Taking stock and making strides toward wellness in the veterinary workplace

Erin M. Brannick Department of Animal and Food Sciences, College of Agriculture and Natural Resources, University of Delaware, Newark, DE 19716.

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Caitlin A. DeWilde Brentwood Animal Hospital, 2907 S Brentwood Blvd, Brentwood, MO 63144.

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Erin Frey Raleigh, NC 27613.

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Tracy L. Gluckman Northwestern University Center for Comparative Medicine, 320 E Superior, Searle 13–511, Chicago, IL 60611.

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Jeremy L. Keen North Madison Animal Hospital, 243 Oil Well Rd, Jackson, TN 38305.

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Michelle R. Larsen Emergency Animal Clinic, 13034 W Rancho Santa Fe Blvd, Ste 101, Avondale, AZ 85392.

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Stephanie L. Mont Army Medical Department Center and School, United States Army Health Readiness Center of Excellence, Department of Veterinary Science, 1050 Taylor Rd, JBSA-Fort Sam Houston, TX 78234.

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Matthew D. Rosenbaum National Jewish Health, Biological Resource Center, 1400 Jackson St, Denver, CO 80206.

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Julie R. Stafford John Day River Veterinary Center, 59989 Hwy 26, John Day, OR 97845.

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Kristi L. Helke Department of Comparative Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC 29425.

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Undoubtedly, the veterinary medical field attracts individuals with high levels of compassion and empathy and the drive to care for others. With increased public recognition of the human-animal bond and the greater value placed on it, veterinarians and their staff members are increasingly expected to display high levels of consideration and compassion in the veterinary workplace. Individuals tend to enter and remain in the veterinary profession in part because of compassion satisfaction (the joy or sense of achievement found in helping others and providing high-quality patient care),1,2 and overall, veterinarians and other animal caretakers report high levels of satisfaction in their work.1,3,4 However, caring at such a high level can be associated with considerable personal and professional costs. Over time, repeated exposure to traumatic events in the lives of patients and their owners (eg, abuse, illness, trauma, and euthanasia), moral dilemmas, and occupational stressors can lead to compassion fatigue or burnout. Compassion fatigue, also known as vicarious trauma, secondary traumatic stress, or secondary victimization, is a result of medical caregivers’ unique relationship with ill or dying patients and the empathy they feel.2,5,6 Burnout, on the other hand, is related to interactions with the workplace environment and feelings of being ineffective in one's work.5,7 Between 15% and 67% of veterinarians are estimated to have a high risk of burnout, as are 35% of other animal care team members.1,3,8 Regardless of underlying causes, both compassion fatigue and burnout can mirror post-traumatic stress disorder and can manifest as negative psychosocial behaviors (eg, detachment or avoidance), physical illness (eg, fatigue or body pain), and detrimental workplace conduct (eg, absenteeism or interpersonal conflict).3,5,9–11 Moreover, compassion fatigue, burnout, and anticipatory grief (ie, subconsciously preparing for illness or death of an animal by disengaging from that animal) can establish a negative feedback cycle that can erode the strong human-animal bond veterinary caregivers feel for their patients, further decreasing compassion and empathy for patient suffering.3

Stressors, Signs of Stress, and Negative Coping Strategies in the Veterinary Workplace

Over the past several decades, empirical and anecdotal12 evidence has come to light that veterinarians and other animal caregivers in a variety of workplaces, including veterinary practices,9,10,13–16 public service corporations,9,16 nutrition and pharmaceutical companies,15,16 animal shelters,17 and academic and research animal facilities,4,9,15,16 face high levels of work-related stress from a variety of causes. In particular, several studies9,10,14,15 involving veterinarians and veterinary staff members indicate that compassion fatigue is an important issue for the profession. Stressors identified in the veterinary workplace range from occupational and environmental to patient- and client-related to personal. For example, the duration and timing of work hours (eg, overtime, weekend, and on-call), high workload, lack of sufficient downtime during the workweek, lack of vacation time, interpersonal conflicts, and administrative or clerical tasks are prominent work environment (occupational) stressors. Veterinarians and other caregivers also report high levels of patient- or client-related stress associated with potential professional mistakes, the threat of malpractice litigation, pressure from animal owners, moral stress in clinical decision making, unexpected case outcomes, and animal death brought about by natural causes or euthanasia.4,14,17,18 In fact, it is estimated that veterinarians experience patient death approximately five times as frequently as their counterparts in human medicine.19 Concerns related to personal finance management, personal relationships outside the workplace, and personal expectations of performance are also common stressors, especially among younger veterinarians.11,14–16 Regardless of the underlying causes, compassion fatigue and burnout can have serious, long-term effects on veterinary caregivers themselves and for others in the workplace or home environment.20 Thus, mechanisms to recognize and combat compassion fatigue and burnout are important.

Psychosocial manifestations of compassion fatigue and burnout reported among animal caregivers include depression, lack of concentration, uncontrolled mood swings, insomnia, and irritability.3,9,11 Over time, psychosocial manifestations can transform into physical ailments and detachment from everyday life, both within and eventually outside the workplace. Signs and symptoms of a more physical nature can include headaches, gastrointestinal upset, and inappetence.3,17 Affected individuals may withdraw from the workplace through detachment (from coworkers, fellow caregivers, and patients), frequent absences, or increased interpersonal conflicts or may leave the workforce altogether (reflected in high staff turnover).3,5,6,8,11 Furthermore, work motivation and effort can suffer to the point that caregivers take an “uncaring or callus attitude toward animals.”3 In the extreme, workplace stressors also begin to have a serious health impact outside the workplace. For instance, in one study,9 veterinarians self-reported a high rate of automobile accidents (> 50%). Additionally, veterinary caregivers may be at higher risk for adopting negative coping strategies (eg, alcoholism, overeating, drug use, excessive sleep, or distancing) or for failing to cope, potentially leaving the profession altogether or pursuing suicidal thoughts and actions.10–12,15,21 In two meta-analyses,22,23 the suicide risk for veterinarians was higher than that for the general public and for other medical professionals. Despite empirical data outlining such risks, awareness of and research into workplace issues facing animal caregivers have been slow to develop, especially given the depth and breadth of research into compassion fatigue and burnout in other medical professions.

Compassion Fatigue and Coping Strategies in Other Professions

Compassion fatigue is not unique to veterinarians and was first described in 1992 as an entity observed in nurses working in human medicine.24 To this day, most available literature on compassion fatigue focuses on nurses, but the condition has since been described in a growing list of other caregiving professionals, including physicians, dentists, social workers, veterinarians, medical interpreters, and chaplains. Important factors leading to compassion fatigue and burnout identified by these groups include lack of manager support, negative relationships with coworkers, increased number of hours worked, increased case or workload, limited resources, competing demands, conflicting expectations, and unpredictable schedules.8,16,25–30 Regardless of profession, individuals experiencing compassion fatigue develop similar symptoms, such as psychological distress; a sense of helplessness, fear, or loss of purpose; and an inability to recognize their own needs.31

On the positive side, there are indications that positive coping strategies can reinforce compassion satisfaction and lessen compassion fatigue. In a 2014 study26 of trauma nurses, even though > 25% of those polled reported some level of burnout and compassion fatigue, > 75% of the nurses still had high compassion satisfaction scores, and compassion satisfaction partially offset negative feelings and impacts associated with compassion fatigue. A separate study27 of emergency department nurses showed similar results, with average to high compassion satisfaction inversely correlated with low to average compassion fatigue. Given these findings, there is a need for research in veterinary medicine to determine whether compassion satisfaction can potentially outweigh or compensate for the negative feelings associated with compassion fatigue and burnout, allowing veterinary professionals to stay engaged and productive in the workplace.

In addition, veterinarians and other animal caregivers may be able to learn from positive coping strategies developed for use by individuals and workplace teams in diverse health-care settings, in addition to those developed specifically for workers in animal care facilities.4,6,11,17,19 Studies have found that mentorship, increased work group cohesion, and organization commitment ameliorate stress and compassion fatigue and that access to external helplines and health-care professionals enhances support for individuals experiencing compassion fatigue and burnout.11,32 However, training in recognizing and responding to compassion fatigue and burnout needs to begin early; professional students who are taught mindfulness in medical and dental school have decreased perceptions of stress, anxiety, and depression and exhibit increased mindfulness, empathy, and self-compassion.33 Mindfulness programs already present in medical and dental schools use poetry and teaching stories to increase emotional connections and to help relate to material in new ways beyond just internalizing information.32 Programs developed for practicing clinicians, which include training in mind-body skills, cognitive coping strategies, and stress education, have resulted in enhanced resilience in participants.25 To combat compassion fatigue among caregivers, at least one hospital has implemented a specific five-week program that includes training in self-regulation, intentionality, perceptual maturation, self-validation, social connection, and self-care.30 This program has shown promising results, with participants having a decline in secondary traumatic stress and burnout. It is now becoming obvious that, in caregiving careers, one needs to care for oneself to care for others.6,34 This advice is reinforced by results of initial studies of implementation of workplace wellness programs.35 Correspondingly, compassion satisfaction increases with self-care strategies such as exercise, meditation, and developing positive coworker relationships.26 These strategies may provide ideas for how veterinary workplaces can progress toward wellness.

Taking Stock of Wellness in the Veterinary Workplace

Experience in other medical professions indicates that compassion fatigue cannot easily be recognized by individuals without an initial awareness that the condition exists.24 Thus, veterinarians and animal caregivers must learn to recognize signs of compassion fatigue and burnout in themselves and others. Doing this requires taking stock of our individual and collective levels of compassion satisfaction, compassion fatigue, and burnout at present and over time. Additionally, we must work to develop both problem-focused (ie, determining solutions to underlying problems) and emotion-focused (ie, normalizing feelings related to stressful events or stressors) coping strategies36 to counteract compassion fatigue and burnout in veterinary medicine.

To this end, the authors, through the 2014–2015 AVMA Future Leaders Program, have worked to gather resources on veterinary workplace wellness. One of the resources identified was a survey instrument called the Professional Quality of Life Scale,37 a validated self-assessment tool developed by Stamm7 that measures compassion satisfaction, compassion fatigue, and burnout across medical professions. This tool is available to all AVMA members through the new AVMA wellness website (www.avma.org/wellness), with the goal that individual AVMA members will complete the survey and receive immediate feedback regarding their current workplace wellness status. Survey results can also be saved and the instrument used multiple times to create serial scores that can be compared over time. Furthermore, the authors have worked with the AVMA Veterinary Economics Division to incorporate the Professional Quality of Life Scale into the Biennial Economic survey, allowing assessment of overall trends in compassion satisfaction, compassion fatigue, and burnout across the profession while maintaining individual member anonymity. To help veterinary caregivers identify compassion fatigue and burnout and develop positive coping mechanisms to counteract them, the authors have assembled an online toolkit for AVMA members (www.avma.org/wellness). This toolkit gathers resources to help individual veterinarians and veterinary support staff achieve balance across all facets of their lives.38 Our sincere hope is that these tools will help open a dialogue on issues of compassion fatigue and burnout among veterinarians and all members of the veterinary team, regardless of the type of workplace.

In closing, we believe it is time to take stock and make strides toward true wellness in the veterinary workplace. To this end, we encourage all AVMA members to use the Professional Quality of Life Scale survey to assess their current status regarding professional compassion fatigue and burnout. We also hope that members will explore the resources available through the online wellness toolkit and educate their colleagues and staff members about compassion fatigue and burnout. As professionals, our health and our profession depend on being able to recognize, prevent, and reverse compassion fatigue and burnout in ourselves and others. Doing so will allow us to maintain the high standards of care and compassion that are fundamental to all veterinary workplaces and animal care teams.

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