Managing patients who have been involved in situations of domestic abuse or violence with compassion and empathy can be stressful, and a health professional’s own health can suffer because of compassion fatigue, burnout or vicarious traumatisation.1
Stress and burnout
A generic definition of stress is the physical, mental or emotional response to outside circumstances that are too overwhelming for our personal resources, a common scenario for health professionals when working with patients who have been involved in abuse or violence. Burnout has been defined as a syndrome of emotional exhaustion, depersonalisation, and a sense of lowered personal accomplishment that leads to a decreased effectiveness at work.2
Dealing with the effects of stress is important, not just for the health professional’s own health, but also so that they can maintain as objective a stance as possible to facilitate a successful outcome for the patient, and maintain good relationships with their own family, friends and community. Dealing with the effects of stress also enables the healthcare team to work together more effectively.
The trauma that many patients have been through constantly challenges the health professional’s individual limits and drains personal and professional resources.2,3 The health professional may feel personally frustrated, helpless and hopeless, which can lead to substance abuse, broken relationships and even suicide, and may also face professional stress leading to important professional consequences such as ‘lower patient satisfaction, impaired quality of care, even up to medical errors, potentially ending up in malpractice suits with substantial costs for caregivers and hospitals’.2
Health professionals can begin to address chronic stress by asking for assistance in dealing with any stressors outside of their work and working to enhance their personal and professional resources.
Vicarious traumatisation is a particular danger when an empathic health professional is dealing with people who are experiencing or have experienced abuse and violence. It involves the inner transformation of the carer’s view of themselves and their world as a result of listening to the patient’s stories and empathic engagement with their trauma.4
Vicarious traumatisation manifests as a spectrum of symptoms, including loss of appetite, fatigue, irritability, inattention, numbness, sleep disorders, fear, and despair. Frequently, these symptoms are accompanied by trauma responses and interpersonal conflicts. However, the symptoms often remain at subclinical level.5,6
Vicarious traumatisation can be similar in its symptomatology to post-traumatic stress disorder (PTSD) and can also resemble burnout in its symptoms and the effects it has on the personal and professional life of the health professional.7 Hypervigilance, nightmares, avoidance and fatigue can be combined with a lack of motivation, cynicism, sense of failure, lack of accomplishment and emptiness, leading to lower job satisfaction, increased job turnover, absenteeism and decreased quality of patient care.1
Burnout and vicarious trauma can also be associated with ‘self-medicating’ with substances, interpersonal conflict, disrupted relationships and a poor quality of life.
Compassion is a ‘sensitivity to suffering in self and others with a commitment to try to alleviate and prevent it’. It is an essential characteristic to successfully work with patients who have been victims of domestic abuse.8
It is important to maintain an environment where there is adequate protection from the ‘compassion fatigue’ that may come from actively listening to the stories of patients involved in abuse and violence. ‘Compassion fatigue is characterised by exhaustion, anger and irritability, negative coping behaviours including alcohol and drug abuse, reduced ability to feel sympathy and empathy, a diminished sense of enjoyment or satisfaction with work, increased absenteeism, and an impaired ability to make decisions and care for patients and/or clients.’9
Health professionals with compassion fatigue will have a depleted emotional reserve and have difficulty experiencing or expressing empathy and effectively responding to it. Along with emotional exhaustion and a lessened sense of accomplishment, such detachment is a symptom of burnout, and if not addressed, may also lead to vicarious trauma.10
Positive effects of working with these patients
Working to help patients and their families be safe and resilient can also lead to health professionals feeling energised, empowered and hopeful. It can align with their personal values and give a sense of purpose, which can further enhance the doctor–patient interaction and relationships with colleagues.11
‘Compassion satisfaction’ derives from an alignment of values and work, a feeling of self-respect and being able to do work effectively.11 ‘Vicarious post-traumatic growth’ and ‘vicarious resilience’ can occur when health professionals’ self-perception, interpersonal relationships and philosophy of life are positively affected by the resilience of their patients, usually in the setting of supportive social and organisational environment.12 Some of the professional and organisational factors that can contribute to this enhancement are ongoing training, clearly delineated practice policies, case management supervision, clear doctor–patient boundaries, and a developed network of resources and referrals.
Considerations for healthcare professionals of specific backgrounds
Health professionals who have a similar background to the community they serve are at a higher risk of burnout and vicarious trauma.7 This includes those of Aboriginal or refugee background, international medical graduates, and doctors who themselves have experienced child abuse or intimate partner abuse/violence (IPAV). Recent pandemics and environmental crises such as bushfires have also impacted health professionals and can add to the burden of traumatic events faced by many.6
GPs who work in rural areas are also at a higher risk of problems with stress, compassion fatigue, burnout and vicarious trauma.13 They are highly likely to find it difficult to access locums, peer support and ongoing training, usually have more after-hours work, are more isolated and find it more difficult to maintain clear boundaries between themselves and their patients.14,15
Many rural GPs are international medical graduates, who have the added burden of having to negotiate different cultures, ethnicities, language, religion, and rural and urban differences in Australia. They will also have to learn about the expectations Australian patients have of their doctor and about a new health system with its attendant bureaucracy. As well as the risk of ‘culture shock’, their anxiety, isolation and insecurity in the face of all these differences is likely to be much higher.16
Younger doctors and doctors in training are at higher risk of stress, depression, burnout and vicarious trauma; those with more training, familiarity with workplace expectations and increased years of service have a lower risk.11,12
Many health professionals themselves may have experienced abuse, or have family or friends in that situation: doctors and nurses have been found to have a rate of family and domestic violence that is at least as high as the rest of the population.17
On the one hand, personal experience of abuse or violence may make health professionals more understanding and willing to ask about it; on the other hand, such personal experience may cause them distress. Health professionals therefore need to be aware of how personal experiences may affect their own health and wellbeing and how to seek help to deal with what is happening in their own lives.17,18