Content uploaded by Sue Klappa
Author content
All content in this area was uploaded by Sue Klappa on Dec 03, 2015
Content may be subject to copyright.
Full Length Research Paper
Compassion fatigue among physiotherapist and
physical therapists around the world
Susan G. Klappa
1
*, Lois E. Fulton
2
, Lauren Cerier
3
, Alexa Peña
4
, Andrew Sibenaller
5
and
Scott P. Klappa
6
1
Davenport University, Doctor of Physical Therapy Program, 6191 Kraft Ave. SE Grand Rapids, MI 49512
2
1813 Arthur Circle, Ames, IA 50010
3,4,5
University of Saint Mary, Stefani Doctor of Physical Therapy Program, 4100 South 4
th
Street, Leavenworth, KS 66048
6
Rosalind Franklin University of Medicine and Science, Department of Psychology, 3333 Green Bay Road, North Chicago, IL 60064
Accepted 20 October, 2015
Physiotherapists work in a variety of settings around the world and exhibit great satisfaction in their
work. Challenges of everyday practice may be a contributing factor to compassion fatigue (CF) and
lower professional quality of life. The purpose of this study was to investigate CF among
physiotherapists (PTs) around the world and discuss coping strategies utilized. Mixed methods
included a survey and phenomenological interviews. Participants (n= 116) completed the Professional
Quality of Life (PROQOL) survey and nine participants engaged in phenomenological interviews. The
PROQOL was used to assess the level of compassion satisfaction (CS), burnout (BO), and secondary
trauma (STS) experienced by PTs around the world. CF was considered a combination of STS and BO.
Group mean CS, BO, and STS scores were low compared to normal populations of caregivers. CS and
BO were negatively correlated (r = - 0.535, p < .001). BO and STS were positively correlated (r = 0.530, p
< .001). Three main themes emerged from interviews and included work environment stress, protective
coping strategies, and the effects of compassion satisfaction. Better understanding CS, as well as CF
in healthcare environments may help therapists develop better coping strategies for mitigating CF.
Key words: Compassion fatigue, compassion satisfaction, physiotherapist
ABBREVIATIONS
Professional Quality of Life (PROQOL)
Compassion Satisfaction (CS)
Burnout (BO)
Secondary Traumatic Stress (STS)
Compassion Fatigue (CF)
Physiotherapist/Physical Therapist (PT)
INTRODUCTION
The healthcare field is characterized by dynamic
environments, evolving research, and patients with
complex diagnoses. Physical therapists are challenged to
provide patient-centered care in an efficient and effective
manner while embracing evidence-based practice and
meeting clinic productivity standards. These challenges in
health care may become a struggle for clinicians leading to
a decreased quality of life for care providers.
*Corresponding author. E-mail: sklappa@davenport.edu, Phone: 616-871-6158
Author(s) agreed that this article remain permanently open access under the terms of the Creative Commons Attribution License 4.0 International
License
ISSN: 2449-1802 Vol. 3 (5), pp. 124-137, October, 2015
Copyright ©2015 Global Journal of Medical, Physical and
Author(s) retain the copyright of this article. Health Education
http://www.globalscienceresearchjournals.org/
Glob. J. Med. Phys. Health Educ. 125
REVIEW OF RELEVANT LITERATURE
The Professional Quality of Life (PROQOL) scale is a tool
used to evaluate and measure three components
associated with quality of life for healthcare professionals
(Stamm, 2010). In the PROQOL, Stamm (2010) utilized a
compassion continuum with compassion and fatigue as
anchors. The three components measured in the
PROQOL tool are compassion satisfaction (CS), burnout
(BO), and secondary traumatic stress (STS).
Compassion Satisfaction is described as the positive
feeling one receives by completing tasks well (Stamm,
2010).According to Stamm (2010), STS refers to the
residual stress of working with or helping a traumatized
individual. This construct may also involve hearing about
a traumatic event that happened to someone. Burnout
includes physical, mental, and emotional exhaustion,
diminished interest in work, and doubt in one’s value
according to Stamm (2010). Burnout is “associated with
feelings of hopelessness and difficulties in dealing with
work or in doing your job effectively” (Stamm, p. 13).
Compassion fatigue, the focus of this study, is a
combination of BO and STS (Stamm, 2010). Compassion
fatigue is defined as the negativity experienced by
caregivers in their occupation or service work while
helping those who have experienced traumatic stress or
suffering (Stamm, 2010). Stamm (2010) suggests that CF
not only involves mental exhaustion, but also has
physical components associated with it that lead to a
decreased quality of life among healthcare workers both
at work and in their personal lives. Personal lives can be
negatively impacted through a lack of joy in life,
personality changes, and changes in personal
relationships (Potter et al., 2010; Potter et al., 2013).
Workplace costs are also high: CF may lead to
decreased productivity, decreased quality of care, more
sick days used, higher turnover rates, increased
mistakes, burnout, and depersonalization of self and
others (McMullen, 2007; Potter et al. 2010; Potter et al.
2013). Lastly, physical symptoms may accompany CF
including a decline in health, chronic fatigue, irritability,
and difficulty sleeping (Bush, 2009; Potter et al. 2010;
Potter et al. 2013).
The PROQOL has been for used for the last 20 years
as an assessment tool to examine quality of life among
caregivers. Stamm (2010) determined the reliability
values for measuring BO (.85), CS (.75), and STS (.81) of
the PROQOL tool. The PROQOL tool is not a diagnostic
test, but can raise awareness to issues found in the
healthcare system regarding clinicians on the
compassion continuum. The PROQOL utilizes a self-
report questionnaire with statements graded on a Likert
scale to assess an individual’s frequency of experiencing
various emotions. The PROQOL is divided into three
different sections representing CS, BO, and STS, with the
sum of the scores in each section determining the level of
CS, BO, and STS experienced by an individual. Studies
have demonstrated instances where healthcare
professionals have scored high in CS, and also high in
CF (Elkonin et al., 2011; Kim, 2013; Klappa et al., 2015;
Stamm, 2010). The PROQOL tool is important in helping
to identify when a caregiver is in danger of being pulled
toward the fatigue anchor of the compassion continuum
by BO and STS.
Environmental conditions of practice for
physiotherapists and physical therapists may also
influence movement along the compassion continuum via
the level of BO and STS experienced by the care
providers. Individuals living and working in war
zones(Ghobarah et al., 2004), areas of civil unrest or
complex humanitarian emergencies (Al Gasseer et al.,
2004; Almedom et al., 2004; Musa et al., 2008;
Shawcross, 2000; Sideris, 2003; Teyhen, 1999) and
disaster situations (Klappa et al., 2013; Klappa et al.,
2014; Klappa et al., 2016) may experience higher levels
of BO and STS leading to CF. Aid workers in these types
of environments are more susceptible to STS as they
hear stories of pain and suffering from patients (Musa et
al., 2008; Klappa et al., 2013; Klappa et al., 2014; Klappa
et al., 2016). It has recently been suggested that aid
workers serving traumatized individuals may develop the
same symptoms as individuals directly exposed to
trauma (Musa et al., 2008; Klappa et al., 2013).
The work environment may also drive the strategies
used to mitigate or heighten CF. Stressful environments
appear related to higher CF levels in clinicians (Bhutani
et al., 2012; Bush, 2009; Craig, 2010; Elkonin et al.,
2011; Kim, 2013; Klappa et al., 2013; Klappa et al., 2014;
Klappa et al., 2015; Musa et al., 2008; Weidlich, et al.,
2015). Potter et al. (2013) noted that CF is a process
caused by prolonged exposure to stressful environments
leading to intrusive thoughts, increased mistakes, and
avoidance. In addition, clinicians working in acute care
inpatient settings with an increased percentage of
patients experiencing post-traumatic stress disorder
(PTSD) tended to experience more BO according to
Craig (2010).
Although clinical work environments may influence
levels of CF and BO, personal factors, such as
personality, may also predispose individuals to
experience CF (Bush, 2009; Cañadas-De la Fuente,
2015; Voss Horrell, 2011). Personality traits associated
with higher levels of CF include individuals who are
idealistic, highly motivated, committed to personal goals,
and highly empathetic (Bush, 2009; Cañadas-De la
Fuente, 2015; Potter et al., 2013). Younger age and the
status of novice professional are other personal factor
linked with higher rates of BO leading to CF (Bush, 2009;
Craig, 2010; Klappa et al., 2015). Researchers suggest
novice clinicians may have difficulty with role identity,
ambiguity in the workplace, large workloads, and
stressful environments (Bush, 2009; Craig, 2010; Klappa
et al., 2015). Individuals possessing adequate stress
management and coping skills, in contrast, are at
decreased risk for CF according to Bhutani et al. (2012).
Craig (2010) reported gender did not appear linked to CF.
Klappa et al. 126
Therefore, individual characteristics and coping skills
should be considered when determining who is at risk for
CF.
By having a greater awareness of the elements of BO,
STS, and CS, therapists may recognize the signs of CF
and utilize constructive strategies to mitigate the effects
of CF. Previous research has examined CF among
service workers, such as physicians (Bhutani et al., 2012;
Voss Horrell et al., 2011), nurses (Bush, 2009; Elkonin et
al., 2011; Hunsaker et al., 2015; Kim, 2013; McMullen
2007; Peterson, et al., 2014; Owen, et al., 2014; Potter et
al., 2013; Potter et al., 2010; Weidlich et al., 2015),
trauma workers (Craig, 2010; Hinderer et al., 2014;
Thieleman et al., 2014), relief aid workers (Klappa et al.,
2013; Klappa et al., 2014; Musa et al., 2008), and
psychological counselors (Bush, 2009; Craig, 2010;
Elkonin et al., 2011; Musa et al., 2008), but there is a gap
in the literature regarding how physiotherapists and
physical therapists are influenced by these constructs.
The purpose of this study was to investigate CS and
CF among physiotherapists and physical therapists
around the world. The results may help raise awareness
of the challenges and barriers encountered by
physiotherapists in the workforce and enlighten
employers and managers on how to best assist clinicians
in strengthening CS and in implementing strategies to
ease CF. The guiding research questions in this project
are:
1. What are the levels of CS, BO, and STS among
physiotherapists and physical therapists around the
world?
2. How might the environment such as rural or urban
work settings influence the levels of CS, BO, and STS?
3. How are CS, BO, and STS levels correlated with work
environments affected by civil unrest or war?
4. How aware are physiotherapists and physical
therapists of CS, BO, and STS?
5. Finally, what are some coping strategies utilized by
these individuals to mitigate CF?
METHODOLOGY
The mixed methods in this study included a survey using
a few short answer questions and the Professional
Quality of Life (PROQOL) survey with optional
phenomenological interviews. The PROQOL survey
allowed the researchers to reach a wide population of
physiotherapist/physical therapist providers practicing in
a variety of settings from many nations in order to obtain
a broad awareness of the issues therapists face in their
home countries. The PROQOL assessment tool
assessed three constructs which included CS, BO, and
STS (Stamm, 2010). Further probing was achieved
through phenomenological interviews conducted with
participants who had completed the survey and wished to
further discuss their experiences. These interviews
allowed the researchers to gain a deep, rich description
of the experience of CS and CF.
Phenomenological research is qualitative in nature
examining the lived experiences of participants by
listening to their stories in order to derive meaning from
these experiences (Dahlberg et al., 2001; Thomas et al.,
2002; van Manen, 1997). Here, researchers bracket and
set aside their beliefs regarding the phenomenon being
studied through bracketing exercises and journaling. In
this process, the researchers and others may begin to
understand trends that develop from such experiences.
Two main assumptions in phenomenological research
are: 1) humans seek meaning in their lives; and 2)
multiple realities exist that are socially constructed
(Dahlberg et al., 2001; Thomas et al., 2002; van Manen,
1997). See Figure1 for a diagram describing the research
methods used in this study. The Institutional Review
Board (IRB) at the University of St. Mary in Leavenworth,
KS, approved this study.
Participants
There were 116 participants in the Phase I survey and
nine participants in the Phase 2 phenomenological
interviews. Participants met inclusion criteria for the study
if they were: 1) a practicing physiotherapist/physical
therapist; 2) male or female; 3) able to speak English;
and 4) positive about their job despite experiencing BO or
STS in the last 30 days.
Instruments/Tools
Professional quality of life is defined as, “the quality one
feels in relation to their work as a helper” (Stamm, 2010,
p. 12). The PROQOL is a tool designed to assess those
in helping professions such as health care, social, or
police service and has been found to have a reliability
between .84-.90 according to Stamm (2010). It is a 30-
item self-report measure of the positive and negative
aspects of care giving. The PROQOL uses statements
graded on a Likert scale which specifically target the
three constructs of CS, BO, and STS.
Procedures
Participants were recruited from the Health Policy and
Administration (HPA) listserv, the HPA Global Health
listserv, and through links on the World Confederation of
Physical Therapy (WCPT). Individuals who accepted the
invitation to participate in this study were emailed an
online link directing them to the PROQOL survey through
QualtricsTM Surveys. Completing and submitting the
survey implied consent. The survey required 10-15
minutes to complete. The survey was open between
December 1, 2014 and September 12, 2015. Additionally,
the participants were invited to an optional interview lasting
Bracketing:
Reflective
Journaling
Glob. J. Med. Phys. Health Educ. 127
Figure 1: Research Methods
Legend: arrows represent line of thought in the process.
Qualitative Mixed Methods Paradigm:
PROQOL Survey (Phase 1) and Phenomenological Interviews (Phase 2)
IRB Ethics Clearance
Participant screening
Written informed consent
Survey (Phase 1)
Interviews (Phase 2)
Interview Transcription
Responses
1. Thick, rich re-entry
descriptions of experiences
2. Levels of compassion
satisfaction and compassion
fatigue
3. Strategies used to ease
compassion fatigue
1. What are the levels of CF, STS, BO, and CF among
physiotherapists/physical therapists around the world?
2. How might the environment such as rural or urban work
settings influence the levels of CS, BO, and STS?
3.How are CS, BO, and STS levels correlated with work
environments affected by civil unrest or war?
4. How aware are physiotherapists of CS, BO, and STS?
5. What are some coping strategies utilized by these
individuals to mitigate CF? BO, STS, and CF?
Horizontal Analysis
1. Saturation of interviews/immersion
in experiences
2. Understanding
3. Abstraction and Synthesis
4. Constituents/Theme Development
5. Understanding Re-entry
Horizontal Analysis
Klappa et al. 128
Table 1: Resonance Round: List of Comments Regarding CF
Thank you for an excellent description of what I have been feeling. It is good to know I am not the only one who goes through this.
As a newer PT, I thought I was prepared for burnout and fatigue, but this description helped me realize that some things cannot be
taught. I had to experience CF to really understand the depth of my problem. Luckily, I had a good support group or I might not
have remained in this profession.
It is great to have a study on this topic. I realize now that I can do more for me and for my colleagues. It is something a caring
profession must be aware of and those in human resources might want to do more.
Wow, you have captured this feeling of CF very clearly. I am glad to know that my satisfaction and love for what I do is very helpful
to keeping me energized. I have some great ideas now for how to stay energized.
I really love what I do but sometimes, I just get so tired of my patients. I am glad to know it is normal. Maybe it is unnecessary but
at least, now I know what to do and what to call it.
Thanks for the description. I wish participants would have discussed the more real and disastrous strategies used. I know . . . I
used sex and alcohol to try to heal my soul.
I get the importance of having fun and a good night out but sometimes we did go too far with our drinking and that was not helpful.
approximately 45-60 minutes in length about their specific
experiences of CS and CF.
Participants consenting to interviews were screened by
the principal researcher via telephone to confirm that they
were indeed PTs and met inclusion criteria. Participants
received an informed consent document prior to their
interview. Upon return of this form, interview
appointments were scheduled. Participants chose an
alias to keep their identity confidential. The principle
researcher transcribed the interviews within one week. A
transcribed copy was returned to the participant by email
to check for content accuracy of the information. Any
concerns of the participant were addressed by the
researcher and corrected for the final transcript analysis.
Furthermore, the lead researcher conducted interviews
using the strategy of processual consent described by
Rosenblatt (1995). By means of this process, the
intensity of interview questions was decreased when
participants appeared distressed and were allowed to
take time for silent reflection.
Data Analysis
Quantitative data were analyzed by SPSS 20 (IBM).
Cronbach’s α was used to determine the internal
consistency of the PROQOL tool for this study. Pearson
correlation coefficient was used to examine associations
between the constructs of CS, BO, and STS.
Interview transcripts were analyzed using a descriptive
phenomenological approach described by Giorgi (1997,
1975) and Dahlberg et al. (2001). This process involved a
whole-parts-whole type of holistic examination of the
interview texts to reveal the constituents or themes of the
experience for each participant interviewed. This process
served as the vertical analysis. A horizontal analysis
across all interviews developed the common description
of CF among all interviewed participants in this study.
Upon completion, a summary of the common themes was
sent to each participant for review to ensure
dependability and credibility. To further determine
credibility and trustworthiness of the final description, a
completed summary of the themes for the CF experience
was shared with providers who were PTs but who were
not a part of this study. These comments were used to
solidify the credibility and trustworthiness of the final
description though resonance with the experiences of the
participating individuals. See Table1 for a list of these
comments which composed the resonance rounds.
RESULTS
Although 140 participants started the survey only 116
completed it for an approximate 83% completion rate.
The demographics for the participants for the Phase I
PROQOL Survey included 116 participants (83 females
and 33 males). The age range of participants in the
survey was from 21-65 years of age. Mean years
practicing as a physiotherapist/physical therapist was 20
+ 5.2 years with a range years of practice from 1-45
years as a therapist. Educational levels of the therapists
participating in Phase I ranged from certificate level through
Glob. J. Med. Phys. Health Educ. 129
Table 2: Home Countries of Participants in Phase I Survey
Number of Participants by Home Countries who Completed the Survey
Afghanistan
1
Australia
3
Bangladesh
2
Belgium
1
Brazil
1
Canada
9
Costa Rica
1
Côte d’Ivoire
1
Dominican Republic
2
Estonia
1
Germany
3
Guatemala
1
Guyana
1
Hungary
1
India
6
Iraq
1
Ireland
1
Israel
1
Italy
1
Jamaica
4
Jordan
1
Malaysia
1
Nepal
1
Netherlands
1
New Zealand
2
Nigeria
4
Romania
1
Russian Federation
1
Rwanda
14
Singapore
3
South Africa
9
Klappa et al. 130
Table 2 continued
Sweden
1
Trinidad and Tobago
2
Turkey
1
United Kingdom of Great Britain & Northern Ireland
2
USA
30
TOTAL
116
Table 3: Participant Information: Phase I Survey
Phase I: Survey
Number of Participants
116
Sex:
Males
Females
28.4%
71.6%
Mean Age (years)
43 (± 9.1)
Mean Years Practicing
20 (± 5.2)
Education Levels
Certificate
Bachelor’s Degree
Master’s Degree
Doctoral Degree
Other
Total
4%
47%
21%
19%
9%
100%
Advanced PT Certifications
Yes
No
65%
35%
Productivity Standards:
Yes
No
69%
31%
Practice Settings:
Acute Care
28%
Table 3 Continued
Education
10%
Home Health
5%
Geriatrics
6%
Outpatient Orthopedics
23%
Prosthetics Center
8%
Private Practice
5%
Neurological Rehabilitation
10%
Pediatrics
2%
Other (Research, Global Health)
2%
TOTAL
100%
doctoral training. Additional training beyond the physical
therapy degree was noted among 65% of the
participants. See Tables 2 and 3 for the descriptive
characteristics of these participants, the practice settings
they represented, and the countries where they lived.
Therapists in this study practiced in urban (71%), rural
(23%), and other (6%) settings. Exposure to armed
conflict in the country of practice affected 12% of our
participants. Participants in the Phase II interviews
included nine participants (5 females and 4 males) from
Phase I who had previously completed our survey.
Average age of participants in Phase II was 45 years with
an average of 20 years of practice as a PT. These
individuals also represented a variety of practice settings.
See Table4 for further details on the participants who
engaged in interviews.
Group means for the PROQOL constructs are
presented in Table5. Values for CS (M = 41.33, SD =
5.60) placed participants in the average category for CS.
Values for BO (M = 22.42, SD = 5.06) placed participants
in the average level with regard to BO. Values for STS (M
= 21.58, SD = 6.05) placed participants in the high level
category for STS. When scores for BO and STS were
grouped together to form CF, the mean score for CF was
Glob. J. Med. Phys. Health Educ. 131
Table 4: Phase II Interview Participants
Phase II: Interviews
Number of Participants
9
Sex:
Males
Females
4
5
Mean Age (years)
45 (±8.2)
Mean Years Practicing
20 (± 3.6)
Home Countries:
Belgium
1
Dominican Republic
1
Germany
1
Guatemala
1
Netherlands
1
Rwanda
1
USA
2
Practice Settings:
Acute Care
2
Emergency Department/Hospital
1
Out Patient Clinic
1
Private Practice
3
Sports Medicine
1
average (M = 44, SD = 9.73). Cronbach’s ɑ for the
constructs of CS (.898), BO (.732), and STS (.849)
indicated that the PROQOL tool had high internal
consistency when measuring each of those three
constructs. See Table5 for mean scores for CS, BO, and
STS and how they related to the normal population of
caregivers.
Correlations between the constructs of CS, BO, and
STS were examined using Pearson product correlation
coefficient to reveal relationships between constructs. CS
and BO were negatively correlated (r = - 0.535, p < .001)
meaning that individuals with higher CS values had lower
values of BO and vice versa. It appeared that higher
levels of CS may be protective against BO levels.
Burnout and STS were positively correlated (r = 0.530, p
< .001). As BO and STS increased so did the CF level
based on the conceptualization provided by Stamm
(2010). Since CF involves a combination of both BO and
STS, CF was higher among therapists experiencing a
combination of BO and STS. No significant correlations
were found between CS and STS (r = .016, p = .863). It
may be that therapists exposed to STS had appropriate
coping strategies to deal with that exposure or CS
operates as a protective factor against STS in this
population. In this study when BO and STS scores were
grouped together, the mean value for CF was high and
indicated that the participants did indeed experience CF
through a combination of BO and STS. For this sample, it
could be interpreted that these participants were able
adaptively cope with CF by speaking with others and
using their perception of CS to decrease the effects of
STS and BO on CF. Finally, an interesting relationship
was found with therapists in areas with no, or unclear,
exposure to armed conflict tended to have higher levels
of CS (r = .186, p = .046).
Less than 50% of the therapists in this study indicated
that they had an awareness of what CF was and how it
affected individuals. The therapists in this study were
able to articulate symptoms they had experienced even
when not knowing about CF. They were able to sense
something was wrong and developed strategies to
mitigate those feelings. Participants reported using more
constructive strategies at times such as using exercise or
talking with others. Other times, participants used more
self-destructive strategies such as drinking to inebriation,
use of drugs, and sex outside of committed relationships.
See Table6 for more details on what therapists knew
about CF and strategies used to renew their spirit.
Qualitative Analysis
Qualitative analysis revealed that three main themes
emerged from interviews and included: 1) work
environment stress; 2) the need for protective coping
strategies; and 3) the effects of CS in mitigating CF.
Therapists described personal strategies used to mitigate
CF, BO, and STS. See Table7 for exemplars of these
themes.
Work Environment Stress
Physical therapists around the world work in challenging
environments with many demands, whether from
patients, work setting, or administration. All therapists in
this study loved their work with patients and colleagues;
however, there are times when the burdens of the job
seemed to outweigh the pleasures of being a
physiotherapist or physical therapist. Feeling a lack of
support from management and administration added to
the work stress felt by the therapists. A lack of time or
resources compounded the pressures felt by the
therapists and added to the frustration of not being able
to meet the needs of every patient. Finally, the pressure
Klappa et al. 132
Table 5: Summary of PROQOL Findings
Variable
Mean Score
Standard Deviation
Level Relative to Normal
Cronbach's Alpha
Compassion Satisfaction
41.33
±5.60
Average
.898
Secondary Trauma
21.58
±6.05
High
.849
Burnout
22.42
±5.06
Average
.732
p = .001
Table 6: Participant Awareness of CF & Strategies to Mitigate CF
Participants who have heard of CF:
Yes
No
48%
52%
% of Participants in Phase I Experiencing Symptoms of CF
Extreme fatigue
66%
Hopelessness
25%
Irritability
64%
Sadness
37%
Difficulty with colleagues
49%
Decreased productivity
45%
Isolation from others
35%
Strategies Used by Participants to Mitigate Symptoms of CF
Talk to family member or friend
74%
Talk to supervisor, colleagues
51%
Talk with counselor
10%
Faith, prayer
46%
Aerobic exercise
70%
Exercise such as yoga, Pilates, etc.
39%
Read
54%
Dine out with friends
57%
Listen to music
47%
Visit an art museum
7%
Glob. J. Med. Phys. Health Educ. 133
Table 6 continued.
Take a day off
55%
Take a vacation
54%
Alcohol, nicotine or other substance
20%
Other: (spend time with animals, continuing
education, knit, play instruments, chocolate &
coffee, practice mindfulness)
14%
Table 7: Qualitative Themes and Exemplars
Work Environment Stress: Unsupportive Managers/Administration; Being Overworked, Pressure for
Results
Feeling Unsupported by Management & Administrators
I compare it to a can of water, where it's a mixture of good and bad things. If you put too many bad things in that
can, you can't make room for the good things…And you have the feeling like you can't fill the can anymore with the
good things because you can't empty it from the bad things. And then you realize at that moment that you’re not
working properly anymore So you try to force yourself and isolate yourself more in your working issues, except
then you face the organizational issues. And you try to act normal, but it is impossible. It is like a struggle,
because you realize that your compassion for your patients gets lower and you become like a machine.
Orlando, Belgium
Overworked/Understaffed & Lack of Time or Resources
So there are those patients who really need you and when you look at the numbers you can't really help some at
all. You can't get to them. Robert, Rwanda
Pressure for Results
There is also the challenge of working one on one with the patients who are in just a really difficult circumstance.
Their lives are so in surmounting or so just hard. It’s like, oh I have this and their capacity to meet their full needs is
not met. And so their pressures and lack of resources come to play in all of that.
Sally, USA
Protective Coping Strategies: Maintaining Boundaries & Importance of Self-Care
Maintaining Boundaries with Patients & Difficult Work Settings
Then it hit me and I started thinking about it because I treated a man who was about my age and he had a family
but had severe neurological problems and I thought well, that got to me that was where I knew I had to protect
myself. Joanna, Germany
Now at this age [Laughter] I can separate the emotions. But at that time [as an early therapist] I could not so
maybe I was thinking about them [my patients] maybe all of the time at home and on my holidays and on
weekends. Fisiokine, Guatemala
Self-Care
You do something like exercise or maybe if you can't you go and do something else. You just move around and do
something creative, something that gives you energy. Robert, Rwanda
Klappa et al. 134
Table 7 Continued
Compassion Satisfaction as a Protective Factor: Sense of Fulfillment & Making a Difference
Sense of Fulfilment
What I like most about my job is meeting all the people and the majority of them get well. Sue, USA
Making a Difference in Patients’ Lives
The exciting thing is that you can actually improve peoples’ lives as a holistic point of view. We impact them on not
only their physical condition, but also on their social and emotional status, and even financially because you're
able to get them back to work. Orlando, Belgium
for results or meeting productivity standards were also a
frustration expressed by the therapists in this study.
Protective Coping Strategies
All therapists in this study commented about the
importance of using protective strategies to maintain
energy and a love for their profession. Participants
commented on the close relationships existing between
patients and therapists but also identified the need to set
boundaries. If therapists did not separate themselves
from work and patients, they may be emotionally and
mentally consumed by the plight of patients. It was crucial
for therapists to identify when they needed to step back
and make time for self-care activities. The chosen self-
care activities were varied in nature and involved both
individual and group strategies. See Table6 for data on
protective coping strategies used by therapists in this
study.
Compassion Satisfaction in Mitigating CF
Love of one’s work and role as a therapist provided a
sense of fulfilment to the participants in this study.
Participants loved caring for others and improving the
lives of their patients. Therapists were excited to see
progress in the skills and accomplishments of patients
but it was also difficult to deal with challenges in the
health care systems. Many therapists were resourceful
and able to maintain a positive outlook on the situation
reflecting on the satisfaction they felt in their role as a
physiotherapist. The ability to connect in a genuine way
with others made the challenges of work less stressful.
Despite challenging work environments and interpersonal
issues, the ability to focus on positive influences the
therapists had on patients seemed to mitigate CF.
Many therapists in this study were familiar with the
terms CS, CF, BO, and STS. Among participants in
Phase I of this study nearly half knew of CF. Many
participants who had heard of CF were able to describe
symptoms they felt when under the influence of CF.
Those who were not familiar with CF were also able to
describe personal feelings that needed to be corrected.
The participants described feelings of extreme fatigue,
irritability, decreased productivity, difficulty with
colleagues, and frustrations when working with patients.
The participants were also able to articulate strategies
utilized to decrease their CF and bad feelings toward
work. Therapists in Phase II of this study shared many
examples of how they learned over the years to self-
identify their feelings of CF as well as strategies for
mitigating CF in their professional practice of physical
therapy.
DISCUSSION
The findings in this research project suggested that mean
values for CS were high. Levels of BO among therapists
in this study were low in general and agrees with findings
in the literature. When a therapist is more experienced,
they tend to have a greater variety of positive coping
strategies compared to novice therapists (Klappa et al.,
2014; Klappa et al., 2015) or health care workers
(Bhutani et al., 2012; Craig, 2010; Elkonin et al., 2100;
Musa et al., 2008).
Compassion satisfaction and BO were negatively
correlated for physical therapists and concurred with what
is found in previous studies (Klappa et al., 2014; Klappa
et al., 2015). The therapists may have successfully
utilized strategies to mitigate the effects of BO on CF.
Although previous studies suggest there is a negative
correlation between CS and STS for therapists, this study
failed to demonstrate any significant relationship between
CS and STS (Klappa et al., 2015; Klappa et al., 2016;
Stamm, 2010). Previous studies reported a moderate
negative correlation between CS and STS, and CS and
BO among new graduates and disaster relief workers;
hence, as STS or BO increase, CS decreases (Klappa et
al., 2012; Klappa et al.,2014). Conversely, CS may be
protective against the BO and STS constructs of CF
(Craig, 2014; Klappa et al., 2012; Klappa et al., 2014;
Klappa et al., 2015; Smart et al., 2014).
A mild negative correlation existed for levels of CS and
practice in an area of armed conflict in a region among
physical therapists. This may be related to the amount of
stress these individuals experience while in these
regions, as described in a study by Musa et al. (2008), in
which individuals working in the Darfur war zone were
surveyed. Thus, therapists in areas of armed conflict
tended to have lower levels of CS. The more rural
regions, representing 26% of our patient group, were
correlated with higher levels of STS among physical
therapists. These individuals described instances of STS
Glob. J. Med. Phys. Health Educ. 135
in these regions because there was a lack of expertise in
the geographic regions that they were working in. This
added pressure, despite training in trauma, may have
increased the potential for STS to influence CF for the
participants in this study.
A majority of our participants, 74%, used talking to a
friend or family member as one coping strategy to
manage their stress levels. Various other coping
techniques included: 1) talking to a friend or family
member; 2) engaging in aerobic exercise; and 3) dining
out with friends. See Table6 for more details on
strategies used by participants. Several authors suggest
adequate stress management and positive coping
strategies are linked to lower CF and BO scores (Klappa
et al., 2015; Voss Horrell et al., 2015; Weidlich et al.,
2015). In addition, individuals with high STS levels were
more likely to have lower BO scores if they have effective
coping skills (Klappa et al., 2015). Our participants had
low or low average scores of CS, STS, and BO compared
to normal, suggesting they likely used effective coping
strategies.
The majority of our patients were not aware of CF
(52%) and how it affects individuals. Some of the
participants described past experiences of CF and their
symptoms. The literature suggests that individuals may
display a variety of symptoms associated with CF which
include fatigue and sleep difficulty, irritability, higher
mistakes, depersonalization of self and others, changes
in personal relationships, lack of joy, and physical
symptoms (Peterson, et al., 2014; Owen, et al., 2014;
Potter et al., 2013). A majority of participants in this study
reported experiencing extreme fatigue (66%).
Participants also felt symptoms of increased irritability,
decreased productivity, increased isolation, increased
difficulty with colleagues, and sadness or hopelessness.
An awareness of CF among participants in this study or
an ability to recognize early personal stress symptoms,
may have allowed participants to utilize helpful coping
strategies because they knew something was not right
even if they were not aware of CF and how to prevent it.
Multiple participants discussed a perceived a lack of
managerial support in the workforce and being
overworked as contributing to their CF level. The
literature suggests that CF increases with lack of
managerial support, lack of staffing, and being exposed
to stressful environments (Horrell et al., 2011; Hunsaker
et al., 2015; Klappa et al., 2013, Klappa et al., 2014;
Klappa et al., 2015). Even though participants perceived
a lack of managerial support in the workforce at times
and reported feeling overworked, they had low STS and
BO levels compared to normal values. This phenomenon
may be due to the protective aspects of CS and love of
what one does as a professional.
Scales such as the PROQOL (Stamm, 2010) and
Mindful Attention Awareness Scale (Thieleman et al.,
2014) may be used to better help identify the effects of
BO or STS on CF since there was some overlap in the
influence of both BO and STS to CF. Specific training
involving coping strategies, as well as stress
management, may provide useful tools to mitigate effects
of CF (Bhutani et al., 2012; Klappa et al., 2014; Klappa et
al., 2015).
When prompted about other coping strategies, those
that involved drugs or alcohol, the response from the
interview participants suggested they didn’t use drugs,
and that if they did consume alcohol, it was more as a
social matter rather than drinking to avoid their stresses.
It was interesting that all participants described stories of
successful management of CF, yet later in the resonance
rounds, participants revealed occasional situations where
coping strategies were not as constructive.
Strengths and Limitations
Strengths of this mixed-methods study included the
sample size for Phase I (n = 116) and for the interviews
for Phase II (n = 9). The Phase I survey provided both
breadth and depth of experiences among the participants
due to the number of countries and practice settings
represented. The survey also had good reliability and
validity. In Phase II, saturation was reached with regard
to participant experiences after seven interviews which
again provided a thick, rich description of CS, BO, STS,
and CF among the physiotherapists and physical
therapists interviewed. The primary researcher
conducting the interviews was experienced in
phenomenological interview skills and appropriately
bracketed out previous experiences prior to the
interviews. Finally, the primary researcher who
interviewed the participants was not involved in the
identification and analysis of themes in order to limit bias
of results.
Several limitations exist in this study. The researchers
acknowledge that the results of this study do not apply to
every physiotherapist or physical therapist. Participants
tended to report healthy coping strategies in the
interviews but then reported more details about unhealthy
coping strategies in the resonance rounds. Perhaps this
biases our results towards physiotherapist and physical
therapists always choosing healthy coping strategies.
Another limitation lies in our survey tool. The PROQOL
tool is meant to be distributed within 30 days of a
traumatic event. In this study, participants were screened
to determine if they had experienced a stressful or
traumatic event and were asked to think about that time
when they experienced BO or a trauma at work. It is
possible that some of the participants did not experience
BO or a traumatic experience within the last 30 days.
Nevertheless, the values for Cronbach α for the
constructs of CS, BO, and STS were very high, indicating
that the survey tool did measure what was intended for
these three constructs.
Future Study Recommendations
Future studies may shed a brighter light on the topics of
CS, BO, and STS if there were other tools to measure BO
Klappa et al. 136
and STS. This project experienced some overlap of
constructs among our participants for BO and STS. By
using an additional tool to discern BO & STS, clarity on
the influence of BO, STS, and CF may more clearly be
teased out of new data. This process may also allow for a
deeper understanding of the role of CS on decreasing
CF. Perhaps a tracer study on therapists who are doing
work in disasters or areas of armed conflict would be
helpful in shedding light on CS, CF, and the strategies
used to overcome CF.
CONCLUSION
Compassion fatigue may be present at any point in a
therapist’s career and may result regardless of the work
setting. When experiencing CF, participants reported
having difficulty demonstrating compassion to their
patients while facing the stresses of productivity and
other job strains. The participants in this study tended to
be skewed toward the satisfaction anchor of the
compassion continuum on the PROQOL. Despite the
high compassion satisfaction among the participants,
many were pulled into feelings of CF due to personal or
environmental situations. The lived experiences of our
participants indicated that many therapists were aware of
the stress of CF and utilized helpful strategies to alleviate
their symptoms. The PROQOL helped detect CF by
examining subscales focusing on CS, BO, and STS.
Interviews and resonance rounds provided opportunities
for participants to further explore their coping strategies.
Some coping strategies mentioned by participants
appeared to be more protective than others in helping
regain higher levels of CS and decreasing levels of CF.
Coping strategies used by the participants primarily
revolved around physical activity and focusing on hobbies
that took them away from the workplace. Supportive
supervisors at work, mentors, or colleagues were also
helpful. The importance of understanding the support
system needed to deal with STS and avoid BO is crucial
for workplace supervisors, families, and therapists
themselves to maintain sustainable and healthy life-work
balance.
ACKNOWLEDGMENTS
We would like to acknowledge theparticipants of this
study.
REFERENCES
Al Gasseer N, Dresden E, Keeney GB, & Warren N. (2004). Status of
women and infants in complex humanitarian emergencies. J.
midwifery & women's health, 49(4 Suppl 1), 7-13.
Almedom AM, Summerfield D. (2004). Mental well-being in settings of
'complex emergency': an overview. Journal of Biosocial Science,
36(4), 381-388.
Bhutani J, Bhutani S, Balhara Y, Kalra S (2012). Compassion fatigue
and burnout amongst clinicians: a medical exploratory study. Ind. J.
Psychol. Med. 34(4): 332-337.
Bush N (2009). Compassion fatigue: are you at risk? Oncology Nursing
Forum.36(1): 4-28.
Cañadas-De la Fuente G, Vargas C, San Luis C, García I, Cañadas G,
De la Fuente E. (2015). Risk factors and prevalence of burnout
syndrome in the nursing profession. International Journal of Nursing
Studies. 52(1):240-249.
Craig C (2010). Compassion satisfaction, compassion fatigue, and
burnout in a national sample of trauma treatment therapists. Anxiety,
Stress & Coping. 23(3):319-339.
Dahlberg K, Drew N, Nyström M (2001). Reflective Lifeworld Research.
Lund, Sweden: Studentlitteratur.
Elkonin D, van der Vyver L. (2011). Positive and negative emotional
responses to work-related trauma of intensive care nurses in private
health care facilities. Health SA Gesondheid. 16(1):1-8
Ghobarah HA, Huth R, Russett C (2004). The post-war public health
effects of civil conflict. Social Science & Medicine. 59:869-884.
Giorgi A (1975). An application of phenomenological method in
psychology. In: Giorgi A, Fischer CT, Murray EL, editors. Duquesne
Studies in Phenomenological Psychology. Vol. 2. Pittsburgh PA:
Duquesne University Press.
Giorgi A (1997). The theory, practice and evaluation of the
phenomenological method as a qualitative research procedure. J.
Phenomenol. Psychol., 28:235-260.
IBM Corp. (2011). IBM SPSS Statistics for Windows, Version 20.0.
Armonk, NY: IBM Corp.
Kim S (2013). Compassion fatigue in liver and kidney transplant nurse
coordinators: a descriptive research study. Progress In
Transplantation. 23(4):329-335.
Klappa SG, Crocker R (2013). Interprofessional collaborative practice
during disaster relief work in Haiti: An ethnographic study. HPA PTJ
PAL. 13(4); J1-11.
Klappa SG, Audette J, Do S. (2014). The role of physical and
occupational therapists in disaster relief post-earthquake Haiti 2010.
Disability and Rehabilitation. Early Online, May 2013. 35:1-9. ISSN
0963-8288. Print: 36(4):330–338. ISSN 0963-8288 print/ISSN 1464-
5165 online.
Klappa SG, Howayek R, Reed K, Scherbarth B, Klappa SP (2015).
Compassion fatigue among new graduate physical therapists. Global
Journal of Medicine, Physical and Health Education. September
2015. 3(4): 100-111.
Klappa SG, Crocker R, Hughes L, Thompson J, Klappa SP. (2016).
Predicting compassion fatigue: A model for disaster relief workers.
Manuscript previously submitted to the HPA PTJ PAL November
2015. Accepted Sept. 18, 2015. In Press January 2016.
McMullen L (2007). Oncology nursing and compassion fatigue: caring
until it hurts. Who is caring for the caregiver? Oncology Nursing
Forum. 34(2):491-492.
Musa S, Hamid A. (2008). Psychological problems among aid workers
operating in Darfur. Social Behavior and Personality. 36(3): 407-416.
Peterson Owen, R, Wanzer, L. (2014). Compassion fatigue in military
healthcare teams. Archives of Psychiatric Nursing. 28(1): 2-9.
Potter P, Deshields T, Olsen S, et al. (2010). Compassion fatigue and
burnout. Clinical Journal of Oncology Nursing. 14(5):E56-62.
Potter P, Deshields T, Berger J, Clarke M, Olsen S, Chen L. (2013).
Evaluation of a compassion fatigue resiliency program for oncology
nurses. Oncology Nursing Forum. 40(2): 180-187.
Rosenblatt P. (1995). Ethics of qualitative interviewing with grieving
families. Death Stud. 19:139-155.
Shawcross W (2000). Deliver us from evil: Peacekeepers, warlords and
a world of endless conflict. New York: NY: Simon & Schuster.
Sideris T. (2003). War, gender and culture: Mozambican women
refugees. Social Science & Medicine, 56(4), 713-724.
Smart D, English A, James J, Wilson M, Daratha K, Childers B, Magera
C. (2014). Compassion fatigue and satisfaction: a cross-sectional
survey among US health care workers. Nursing and Health Sciences.
March 2014; 16(1): 3-10.
Stamm BH (2010). The Concise ProQOL Manual. 2nd edn. Updated
2010. Retrieved from:
Glob. J. Med. Phys. Health Educ. 137
http://ProQOL.org/uploads/ProQOL_Concise_2ndEd_12-2010.pdf
Accessed September 30, 2014.
Teyhen DS. (1999). Physical therapy in a peacekeeping operation:
Operation Joint Endeavor/Operation Joint Guard. Military Medicine.
164(8): 590-594.
Thieleman K, Cacciatore J (2014). Witness to suffering: mindfulness
and compassion fatigue among traumatic bereavement volunteers
and professionals. Social Work. January 2014; 59 (1): 34-41 (26 ref).
Thomas SP, Pollio HR (2002). Listening to patients: A
phenomenological approach to nursing research and practice. New
York, New York: Springer Publishing Company.
van Manen M (1997). Researching lived experience: Human science for
an action sensitive pedagogy. 2nd ed. London, Canada: Althouse
Press.
Voss Horrell S, Holohan D, Didion L, Vance G. (2011). Treating
traumatized OEF/OIF veterans: how does trauma treatment affect the
clinician? Professional Psychology: Research & Practice. 42(1):79-
86.
Weidlich C, Ugarriza D (2015). A pilot study examining the impact of
care provider support program on resiliency, coping, and compassion
fatigue in military care providers. Military Medicine. 180(3): 290-295.
