While clinician resilience has been a top priority for years among health care leaders, staff in Covid-19 hot spots are experiencing trauma and grief on a nearly unprecedented scale. To learn about how leaders can identify and support their colleagues with compassion fatigue, Advisory Board's Lauren Rewers and Taylor Hurst spoke with Air Force Maj. Natasha Best, an Assistant Professor in the Family Nurse Practitioner and Women's Health Nurse Practitioner Program at the Uniformed Services University of the Health Sciences, and Air Force Lt Col Regina Owen, an Assistant Professor and Deputy Program Director of the Psychiatric Mental Health Nurse Practitioner Program at the university.

Compassion Fatigue Assessment: Determine your frontline staff's risk of emotional burnout

Question: Natasha and Regina, thank you for joining us.

Regina Owen: Thank you for inviting us to share what we do. I think it's important that we do what we can to help one another right now.

Question: To start, how would you define compassion fatigue?

Owen: Many conditions, such as compassion fatigue, burnout, and PTSD, are along the same spectrum—but when I reference compassion fatigue, I think specifically of the nurses, doctors, and other caregivers who provide care to patients suffering physical or mental anguish. Compassion fatigue is about your connection to others. I describe it as a "heavy heart" to my health care colleagues. By virtue of their occupation, they have to have a connection with different people. Most people come into the profession heartful—it's part of who they are. When one is faced with emotional and physical exhaustion, then their heart can begin to feel heavy, making it harder to make empathetic connections with others.

Natasha Best: I echo what Regina said. Compassion fatigue can be a mental or emotional reaction to a patient's experience—it's about channeling the pain of others. It can have a quick onset, particularly among new clinicians, nurses, and providers who might not have developed the tools or mental fortitude to handle difficult situations. I would add a caveat: People have individualized experiences with common features. For example, onset can happen more quickly for some depending on their background, their resiliency, or what they're dealing with outside of work.

Q: Given that the epidemic might cause a greater prevalence of compassion fatigue among the front line, what symptoms should leaders keep an eye out for?

Best: One red flag for clinicians is an uptick in patient-related mistakes, such as near misses or a decrease in patient satisfaction. At the same time, you also may see an uptick in the providers' dissatisfaction with their work, so a disillusioned effect regarding their performance. Leaders might not be in tune with it initially, but over time, you may notice some uncharacteristic behavior, such as late arrivals, being short with colleagues, or an uptick in alcohol intake.

Owen: Other signs leaders might see in the beginning are around sleep, such as daytime fatigue, irritability, and maybe an increased sensitivity towards the small things. Long-term, clinicians might begin to isolate or experience physical pain such as increased headaches. They might seem numb or distance themselves from others. They don't seem like themselves.

Q: Hearing you say that raises the question of performance management. Often, leaders may respond to declines in quality with a punitive approach. But given that errors might be symptoms of compassion fatigue, do you think leaders should change their perspective? And if so, how can leaders support staff as signs of compassion fatigue surface?

Best: Absolutely! It's important to take a proactive approach, rather than reacting to a decline in quality. First, leaders and managers need to educate themselves on compassion fatigue to understand the issue—and then educate their staff. Next, leaders need a method to check in on staff well-being. It can be as simple as asking individuals, "How are you doing?" Or it could be a survey. In the military, we're all about surveys. But you have to know your staff to see what would work best for them. Is it a staff meeting where everyone expresses themselves, 5-minute one-on-one conversations, or an anonymous survey? It's going to be different for every facility, but there's so many tools out there.

Owen: I agree. It's crucial for leaders to acknowledge the problem out loud with their teams. That's how they'll be able to start dialogue on the issue. In the military, we're fortunate enough to have access to a disaster mental health management team, or a mental health readiness team for short. The team is comprised of mental health professionals who assess unit needs and work closely with unit commanders, which are the equivalent to nurse managers or supervisors in a hospital.

It's not fair to ask managers to become mental health professionals dedicated to addressing staff compassion fatigue. They're dealing with the everyday stressors of keeping the unit running. The readiness teams act as the eyes and ears for leadership to assess their unit's needs and provide a plan for leadership to address these needs.

Q: You raise a great point that managers may not be equipped address staff trauma alone—nor should their organizations expect them to. Can you tell me more about the responsibilities of the readiness team?

Owen: Yes. Readiness teams are composed of usually four mental health professionals who step in to help leadership maintain staff well-being before, during, and after a disaster. If we anticipate a disaster, we start with a pre-preparation phase, which involves completing a risk analysis and ensuring staff have what they need before the disaster hits. We do trainings on the common symptomology of compassion fatigue, how to get a good night’s sleep, and how to manage difficult feelings.

We also work with leadership to ensure they have a way to check in on staff well-being during a crisis, and help them build unit cohesion and safety. For example, we encourage them to assign people who get along to the same shift. They can also do little things like take time for breaks and team huddles. Recently on the news, a nurse practitioner facilitated 5-minute meditations with staff at nurses' stations, which I thought was fabulous. That type of brief wellness activity mean a lot to people and can bring a sense of team support.

Q: Before we wrap up our conversation, I want to touch on the transition period after a disaster. Many health care organizations have passed the apex of their Covid-19 surge and are transitioning back to life as normal, whatever that means for them. As they are making this transition, what should they do to ensure their clinicians feel supported?

Best: We absolutely cannot act like nothing happened and go back to business as usual.

In the military we use something called the "after-action review." It helps us review lessons learned. It's vital to hit the pause button and talk about what they went through and then assess what steps forward to take. For some facilities, that may mean bringing in grief counselors and setting up a relaxation room. But the first step is to determine a baseline and then move forward from there.

The biggest risk of compassion fatigue for providers is leaving the profession altogether. You need to acknowledge these events prior to losing people. There's plenty of great people in this profession and you don't want to lose them by ignoring the experience of what they went through.

Owen: Use a questionnaire to gauge where your teams are and determine their needs and areas of struggle. Questionnaires can provide managers metrics to share with leadership, enabling them to track improvement. Most organizations already have some kind of a wellness program—this is the time to focus on increasing their resources and meeting the new wellness needs of their staff.

Q: Do you have any other advice for civilian organizations that we haven’t already discussed?

Owen: I encourage the leadership to continue processing what has occurred, what is occurring, and will occur. We are faced with something outside normal. The sooner you begin to talk about it and provide the appropriate resources, the sooner health care professionals feel like they are being heard, and the less of a chance they will suffer from chronic, long-term, devastating impact.