Journal Watch: Compassion Fatigue

Reviewed This Month

Secondary Traumatic Stress in Emergency Services Systems (STRESS) Project: Quantifying and Predicting Compassion Fatigue in Emergency Medical Services Personnel

Authors: Renkiewicz GK, Hubble MW

Published in: Prehospital Emergency Care, 2021

This month we discuss a study that looks at the mental stress EMS professionals endure. It is no surprise patient care providers are at risk for developing secondary traumatic stress syndrome (STSS). The authors of this study explain that STSS can occur when providers experience emotional distress after exposure to the firsthand traumatic events suffered by others, such as their patients. STSS can mimic symptoms of post-traumatic stress injuries. It can be acute or chronic and debilitating, even leading to suicidality. 

Compassion fatigue (CF) is a secondary traumatic stress syndrome defined as a “sudden or gradual loss of compassion resulting from exposure to stress or stressful events.” In other words it is a process by which compassion and empathy felt by caregivers for their patients can erode into a lack of compassion due to continuous exposure to traumatic situations. 

In addition to the difficulties experienced by care providers, CF can be compounded by childhood trauma, demographics, and socioeconomic factors. The authors highlight a few examples of how CF might manifest, including providers delaying or refusing to care for patients (including children) and taking selfies with deceased patients. There are obviously more examples. We’ve all heard about them and cringed, but while unethical, these actions can be due to symptoms of CF. 

Study Parameters

Compassion fatigue has not been well studied in EMS. This month’s study was part of the larger Secondary Trauma Response in Emergency Services Systems (STRESS) project. The aim of this part was to identify the prevalence and predictors of CF among EMS professionals. 

The study used a cross-sectional survey. Data were collected from March to July 2019. There were 12 agencies throughout North Carolina selected for participation. These agencies were chosen to maximize geographic diversity and included rural, suburban, and urban areas. 

Once the agencies were selected and agreed to participate, individual EMS professionals were recruited in person at monthly training sessions. Participation was optional, and no incentives were provided. The study only included third-service EMS professionals. 

Once consent forms were signed, each participant was provided an anonymized 108-item paper survey. While that may seem long, the authors noted it only took roughly 15–20 minutes to complete. The survey included 21 questions regarding sociodemographic and occupational factors, as well as 8 questions on military history and experience. The authors also included validated scales to meet their study objective, including the 10-question Adverse Childhood Experiences questionnaire, the 17-question Life Events Checklist for DSM-5, the 30-question Professional Quality of Life Scale, and the 22-question Impact of Events Scale-Revised. 

Because this survey included sensitive questions, the authors took the wise step of providing a resource page that included not only information about how to find a local counselor but also contact information for a 30-year paramedic who was a licensed counseling associate and could provide profession-specific counseling. 

Results

A total of 686 individuals participated in the CF portion of the survey. Overall, 48% were identified as likely having CF. The percentages of males (51%) and females (49%) with CF were similar. There were 86% of the study population categorized as Caucasian, 6% African American, 2% American Indian or Alaskan Native, and 1% Asian American or Pacific Islander. Five percent were of 2 or more races, and 1% were categorized as other. The study did not report data on ethnicity. 

In the study population the prevalence of CF was significantly higher for those who were African American or identified as 2 or more races. Paramedics had a prevalence of CF. Years of experience was also significant, with a 20%–40% increase in CF between years 6–20. Full-time EMS employment was also significant, and those with CF had, on average, shifts that were 1.2 hours longer compared to those who did not have CF. However, there was no difference between the groups regarding the resources available to EMS personnel when a critical incident was experienced. 

Childhood trauma was also more prevalent among EMS professionals with CF. Those with CF had an average score on the Adverse Childhood Experiences questionnaire that was nearly a full point higher than those without CF. 

Multivariable logistic regression adjusted for gender, race, credential level, employment-related factors, field experience, and previous history of childhood trauma. After adjustment only African American race (aOR 3.10, 95% CI 1.32–7.29) and the employment-related factors of vicarious trauma (aOR 4.61, 95% CI 3.13–6.79) and burnout (aOR 3.35, 95% CI 2.27–4.95) remained significantly associated with CF. The experience of a coworker suicide was borderline significant (aOR 1.48, 95% CI 1.00–2.19). 

Limitations to this study included only using data from one state. It is also likely that those who chose to participate were somehow different from those who chose not to participate. Nevertheless, this was an important study that found nearly half of respondents could be categorized as having CF. There were important findings related to African American race, and the authors noted this may be due to more than just working in EMS, such as racism-related stress. This is an important finding that describes a clear disparity and should be studied further. 

I congratulate the authors on publishing this important work. It is important that our research focuses not just on the health and safety of our patients but also on taking care of ourselves. I hope you have an opportunity to read this manuscript in its entirety; it also contains important findings related to the severity of CF in this population.  

Antonio R. Fernandez, PhD, NRP, FAHA, is a research scientist at ESO and serves on the board of advisors of the Prehospital Care Research Forum at UCLA.