Emotional Wellbeing and The Healthcare Workforce: A Review
NYC Health + Hospitals/North Central Bronx, NY, USA
Healthcare systems have long recognized the impact of adverse health events on patients and families, and in recent years have gone further to identify the resulting emotional strains on the healthcare workforce. This attention to emotional health, which has been described as the overall state of one's emotions and the ability to manage and adapt to stressors, is also referred to as "emotional wellness" or "wellbeing." As this concept of wellness expands and evolves in the midst of the COVID-19 pandemic into a priority on the wellbeing of those in the helping professions, the current review explores the existing literature on the impact of compassion fatigue, compassion satisfaction, and their relationship to occupational burnout, with the conclusion that the emotional wellness of healthcare stakeholders and the health of an organization itself are not mutually exclusive. A review of these identified areas of occupational wellness is conducted, as well as a summary of findings emphasizing its significant implications for the healthcare workforce moving forward, both in relation to tangible costs to the healthcare industry and its reach to the bedside in the form of reported patient experience.
Adverse events in healthcare settings have been defined as "an injury that was caused by medical management (rather than the underlying disease) and that prolonged the hospitalization, produced a disability at the time of discharge, or both" (Brennan et al., p. 370)1. The devastating impact of such events for patients and their families cannot be overstated, and has been an important and longstanding area of regulatory research and policy2. In turn, the resulting emotional strain of such events on the healthcare workforce and the systems within which they occur continues to be investigated in the existing literature, with organizational support evidenced through the proliferation of employee wellness programs. As this issue of wellness expands and becomes a priority within traditional healthcare organizations and the community-at-large, the subject of workforce wellness has gained increasing attention in the last several years.
Amplified by our shared experiences during the COVID-19 pandemic, organizations have been compelled to expand their conceptual frame to incorporate the impact of compassion fatigue and its relationship to occupational burnout, with the conclusion that the emotional wellness of healthcare stakeholders and the health of an organization itself are not mutually exclusive. To facilitate and sustain this dyad moving forward, familiarity with these identified areas of emotional wellness, together with its impact on the "health of healthcare", would serve as a meaningful step towards informing organizations as to strategies, polices, and procedures to address the evolving needs of an ever-changing healthcare landscape.
The concept of compassion fatigue was introduced into the healthcare lexicon nearly thirty years ago3,4 in attempts to define the cumulative emotional impact of both direct and indirect exposure to patient trauma. The term has since been used interchangeably in the literature with secondary traumatic stress and vicarious traumatization, yet with slight variations in interpretation that nevertheless focus on compassion fatigue as the multilayered impact of helping others: emotionally, psychologically, and physically. The features consistent with compassion fatigue can mirror those of a post-traumatic stress disorder - itself defined as the result of direct exposure to a traumatic experience - to such an extent that the term secondary post-traumatic stress disorder is sometimes considered to describe the impact of secondary (or indirect) trauma exposure. Features include the following: an avoidance of stimuli (physical and/or emotional); hypervigilance; emotional numbing or inability to empathize; difficulties with concentration/attention; appetite and/or sleep disturbance; physical fatigue/ailments; irritability and lability of mood5,6.
The prevalence of compassion fatigue has historically been studied primarily amongst those working in the therapeutic professions7,8,9, and law enforcement10,11,12 with its real and often underappreciated impact on other roles also explored in recent years, such as jurors and spoken-language interpreters13,14,15. Yet with the arrival of COVID-19, recent studies have turned this lens towards the medical workforce with even more sobering results. A systemic review conducted by Vizheh and colleagues16 found the prevalence of self-reported anxiety, depression, and stress among healthcare workers exponentially increase since the start of the COVID-19 pandemic, with the highest levels of emotional distress identified among nurses, female workers, frontline healthcare workers, younger medical staff, and workers in areas with higher infection rates. A 2021 study17 similarly found increased rates of depression and Post-Traumatic Stress Disorder among healthcare professionals since COVID-19, with nearly 25% showing signs of PTSD and nearly 50% signs of alcohol use disorder.
Yet long before compassion fatigue was introduced into the language of the workforce, there was the concept of occupational "burnout". First introduced by psychologist Herbert Freudenberger18,19 in the mid-1970s, Dr. Freudenberger's seminal work explored the emotional and physical consequences of those employed in the "helping" professions - physicians, nurses, psychologists, social workers, law enforcement, etc. Unlike compassion fatigue or secondary traumatic stress, which stem from indirect exposure to trauma, occupational stress is associated directly with one's work environment and institutional-related stressors. Some familiar occupational stressors include the well known culprits of salary, scheduling, caseload, deadlines, and limited resources. The course of burnout is gradual and cumulative, occurring either independent from compassion fatigue or stemming from such, and has become an increasing priority in the midst of the COVID-19 pandemic20,21.
The syndrome of burnout or institutional fatigue has continued to be the focus of research, most notably in the work of psychologist Christina Maslach22,23, who published the first and most widely used instrument for assessment of burnout, the Maslach Burnout Inventory (MBI)24. Initially designed for use with individuals employed in the helping professions, it has been psychometrically validated for use among a wide variety of occupations. Relatedly, one of the most significant developments in relation to workforce wellness occurred in 2019, when the World Health Organization (WHO) included Burnout in the 11th Revision of the International Classification of Diseases (ICD-11) as an occupational phenomenon25,26:
"syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed... characterized by three dimensions... (a) feelings of energy depletion or exhaustion, (b) increased mental distance from one's job or feelings of negativism or cynicism related to one's job, (c) reduced professional efficacy"
This identification of the consequences of burnout serves multiple important functions - distinguishing this phenomenon from other experiences such as depression or anxiety; destigmatizing the adverse emotional and physiological impact of organizational systems; recognizing its prevalence across the occupational landscape and providing systems an opportunity to focus its resources on addressing this now legitimized public health issue27.
A review of the elements of wellness would be incomplete without recognition of the other side of the coin: the important role compassion satisfaction plays in mitigating the risks of compassion fatigue and burnout. Not all those in the helping professions experience compassion fatigue, nor is the experience the same with every provider, and it is the degree to which one experiences satisfaction from working within these systems that can serve as a meaningful buffer to the cumulative impact of such. Studies have identified the significance of feeling fulfilled from the work of caregiving, together with the resulting altruistic rewards and sense of efficacy and competence in one's role as a helping professional28,29. Additional variables that have been found to bolster compassion satisfaction among the healthcare workforce include the availability of programming that supports wellness and resiliency, spreads awareness, and reinforces preventative measures; opportunities for professional growth; professional recognition (either formally or in the form of positive feedback about one's performance) and an organizational culture experienced as compassionate - essentially the inverse of contributors to burnout30,31,32,33.
To facilitate identification of these workforce elements, a number of self-assessments have also been created and tailored for those employed in the helping professions34. The most widely used and accepted such measure is the Professional Quality of Life Scale (ProQOL)35,36. An empirically reliable and validated screening measure that explores the positive and negative aspects of caregiving, the ProQOL is a 30-item questionnaire that asks responders to identify how often they have experienced a list of feelings over the preceding thirty (30) days on a 1-5 Likert Scale, with responses falling within the three domains of Compassion Fatigue, Burnout and Compassion Satisfaction.
The implications for healthcare are significant. In addition to the identified physio-emotional consequences of providing quality patient care, available statistics also highlight the significant organizational impact of workforce wellness on the larger healthcare systems within which healthcare providers operate. A report released by The Joint Commission in 201937 summarized a survey revealing that among healthcare systems, a significant patient safety and quality concern is burnout. The near daily media reports predicting an exodus among the healthcare workforce38,39,40 has also contributed to organizational reassessments of ways to both maximize wellness and mitigate risk of burnout. It has been calculated that physician burnout costs the healthcare industry an estimated $4.6 billion per year, and approximately $7600 per employed physician at the organizational level - even more concerning when these estimates are considered pre COVID-19 figures41. This reach also extends to the bedside in the form of patient experience, where patients have been found as less likely to recommend a facility to others in hospitals where nurses regularly work 13+ hours, and further tend to provide lower Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS, a publicly reported survey of patient experiences of hospital care) ratings overall when rating hospitals with longer shifts for nurses42. Errors stemming from burnout also carry additional burdens, with some estimates of errors cost approximately $20 billion per year overall and resulting in 100,000 deaths annually43.
The importance of wellness within healthcare systems has long been recognized. Yet as the longer-term consequences and emotional impact of COVID-19 on the healthcare workforce comes into focus, organizational approaches are evolving to expand beyond the limiting lens of adverse events and beyond traditional human resources programming. In the midst of urgency to stem this tide, the current landscape also brings with it an opportunity to broaden the scope from "wellness" to the more holistic "wellbeing" of the healthcare workforce44,45, and as studies begin to show the benefits to this approach at both organizational and workforce levels by virtue of increased productivity and retention46, continuing this trend within healthcare systems is within reach.
The author thanks Dr. Neena Philip and Dr. Haseen Sharma-Cooper for their ongoing mentorship and feedback.
Conflict of Interest
The authors declare no conflict of interest.
The author received no financial support for the research, authorship, and/or publication of this article.
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