Burnout, Compassion Fatigue, Moral Injury

As a physical therapist who is married to a physician, and a person with friends in different health care professions, I hear a LOT of opinions about the current climate in health care. People are feeling stretched thin and sad about the ways that insurance dictates which treatments are available, the way that everyone’s schedules are overflowing, the way that no patient seems to be able to get what they actually need to be well. People feel jaded, frustrated, and like there is no way to change such a broken system. People are feeling that they really care about their patients….until they have to stop caring in order to save their own sanity. They also feel completely unsupported by the system of health care, and, post-pandemic, by society at large, who is happy to take medical advice during an emergency but is often not happy to take medical advice in a preventative situation.

In all of these conversations, I hear a lot of different words used to describe this complex and helpless feeling. People use the terms burnout, compassion fatigue, and moral injury most often. Sometimes conversations even escalate to argument over which word best describes the utter despair of many clinicians. It might sound dramatic, but I really believe that providers feel jaded and hopeless about the current medical climate in the United States. I want to define and compare/contrast these terms today, partly for my own benefit (because I’m not exactly sure about the specifics of each term, and where their overlap lies), and partly because the first step in making effective change is naming the problem.

According to WebMD (everyone’s favorite source of medical info, right?) burnout is “a form of exhaustion caused by constantly feeling swamped. It’s a result of excessive and prolonged emotional, physical, and mental stress. In many cases, burnout is related to one’s job. Burnout happens when you’re overwhelmed, emotionally drained, and unable to keep up with life’s incessant demands.” I think this describes many health care workers. I have written about burnout in previous posts, and it seems that burnout is both a systems issue and a personal issue. High burnout correlates with low self-compassion, and it often stems from people beating themselves up about not being able to provide a superhuman solution to a massive problem. There is also a lot of research that suggests that burnout cannot be addressed by self care. Systems or employers need to take stock of their employees’ wellbeing, and then, instead of giving everyone “wear jeans on Fridays”, actually make changes like hiring enough staff, decreasing demands on current staff members, and decreasing staff shaming behaviors.

Again according to WebMD, compassion fatigue is “a term that describes the physical, emotional, and psychological impact of helping others – often through experiences of stress or trauma. Compassion fatigue is often mistaken for burnout, which is a cumulative sense of fatigue or dissatisfaction.” It seems like compassion fatigue is a more specific term than burnout, and it is sometimes referred to as secondary stress reaction or vicarious trauma. Bearing witness to the hardest parts of life – sickness, distress, death, and pain - does not come without a cost to the witnesses. In order to protect against compassion fatigue, t would be beneficial in medical and psychological training programs to help students differentiate between the two types of empathy: cognitive empathy and affective empathy. Cognitive empathy is the ability to recognize and understand another person’s emotions (perspective taking). Affective empathy is one’s own emotional attunement with another person’s experience (experience sharing). Brene Brown has written that her research indicates that affective empathy is a slippery slope to compassion fatigue and overwhelm. An open acknowledgement that caregiving and health care professions can be emotionally taxing, along with providing employer based support to health care workers, would go a long way in mitigating compassion fatigue.

According to The Schwartz Center, moral injury occurs when “someone engages in, fails to prevent, or witnesses acts that conflict with their values or beliefs. Moral injury usually involves experiences that contradict an individual’s personal or shared values or expectations, such as having to make decisions that affect the survival of others, having to make decisions where all options will lead to a negative outcome, engaging in an act of wrongdoing, failing to prevent serious unethical behavior, witnessing or learning about such an act, or betrayal by trusted others”. It’s important to note that moral injury is considered to be a component of PTSD. There has been much discussion of moral injury in conjunction with the pandemic, particularly concerning resource triaging when patient overload overwhelms the capacity of medical facilities,

Pre-pandemic, health care workers were already moving toward burnout and compassion fatigue. Setting unrealistic expectations for what a normal human can accomplish in one day while failing to note that, any time you’re dealing with sick people, nothing goes quite according to schedule, is a recipe for burnout. This business optimization strategy of health systems also fails to recognize that caring for people who are suffering takes an emotional toll. In talking to students and colleagues, it seems like most of us recognize that patient care requires a component of emotional labor, but that we feel unprepared after graduating to juggle the emotional load AND the production load. This leads to compassion fatigue because, not only do we have to attend to our patients' emotional needs, but because we feel let down by the system that thwarts many genuine attempts to provide care.

Prentis Hemphill states that, “Boundaries are the distance at which I can love you and me simultaneously”. It’s a delicate balance in patient care to love and empathize with our patients enough to be effective, but not enough that it consumes us, resulting in compassion fatigue. Compassion fatigue plus the organizational cultures that lead to burnout result in feelings of moral injury. Perhaps if medical training programs included information about boundary setting, utilizing cognitive vs. affective empathy, and discussed accurate portrayals of common workplace scenarios and ethical dilemmas (like I discussed last week), new providers would feel better prepared and protected against these negative emotions and experiences.