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Abstract
Objective To estimate prevalence and explore potential causes and consequences of compassion satisfaction and compassion fatigue in UK emergency medicine consultants.
Methods A sequential mixed-methods design. Cross-sectional e-survey to all UK NHS emergency medicine consultants (n=1317) including Professional Quality of Life (ProQOL) (compassion satisfaction/fatigue), followed by interviews with consultants scoring above (n=6) and below (n=6) predefined ProQOL thresholds.
Results 681 (52%) consultants responded. Most (98%) reported at least ‘average’ compassion satisfaction. Higher scores were associated with type of workplace (designated trauma centres faring better) and number of years worked as a consultant (gradually worsen over time, except 20 years onwards when it improves). Consultants with lower (worse) compassion satisfaction scores were more likely to report being irritable with patients or colleagues and reducing their standards of care (a third reported these behaviours at least monthly) and were more likely to intend to retire early (59% had such plans). Key features distinguishing ‘satisfied’ from ‘fatigued’ interviewed consultants included having strategies to deal with the high work intensities associated with their role and having positive views of the team within which they worked. The degree of variety in their roles and the ability to maintain empathy for their patients were also distinguishing features between these groups.
Conclusions Findings support an urgent review of workforce and resources in emergency medicine and suggest that a multifactorial approach to identification, prevention and treatment of occupational stress in the workforce is required that considers individual, job and organisational factors, particularly those that impact on perceived control and support at work.
- emergency departments
- psychology, staff support
- clinical care
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Key messages
What is already known on this subject?
Numerous observational studies have suggested that emergency physicians are at risk of occupational stress and burnout however few studies have looked at compassion satisfaction and fatigue, their impacts on patients, colleagues and risks of medical error, and the factors which contribute to or protect against these.
What this study adds
Levels of compassion satisfaction amongst UK emergency physicians are average or above average.
Consultants with lower compassion satisfaction scores more commonly report irritability with patients, reduced standards of care and making mistakes that could have harmed patients.
Factors which reduce workload intensity and repetitiveness and enhance individual coping styles and team cohesiveness are associated with higher compassion satisfaction. These may provide a focus for future workforce development in emergency medicine.
Introduction
Background
A recent report from the King's Fund on Health and Social Care in England revealed an emergency care system under pressure with more patients waiting over 4 h and waiting for admission to hospital than at any time since 2003.1
The ability of emergency service staff to provide high-quality clinical care will depend on a variety of factors, however, continued pressure on staff within this challenging clinical environment, may lead to stress, burnout and a loss of compassion, resulting in poor quality care. Previous research into stress among doctors support this link between the work environment, stress and impacts on patients and clinical teams.2–5
The potential implications for patients in an emergency care system which lacks compassion have been identified in a number of reports. The report by the Health Service Ombudsman into care and compassion for older people highlighted failings within the NHS and, in particular, emergency care.6 Additionally, the public inquiry which examined the serious failures in care at the Mid Staffordshire NHS Foundation Trust between 2005 and 2008 also highlighted the need for caring, compassionate and committed staff as key in the provision of an NHS where patients are the first priority. Furthermore, the report of this public inquiry stated that consultants should be leaders in the promotion of a culture that is committed, caring and compassionate.7 We sought to assess the current prevalence, causes and consequences of compassion satisfaction and compassion fatigue in UK NHS emergency medicine consultants.
Methods
Study design
A sequential mixed-methods design was applied.8 A national e-survey was administered to estimate the prevalence of compassion satisfaction and compassion fatigue and to provide the sampling frame for subsequent interviews aimed at describing causal and protective factors.
National survey
An electronic survey was sent to all consultants in emergency medicine working in UK emergency departments in April 2012. Consultants were identified using the UK College of Emergency Medicine's database of Fellows. Duplicate and undeliverable email addresses, non-UK-based consultants and consultants who had not worked in the previous 30 days (eg, due to maternity or other long-term leave) were removed from the denominator, leaving a sample of 1317 consultants. This was in line with NHS workforce statistics which showed that in 2012 there were 1279 whole time equivalent consultants in Emergency Medicine in the NHS.9
The survey was designed using SurveyMonkey and consisted of three parts:
The ProQOL questionnaire10: 30 items rated according to frequency over the previous 30 days on a 1–5 scale (1=Never, 5=Very Often). Ratings summed to produce scores for compassion satisfaction (10 items) and the two components of compassion fatigue: burnout (10 items, some items reverse scored) and secondary traumatic stress (10 items). Thresholds for summed totals based on 25th and 75th centiles are: 22 or less—below average (indicating low compassion satisfaction (less desirable) or low burnout (more desirable) or low secondary traumatic stress (more desirable)), 23–41—average, 42 or more—above average.
Demographic and job characteristics: age group, sex, marital status, number of children <18 living at home, type of workplace, number of years worked as a consultant and years in current consultant post (see table 1 for categories).
Potential impacts of compassion fatigue: using an adapted scale11 measuring the frequency (on a 4-point scale, see table 4) that stress at work over the previous 6 months had caused irritability with patients, irritability with colleagues, reductions in standards of care or making mistakes that could or did harm patients. Consultants were also asked whether they planned to retire early (yes/no).
Consultants were assigned a unique identifier to maintain confidentiality. Details of support services were also provided. Participants were asked to provide their e-mail address if willing to consider participating in an interview.
Interviews
Two groups of consultants were identified and invited to participate: A ‘SATISFIED’ group consisted of consultants who had scored above average in compassion satisfaction and below average in both components of compassion fatigue. A ‘FATIGUED’ group consisted of consultants who had scored above average in either of the components of compassion fatigue or below average in compassion satisfaction. Six consultants were purposively selected from each group (12 in total) to aim at geographical spread and gender balance. Interviews took place in November 2012 and were conducted by an independent researcher (PG) trained in qualitative methods. As the study aims were to explore protective and contributory factors for compassion satisfaction and compassion fatigue, both the interviewer and interviewee were aware of the interviewee's ProQOL scores at the time of interview. All interviews followed a topic guide and lasted 30–50 min and were digitally recorded and transcribed.
Analysis
Demographic survey data was analysed descriptively. Raw ProQOL scores were converted to standardised scores prior to analysis, and categories for ‘below average’, ‘average’ and ‘above average’ were calculated based on thresholds specified by previous research.10 The prevalence of compassion satisfaction and compassion fatigue were calculated with 95% (exact binomial) CIs. Multivariate linear regression analysis was conducted to examine the relationships between the outcome variables (compassion satisfaction, burnout and secondary traumatic stress) and independent variables (demographic and work related factors). Logistic regression analysis examined the associations between the potential consequences (impacts on patients, impacts on colleagues and plans to retire) and independent variables (compassion satisfaction, burnout and secondary traumatic stress). Model fit for survey data was analysed using Stata V.11 (Statacorp LP, Texas, USA). Due to the high correlation between ‘number of years as a consultant’, ‘number of years in current post’ and ‘age’, only ‘number of years as a consultant’ was entered to models.
Interview transcripts were analysed thematically using established best practice methods for qualitative research as described by Braun and Clarke.12 Two researchers (PG and CT) trained in qualitative analysis independently familiarised themselves with a random sample of the transcripts to identify, discuss and agree key themes. Care was taken to identify both ‘shared’ themes (relevant to both groups) and themes only emergent from one group. Transcripts were coded individually according to this initial thematic framework giving the opportunity to highlight any divergent cases or new emergent themes. Following revisions, this led to the development of the final framework which was used to code all transcripts. Due to a key element of the design being the comparison between the SATISFIED and FATIGUED groups, analysis initially focused on highlighting similarities and differences between the narratives of the two groups, and examining relationships between themes, as well as examining similarities and differences ‘within’ groups. All analysis was underpinned by a theoretical and empirically supported model of job stress that considers individual and job/organisational level factors.13
Results
Characteristics of the survey respondents
In total, 681 consultants responded to the survey (response rate 52%). The demographic and work-related characteristics of respondents are shown in table 1. Two-thirds were men and most (78%) were aged 30–49 years. Although no demographic data for comparison was collected from non-respondents, NHS workforce data from 30 September 2013 showed a gender split of 69% men and 31% women among consultants in emergency medicine. The majority of survey respondents were married and had at least one child (<18 years of age) living with them. Most worked full-time in an emergency department with one-fifth working in a designated major trauma centre. The average number of years worked as a consultant was eight (median: 8 years, mean: 7.89 years).
Characteristics of the sample
Prevalence of compassion satisfaction and compassion fatigue
The prevalence of compassion satisfaction and the two components of compassion fatigue (burnout and secondary traumatic stress) are shown in table 2. Most consultants (98%) reported ‘average’ or better than average scores. Only 15 consultants (2.3%, 95% CI 1.3% to 3.7%) had scores indicating low compassion satisfaction; two of whom reported high burnout (0.3%, 95% CI 0.0% to 1.1%) and one reported high secondary traumatic stress (0.2%, 95% CI 0.0% to 0.8%).
Prevalence of compassion fatigue
Relationship with demographic/work-related factors
The bivariate relationships of the ProQOL outcomes with demographic and work-related factors are shown in table 3. Multivariate regression models that included all demographic predictors only explained a small amount of the variance in ProQOL scores (R2 3%–5%, table 4).
Relationship between job/demographic variables and ProQOL outcomes (bivariate analyses)
Multivariate predictors of ProQOL outcomes
The two key variables explaining variance in compassion satisfaction were type of workplace and years worked as a consultant. Working in a designated trauma centre was associated with higher compassion satisfaction compared with working in an emergency department (mean difference 2.5, 95% CI (0.9 to 4.07); number of years worked as a consultant had a non-linear relationship whereby mean compassion satisfaction reduced marginally over the first 10 years and increased after 20 years. The two key variables explaining variance in burnout and secondary traumatic stress were marital status and years worked as a consultant. The number of years worked as a consultant for both models had a non-linear relationship where the mean score marginally increased over first 10 years and decreased after 20 years.
Association with patient care, relationship with colleagues and personal career plans
Around a third of consultants reported that stress at work had caused them to be irritable with patients, irritable with colleagues or reduce their standards of care at least monthly in the past 6 months (table 5). A third reported that stress at work had led to them making mistakes that could have harmed a patient at least once or twice in the previous 6 months and 11% reported making mistakes that did harm a patient. Fifty-nine percent of consultants reported intending to retire early. All reported impacts of stress at work were more common in consultants with lower compassion satisfaction and higher compassion fatigue scores (table 5).
Relationship between ProQOL outcomes and hypothesised consequences for patient care (bivariate analyses)
Characteristics of the interview sample
Participant flow from survey to interview sample is shown in online supplementary figure S1. Within the interview sample, there were more women in the satisfied group than in the fatigued group (four vs two) with the satisfied group representing a younger age range which was also reflected in the lower mean number of years as a consultant (8 vs 10.5) and in the current post (7.2 vs 8.3). All satisfied interview participants were married while one was single in the fatigued group and all but one participant in the fatigued group had at least one child under 18 years of age in their household (table 1).
Factors associated with compassion satisfaction and fatigue
The thematic analysis of interview transcripts and, in particular, the comparison between SATISFIED and FATIGUED consultants resulted in the development of a multifactorial explanatory model, comprising individual, organisational and job-related factors, and the hypothesised inter-relationships between them (figure 1). Key elements are described here.
Hypothesised explanatory relationships between job, individual and organisational factors and risk of compassion fatigue.
Central to the model is the relationship between job demand, control and support as this emerged as a common theme in accounts from both SATISFIED and FATIGUED consultants. While all consultants reported having a high-intensity job (many mentioning increasing patient numbers and staff shortages, particularly middle grade doctors and inexperienced trainees) and most described the challenge of meeting the waiting time target, the FATIGUED consultants particularly expressed their perceived lack of control and/or support at work in relation to such pressures:… too much to do, not enough time…unreasonable demands to achieve certain targets despite no additional funding or resources (F12); the elements that I have control over are outweighed by the magnitude of the effects of other people's decisions that are impacting negatively on the service…when the combination of that lack of control and personal exhaustion comes in you start getting demoralised and don't feel you are able to, you can't be that calm relaxed person you want to be for your staff and for your patients (F52).
This high-intensity workload was described to impact both physically (through having to work for longer or more intensely due to patient volume) and emotionally (by raising anxiety regarding patient safety and quality of patient care in relation to supporting doctors-in-training and locum doctors to make appropriate clinical decisions). Work intensity was also exacerbated by on-call responsibilities, particularly where there was no provision for ensuring time to recover from long shifts: ‘you can get called after midnight and we still have to function the next day because there's no one else on the rota to do it’ (F32).
On the contrary, SATISFIED consultants highlighted strategies to regain or maintain control over their work. These included coping strategies such as physical activity (ie, cycling), which gave them time to ‘de-stress and think’ (S41) or even simply having a 5 min tea break if they felt themselves becoming irritable. All 12 consultants mentioned the importance of good teamwork as a ‘moderator’ of the high demand they experienced. A number of satisfied consultants specifically stated that support from their consultant teams was key to preventing/reducing stress and compassion fatigue: ‘The spirit of the team is one of the things that helps to keep you from burning out…even on the bad days if I've ever thought I need to go and work somewhere quieter, I wouldn't because even on those bad days the colleagues I have here and the team I work in here are likely to keep me here’ (S21). Others described the importance of the wider team, including secretaries, porters and cleaners: ‘Our cleaner Sam is part of the team’ (S61). Fatigued consultants, on the contrary, were more likely to reflect on the negative impact of poor team relationships: ‘You have to maintain working relationships or it is hugely detrimental to the department’ (F42), and either did not mention their colleagues at all or only in relation to feeling unsupported: ‘I was starting to get the feeling that I was the only one trying to solve this problem…that feeling of loneliness…would mean that I stopped engaging with colleagues’ (F62).
Another common factor mentioned by four satisfied consultants was the importance of having variety in their job, by having a split clinical and managerial role: ‘Not being 100% in emergency…If I did I probably would be more burnt out and more frustrated because a lot of the frustration comes from the failure of the systems within the hospital and if you are dealing with that day in day out…so for me to have found kind of an outlet…decreases the stresses from having to work in emergency 100%’ (S21). On the contrary, two of the fatigued consultants specifically referred to the repetitiveness of the job as being a contributory factor: ‘it's the long hours, the pressures of the job, the repetitiveness of the job and the unreasonable demands of some patients’ (F32).
The desire to provide good patient care was specifically mentioned by a number of satisfied consultants as a key motivator when work was pressured, regardless of whether the patient was seriously ill or not: ‘everyone is entitled to be here so don't get annoyed that some people have come with a sore throat’ (S41). However, for some of the fatigued consultants, this sense of understanding towards patients had clearly waned: ‘It's very easy to be compassionate and sympathetic to patients who are clearly unwell, severely injured and so on, it's much more difficult to maintain compassion and sympathy for individuals who have relatively minor injuries but who are ungrateful or making demands, or making complaints’ (F42).
Discussion
Levels of compassion fatigue among UK NHS emergency medicine consultants were found to be low. Nevertheless, consultants with worse compassion satisfaction/fatigue scores were more likely to report being irritable with patients or colleagues and reducing their standards of care (with almost a third of consultants reporting these behaviours at least monthly) and were more likely to intend to retire early (nearly 60% of consultants had such plans). Key risk factors included type of workplace (those in designated trauma centres faring better) and number of years worked as a consultant (scores generally worsen over the first 10 years and then improve from 20 years onwards). Key features distinguishing ‘SATISFIED’ from ‘FATIGUED’ consultants included having higher perceived control and support at work which, in turn, were associated with factors at individual, organisational and job-specific levels.
Previous UK studies with higher response rates have reported mixed findings in relation to whether emergency consultants are particularly at risk of psychological distress.14 ,15 Regardless, these were conducted over 10 years ago and so may not be relevant given changes within emergency services16 and increasing patient numbers.1 Findings from non-UK studies have reported high rates of burnout among emergency physicians compared with other physicians,17 ,18 but levels of job satisfaction and burnout in studies solely including emergency physicians have varied widely.19–21 The disparity in findings may be for a number of reasons including differences in service configuration between countries or methodological differences, including incomparable outcome measures. The only study to investigate compassion fatigue among emergency physicians (in California, N=227) reported higher levels of compassion satisfaction but also higher burnout compared with general population norm data.22 The associations between work stress and physician performance we report have been previously documented among consultants and senior doctors in other specialties5 ,11 but have not previously been investigated within emergency care.
The response rate of 52% means the sample is potentially biased.23 It is impossible to know if responses of the non-respondents would have differed significantly from respondents. This could be in either direction, but may mean that the prevalence we report is an underestimate. The ‘years as a consultant’ finding (that scores improve after 20 years as a consultant) may be due to ‘survivor bias’ (ie, those who were very unhappy, more likely to have stopped working). Interviews were conducted prior to full analysis of the survey data which meant that the key risk factors could not inform the interview sampling frame. However, all except one of the consultants meeting ‘fatigued’ criteria were interviewed.
This study used a total population sampling frame and validated measures to assess prevalence. Furthermore, the mixed-methods design has facilitated the creation of an explanatory model that, if further validated, could inform practice. National Institute of Health and Care Excellence (NICE) guidelines for promoting mental wellbeing at work24 include recommendations for strategies and interventions to identify, prevent and treat occupational stress. With further validation, the model we present could help focus interventions on those consultants at most risk and also identifies potentially modifiable aspects of the job and organisation that may protect consultants from compassion fatigue. Furthermore, the ProQOL questionnaire could be a useful tool for monitoring the wellbeing of staff and providing opportunities for early intervention.
There is an urgent need for a review of emergency care workforce25 and the high-intensity workload associated with this specialism, to ensure the delivery of safe, high-quality compassionate care to the increasing numbers of patients presenting to emergency departments. Strategies suggested by this research could include a review of consultant on-call rota systems to ensure appropriate downtime after periods of intense weekend, evening and night-time working. More varied job plans could also assist in reducing intensity and repetitiveness within this role. These strategies plus those targeted at developing individual coping styles and greater team cohesiveness could also help maintain compassion satisfaction into the future.
Acknowledgments
We thank all study participants and the College of Emergency Medicine for funding this study.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online supplement
Footnotes
Contributors SD was involved in all aspects of the study design, designing and managing the survey, interpreting findings from both components, and co-writing the manuscript. CT was involved in all aspects of study design, analysing and interpreting survey and interview data and co-writing and reviewing the manuscript. VC analysed and interpreted the survey data and contributed to the manuscript; PG conducted the interviews, supported analysis of interview data and reviewed the manuscript.
Funding The College of Emergency Medicine funded the study and had no involvement in study design, data collection, analysis, or the decision to submit for publication.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.