond as empathy for the client experienced by the therapist and notes that psychological therapists who have a solid personality see more positive than negative changes in their thinking after working with distressed clients than negative changes.⁸ The researcher also points out that factors that influence the positive or negative absorption of traumatic material from clients include number of work responsibilities, the therapist’s own experiences with traumatic events, and amount of clinical supervision.⁸

Conversely, the negative effects on the practitioner can include apathy, anger, feeling ineffective, fear, worry, and family difficulties.^1,2,4,5,7 Left to their own course, these emotions create a situation for the practitioner that mimics depressive qualities, if these are independent of a depression diagnosis.^2,4,5 Nonetheless, depression can also be a consequence.^2,7 The practitioner’s worth can become dismantled.¹⁰ A state of fatigue and burnout can trigger a sympathetic response to flee, battle, or withdrawal.⁴ Researchers in Sweden have also identified what they call a “stress of conscience,” describing what some practitioners are almost always forced to contend with while working in a healthcare system — lack of time to treat patients, having to change one’s scruples, and attempts to balance work demands with family life.¹ Clinicians set out in their careers to accomplish ethical objectives at a great personal expense, and they experience the effects of a system that they may have been unprepared to encounter. For example, treatments may be cut due to insurers, organizational pressure may require practitioners to treat more patients in less time with fewer resources, and longer hours may allow little time for family. The latter characteristics are responsible for contributing to burnout and emotional frustration or dismantling.

Patients are also affected by compassion fatigue and burnout. Loss of ingenuity, inability to concentrate, and loss of empathy hinder the practitioner’s effectiveness. And, unfortunately, it can sometimes be the most enthusiastic, dedicated, and knowledgeable practitioners who are affected.^4,5 Their once optimistic state as eager new practitioners can evolve into one of doubt and pessimism.⁴ The strain of the system in which the clinician practices intrudes into the therapy session. The patients become aware of it. When practitioners can no longer reliably sort patients’ emotions from their own, the level of care for the patient can be diminished.10 The organization in turn becomes adulterated by the loss or reduced functioning of a valued team member who once provided exceptional care.

Staff shortages occur in just about every healthcare discipline. Many facilities try to combat shortages by mandating weekend work and requiring staff to take on extra responsibilities that may be beyond their roles. Budgets are sometimes small, especially for OTs, which gives practitioners limited resources to fulfill clinical and professional responsibilities. Despite these obstacles, many therapists adapt well to high caseloads, little continuing education opportunities, and less–than–adequate support from administrators and colleagues. However, after repeated expectations to do more with less, some therapists falter.^1,6,9,10 Some burnt–out practitioners flee to non–clinical roles, trying to escape from something they feel will never change, or they leave the field completely.^6,11 Ironically, the cost to the organization is losing therapists even as the goal of organizations is to retain them in the face of a growing demand.

Therapeutic Work Environments for Therapists

Organizations need to be aware of how to create environments that reduce compassion fatigue and burnout while still achieving organizational goals, such as staff retention. Better environments can be achieved by reorganizing staff, carefully assessing caseloads, and regularly assessing therapist during the year. Organizations can add time to the clinicians’ workdays for research, professional development, or other appropriate ways to positively channel work related feelings. In reality, most clinicians would benefit from a simple, solid lunch hour. Indeed, what clinicians want — to be thorough, precise, and effective — is the same as organizations’ goals. It benefits the organization to create an environment for success for the clinician, just as we try to do with patients. This creates a win–win situation for everyone.

OTs and assistants are providers who consider the impact of environment in their patient care. The therapeutic work environment in which each therapist functions shouldn’t be much different than that contrived for patients. The fast pace of the workplace, the high census of patients, competencies, and demands of administration or insurance companies all play key roles in the therapist’s functioning. Research has suggested specific environmental modifications to avoid compassion fatigue and burnout,^9–12 but the general theme that all practitioners can agree upon is the promotion of a healthy work environment. Recent literature delineates the basics for a healthy work environment that encompasses OT practice, such as matching therapist skills with the patients they treat, regardless of staff ratios; frequently collaborating with team members; giving credit where credit is due to establish and maintain therapist self–worth and efficacy; and promoting positive supervision through panels for discussion where the therapist is not threatened.^{1,7,9,10,11,13} These healthy environmental changes counter difficult situations and help therapists with their daily encounters with patients.

When practitioners are treated for their own difficulties within healthcare environments outside of their practice settings, they see the impact of stressors. However, it is often not so obvious to practitioners immersed solely within their own practice setting. To heal themselves of compassion fatigue and burnout, practitioners must stop and take a mental, physical, and spiritual self–inventory.^3,4 Clinicians can do this in several ways, such as speaking to a counselor, reassessing career goals, altering work hours, and modifying habits in their daily routine. By critically examining their own work environments, therapists can determine if the same issues are always present and never resolved, even with remediation. The cumulative effect of many years of the same difficulties without resolution can set the stage for compassion fatigue and burnout.

Putting Some New Tools in Your Own (OT) Tool Kit

How many times has a healthcare practitioner given advice to a patient only to do the direct opposite in his or her own life? For instance, you notice the provider who is treating you has an unhealthy diet or that the therapist who teaches muscle health has never exercised a day in his or her life. It is true that OTs may not always follow our own best medicine. But as OTs, we are holistic practitioners who stress to our patients the importance of a balanced mind, body, and spirit. The OT framework embodies these concepts.¹⁴ This same philosophy can mend and restore health to distressed practitioners.

First, find balance by critically looking at where you are spending your time. Are too many hours of the day spent in work and too little time with your family and friends? Decide to spend more time in the company of those you care about and who care about you. Other obligations will wait until the next day. Family participation and support is essential to having a sense of connectedness and a foundation for personal and professional growth. Family time can become short and devoid of quality, which is a recipe for disconnection. Those with compassion fatigue and burnout are lacking or have grown away from family connections.⁴

Second, analyze the things that are done well, and as one researcher points out, practice the possible.⁴ Take initiative to implement supports that are not existent in the workplace, such as starting a lunch–hour article review group (no patients should be scheduled during the review) or discussing a difficult patient and brainstorming treatment strategies with a team member on a regularly scheduled basis, such as once per month. The U.S. Army Institute of Surgical Research has created a program for compassion fatigue called Care for the Caregivers. Stress management and awareness are the program’s central themes.¹⁵

Third, take a look at coping strategies that you employ and why they’re not working. Do you tend to withdraw? Use humor? Find fault with things? Get anxious or upset? Coping strategies can be either positive or negative, but they are learned. One option is to seek counsel from an employer–sponsored assistance program to identify more adaptive coping mechanisms. If necessary, reassess your career goals and objectives.^5,7

Fourth, become physically engaged in healthy activity. Healthcare personnel often have poor diets due to time constraints in a typical work day. Take a lunch break, and eat healthy items like fruits and vegetables. Resist that fast–food lunch. You get out of your body what you put into it. A body that is already lacking energy will lack more of it with a poor diet. Choose an exercise program appropriate for your needs. Do you need more energy? Try aerobics to build cardiovascular endurance.  Do you need to get rid of excess energy? Try yoga or Tai Chi. Additionally, in collaboration with your provider, resolve or treat health difficulties that may be exacerbated by high stress. Many practitioners are so busy they don’t take the time to take care of themselves. In essence, schedule some physical activity time each week, and stick with that time for overall physical health.

Fifth, reconnect with the spirit. Spirituality comes in many forms. Many people find their way back to their faith center in the questionable times in their lives, as seen with patients each day. Spirituality helps to restore peace within, to aide in balancing the good and bad that we experience, and to return to rediscovering our purpose in the world and in our profession. Those who experience compassion fatigue and burnout need this renewal of faith, and motivation to seek the positive both in their patients and themselves.

Finally, return to the reason that OT was an important career choice.

Online Information

The Internet is an easily accessible tool to learn about compassion fatigue and burnout and associated coping or prevention strategies. When conditions are identified early, other health difficulties can be prevented.⁷ As with other health difficulties, prevention is the key. Many different Web sites are helpful in self–assessment, after which the appropriate professional assistance should be sought or career goals reanalyzed.

Compassion fatigue self-test:¹⁶ http://www.compassionfatigue.org/pages/CompassionFatigueSelfTest.html

Burnout self-test:¹⁷
http://www.mindtools.com/stress/Brn/BurnoutSelfTest.htm

Postive Psychology Center:¹⁸
http://www.ppc.sas.upenn.edu/

National Board Certification for Occupational Therapy:¹⁹
http://www.nbcot.org/webarticles/articlefiles/2005_otr_self-assess_resource_tool.pdf

AOTA Members:²⁰
http://www.aota.org/Practitioners/ProfDev/PDT.aspx