Assessment of and Intervention for Compassion Fatigue in Psychotherapists

A 2017 meta-analysis of 90 studies related to compassion fatigue confirms that healthcare professionals across all disciplines experience impairments to their physical, mental, and interpersonal health caused by work-related stress. This project explored whether a compassion fatigue workshop increased awareness of the phenomenon and reduced the level of compassion fatigue present in members of a small, private mental health care clinic in Provo, Utah.Psychotherapists were asked to complete the Professional Quality of Life Questionnaire (Pro QoL) and a short survey prior to attending an educational workshop designed to address compassion fatigue, (CF). A one-hour workshop that educated participants about the sign/symptoms, epidemiology, risk factors, treatment and outcomes of CF was delivered. One week following the completion of the workshop, participants completed a second Pro QoL and a short survey. The pre- and post-workshop Pro QoL responses were analyzed for change using a Wilcoxon signed-rank test. A 5-point Likert scale was used to rank participants' level of concerns regarding CF in professional life and the strength of its effect on them individually. Therapists practicing at a Utah County mental health clinic indicated low levels of burnout and secondary traumatic stress on the pre-intervention Pro QoL. The site had average to high levels of compassion satisfaction. A total of four participants completed both the pre- and post-Pro QoL and survey (n=4), which precluded any meaningful conclusions about the workshop's efficacy. In a short questionnaire, using a Likert-type scale, participants rated CF as an important concern in their professional lives with a mean score of 4.79 (n=13). They also indicated that CF significantly affected them on a personal level with a mean score of 3.24 (n=13). Despite working without a protocol targeting the management of CF, therapists at this clinic appear to be effectively managing CF. Pre-intervention Pro QoL scores for burnout and secondary traumatic stress were low before the CF workshop intervention. Workshop participants found it helpful according to participant feedback gathered at the conclusion of the workshop. The small number of participants precludes generalization of results to other settings.

Assessment of and Intervention for Compassion Fatigue in Psychotherapists Karl Tucker The University of Utah College of Nursing In partial fulfillment of the requirements of the Doctor of Nursing Practice 1 Abstract Background: A 2017 meta-analysis of 90 studies related to compassion fatigue confirms that healthcare professionals across all disciplines experience impairments to their physical, mental, and interpersonal health caused by work-related stress. This project explored whether a compassion fatigue workshop increased awareness of the phenomenon and reduced the level of compassion fatigue present in members of a small, private mental health care clinic in Provo, Utah. Methods: Psychotherapists were asked to complete the Professional Quality of Life Questionnaire (Pro QoL) and a short survey prior to attending an educational workshop designed to address compassion fatigue, (CF). A one-hour workshop that educated participants about the sign/symptoms, epidemiology, risk factors, treatment and outcomes of CF was delivered. One week following the completion of the workshop, participants completed a second Pro QoL and a short survey. The pre- and post-workshop Pro QoL responses were analyzed for change using a Wilcoxon signed-rank test. A 5-point Likert scale was used to rank participants' level of concerns regarding CF in professional life and the strength of its effect on them individually. Results: Therapists practicing at a Utah County mental health clinic indicated low levels of burnout and secondary traumatic stress on the pre-intervention Pro QoL. The site had average to high levels of compassion satisfaction. A total of four participants completed both the pre- and post-Pro QoL and survey (n=4), which precluded any meaningful conclusions about the workshop's efficacy. In a short questionnaire, using a Likert-type 2 scale, participants rated CF as an important concern in their professional lives with a mean score of 4.79 (n=13). They also indicated that CF significantly affected them on a personal level with a mean score of 3.24 (n=13). Conclusions: Despite working without a protocol targeting the management of CF, therapists at this clinic appear to be effectively managing CF. Pre-intervention Pro QoL scores for burnout and secondary traumatic stress were low before the CF workshop intervention. Workshop participants found it helpful according to participant feedback gathered at the conclusion of the workshop. The small number of participants precludes generalization of results to other settings. 3 Introduction Problem Description A meta-analysis of 90 studies related to compassion fatigue identified that healthcare professionals across all fields of expertise experience impairments to their physical, mental, and interpersonal health caused by work-related stress (Sinclair et al., 2017). Compassion fatigue (CF) is a strong predictor of poor job satisfaction and has a negative effect on clinical outcomes for patients (Baggerly & Osborn, 2006). In addition, a positive correlation between CF and ethical breaches committed by healthcare workers was found (Gentry, 2007). There is currently no industry standard for employers of healthcare workers to identify and support healthcare workers who experience CF. Existing programs that educate healthcare professionals about compassion fatigue and how to recognize its symptoms are clearly lacking in the literature. Furthermore, workplace programs to guide their workers into treatment for CF need to be put into place. Available Knowledge Compassion fatigue is a concept created in psychotherapy that was adapted by the nursing profession, where it has been studied most extensively. A distinct phenomenon, it has been established to occur in all areas of healthcare work (Sinclair et al., 2017). Little work has been done to challenge the tenets of compassion fatigue, but researchers of compassion fatigue uniformly concur that providers experiencing compassion fatigue are most likely to be affected in a way that has a negative effect on patient care (Alkema et al., 2008; Canadian Nursing Association, 2010). 4 While CF is clearly present in all healthcare settings, broad applications of conceptual framework to manage CF is a challenge. It is hard to imagine how the cause, assessment, treatment, implications, and outcomes of CF could be the same for a psychotherapist, an ICU nurse, a hospice nurse, a family practitioner and a crisis worker (Sinclair et al., 2017). Another limitation to the identification and management of CF is the varying definitions of compassion. Most research focuses on the behaviors and motivators of compassion without taking into consideration other identified components of compassion, which include virtues, a proactive response, seeking to understand, relational communicating, confronting and actions (Sinclair et al., 2017). The antecedents, risk factors and pathways of CF must be delineated in an applicable way across healthcare settings before the phenomenon of CF can grow in validity and confidence in the academic world (Sinclair et al., 2017). Another limitation identified in current CF research is the lack of a uniform definition of CF coupled with no established diagnostic criteria for CF. Current literature identifies the application of over 40 symptoms in the discussion of CF (Huggard, 2016; Mathieu, 2008). Other assessment problems exist in research, including the use of the Professional Quality of Life Assessment (Pro QoL), which is an assessment tool used to assess life satisfaction amongst working professionals. The Pro QoL is the dominant method used to screen for CF. The uniform use of the Pro QoL is helpful when comparing study results; however, it is lacking as a valid tool for measuring CF. The Pro QoL reduces the concept of CF to a metric for professional and personal satisfaction. It does not assess for compassion or other common elements of CF such as trauma, 5 cognitive symptoms, psychological distress, and burnout (Bride et al., 2007; Ledoux, 2015). More work needs to be done in the development of an appropriate measurement tool for CF. 6 Rationale Components of education and intervention used in this educational workshop were drawn from an assortment of research conducted by various authors. An article by Sinclair et al. (2017) provides an extensive compilation of research related to both education and interventions for CF. Teaching materials for this project were primarily drawn from this source (Sinclair et al., 2017). The rationale for the workshop portion of this program can be divided into two primary components: educating about CF and discussing proactive interventions for those experiencing or at risk of CF. The theoretical framework for this project used was the Health Belief Model (HBM). This model is used to predict, influence and understand health behaviors. The HBM is divided into three distinct stages: (1) individual perceptions, (2) modifying factors, and (3) likelihood of action. In the first stage, participants were assessed for their individual perceptions related to CF. This was accomplished through the administration of the Pro QoL and an additional short questionnaire (Appendices A, B). In the second stage clinicians participated in a workshop to learn more about CF and learn about effective interventions to prevent as well as manage CF. In the third stage, likelihood of change was assessed through the re-administration of the Pro QoL and an additional short questionnaire. These data were assessed to evaluate the need for further intervention and the efficacy of the CF workshop. Education. The education component of this project focused specifically on symptom recognition. This was done to help participants recognize signs and symptoms 7 of CF and be better able to seek treatment or intervene in their individual lives. The effects of CF are very broad. Gentry et al. (1997) broke them into three domains: physical, psychological and spiritual. These domains describe the myriad effects on the individual. Some of these effects include maladaptive changes to identity and existential well-being. Untreated, it is conjectured that these effects may spread to the social circle of the individual suffering from CF. There are even implications of generational effects. Commonly identified physical symptoms of CF include exhaustion, insomnia, poor immunity, somatic complaints, headaches, upset stomach, sleep disturbance, emotional fatigue, and hypochondria (Mathieu, 2008; Huggard, 2016). Behavioral symptoms reported in CF include increased alcohol and illicit drug consumption, irritability, strained personal relationships, increased absenteeism at work and with other responsibilities, higher attrition rates, avoiding patients, diminished clinical decision making, increased ethical breaches, and compromised patient care (Mathieu, 2008; Huggard, 2016). Common psychological symptoms reported with CF include emotional fatigue, distancing relationships, poor self-image, depression, reduced sympathy and empathy, cynicism, resentment, dread related to certain patients, helplessness professionally, reduced career satisfaction, depersonalization, fear, broken worldview, increased anxiety, irrational fears, increased feelings of personal vulnerability, intimacy problems, intrusive thoughts, avoidance, increased or decreased sensitivity to emotionally charged situations, problems separating personal and professional life, and failure to nurture/engage in non-work aspects of life (Mathieu, 2008; Huggard, 2016). Intervention and Prevention. Hevezi (2015) conducted a study on the effects of 8 meditation on CF in registered nurses working in the oncology setting. The sample size of this study was a modest 17 participants, but the results showed a significant increase in job satisfaction (p = 0.027), with a corresponding reduction in burnout (p = 0.003) and secondary trauma (p = 0.047). Flarity et al. (2013) also used meditation as a primary component of a program targeting the reduction of compassion fatigue. This program included 73 registered nurses working in the emergency department. The results of the intervention showed an increase in job satisfaction (p = 0.0004), with a corresponding reduction in burnout (p < 0.001) and secondary trauma (p = 0.001) in the study participants. Weidlich and Ugarriza (2015) collected data on a program targeting the reduction of CF by implementing a program targeting self-awareness and self-care. The program consisted of 93 registered nurses/licensed practical nurses/medics at an army medical center. There was a significant reduction in burnout among participants (p < 0.001). Potter et al. (2013) studied the effect of a CF resiliency program. This program utilized concepts of self-care, self-validation, connection, and intentionality to teach regulating skills to its participants. Thirteen registered nurses working with oncology patients comprised the group of participants. Researchers saw a significant decrease in secondary trauma that was sustained in the six months following the program (p < 0.05). Supported by the preceding evidence, this project focused on the design and implementation of an educational CF workshop targeting concepts of self-care, selfmanagement, awareness, professional assistance, connection, intentionality, and meditation in order to provide participants with education and skills to prevent and treat CF in their personal lives. 9 Despite more than 20 years of research, scholarship surrounding CF is still in its infancy. This is evidenced by the small sample sizes and limited number of publications related to the treatment of CF. While research points the healthcare community in the direction of evaluating for the presence of CF and its subsequent management, it falls short of providing professional consensus of the best practices when it comes to treating CF. The available knowledge does not provide appropriate context of the phenomenon for all health care providers who may be at risk for or actually experiencing CF. All of the research that underpinned this project was conducted on registered nurses or subsets thereof. It is assumed that the care protocols proven efficacious in treating nurses with CF will also guide the approach to treating counseling therapists who are at risk of or currently experiencing CF. This project focused largely on education about the symptoms of CF with the assumption that this will be the most valuable material for participants to recognize and manage CF in their practice. Other possible focuses may include a focus on prevention, family history, workplace culture and relationships, or a comprehensive organizational approach to work environment and employee support. Specific Aims The purpose of this project was to increase awareness of compassion fatigue and educate therapists at a privately-owned mental health clinic through implementation of a workshop and development of a tool kit to address compassion fatigue. The aim was to improve patient care by enhancing the well-being of therapists through reduction of CF burden in the healthcare professionals who care for patients in a mental healthcare setting. 10 Methods Context The clinical site for implementation of the project was one of multiple clinics operated by a larger mental health services system in Utah County. This site provides mental health treatment for pediatric Medicaid patients suffering from a wide range of mental illnesses. The clinic located in Provo, Utah, serves a suburban, culturally and ethnically diverse patient population of lower socio-economic status. Mental health professional staff who treat clients at this location is composed of approximately 12 clinical therapists, two prescribing practitioners and two registered nurses. Participants in this project include the 10 therapists practicing at the implementation site. The clinic staff is managed by Clinic Supervisor Scott Taylor and Assistant Supervisor Elizabeth Feil. There were no similar or competing projects being conducted at the clinical site during implementation of this project. Interventions Objective 1. Assess therapists in the selected clinical site for the presence of compassion fatigue and knowledge regarding the phenomenon. In order to accomplish this objective, staff members were assigned a random three-digit identification number in order to protect the anonymity of participants. Staff members completed the Pro QoL questionnaire and a brief survey prior the workshop to evaluate the presence and severity of CF (Appendices A and B) Objective 2. Develop a compassion fatigue presentation and tool kit for use in the selected clinical site. The CF workshop was based on a presentation curated by Dallas 11 Earnshaw (2019). Dallas is the superintendent of the Utah State Hospital, which is a mental hospital located in eastern Provo, Utah, United States of America. He is an advanced practice registered nurse (APRN) specializing in mental health and has presented at multiple professional conferences on the topic of CF (Earnshaw, 2019). As part of the CF tool kit, worksheets were printed and provided to the participants to help them identify personal areas of risk for CF and to help them identify and set goals for the prevention and treatment of CF. The worksheet included discussion about five key warning signs of compassion fatigue: arousal, intrusion, avoidance, depression, and dissociation. There was also a discussion and handout given regarding a preventative wellness workshop for CF, which included a discussion regarding self-care, selfmanagement, developing awareness, seeking professional assistance, connecting with others, intentionality, and meditation (Appendix C). Participants were also made aware of the benefits offered by the parent healthcare system that could be used by therapists to prevent or treat existing CF. Some of these benefits include six sessions of paid therapeutic counseling, paid vacations, and support provided through supervisors staffed at the clinical implementation site. Objective 3. Implement a compassion fatigue workshop with members of the clinical practice. The CF workshop took place on January 2, 2020. There were 10 staff members in attendance. The presentation was one hour in length. It consisted of a discussion-aided PowerPoint that targeted prevention and treatment of CF. Objective 4. Evaluate compassion fatigue approximately one week after the intervention using the Pro QoL questionnaire to determine the effect of the presentation 12 on staff. In order to accomplish this objective, using the same three-digit identification number, staff members again filled out the Pro QoL questionnaire and a brief survey. Results from pre-workshop questionnaires were compared to post-workshop results for change. Study of the Interventions The Pro QoL was chosen as the primary tool to measure both the presence of and risk for CF before the intervention and as a means to assess the impact of the intervention following the workshop. Despite its limitations, the Pro QoL was chosen because it was the most commonly used measurement tool in research studies of CF (Sinclair et al., 2017). Participants were asked to complete the Pro QoL before attending the CF workshop. One week following the workshop, participants were asked to complete the Pro QoL for a second time. Results from the pre- and post-workshop Pro QoL tool were compared to assess for change. Responses from questionnaires used to collect participant feedback of the workshop were also analyzed word for word and categorized. 13 Measures The Pro QoL, a valid and reliable tool, was found to be the most commonly used measure of CF in the evidence that underpins this project. The uniform use of the Pro QoL in studies reviewed was helpful when comparing and analyzing study results. However, it is not a specific measure of CF. The Pro QoL reduces the concept of CF to a metric for professional and personal satisfaction. It does not assess specifically for compassion or other common elements of CF, such as trauma, cognitive symptoms, psychological distress, and burnout (Bride et al., 2007; Ledoux, 2015). Researchers assessed the construct validity of the Pro QoL using a sample of 310 child protection workers (Geoffrion et al., 2019). They found that the Pro QoL moderately correlated with the Posttraumatic Disorder Checklist (r = -.427, p < .001). They also found a strong correlation with scales of work well-being (r = .694, p < .001) and psychological distress at work (r = -.666, p < .001). Researchers in another study also assessed the construct validity of the Pro QoL using a sample of 1615 registered nurses (Heritage et al., 2018). They found that the Pro QoL performed adequately as a measurement tool of compassion satisfaction. However, the Pro QoL did not show adequate measurement properties in relation to burnout and secondary stress. Studies related to the validity and reliability of the Pro QoL are very limited. In addition to taking the Pro QoL, participants were asked to complete a short questionnaire following the CF workshop (Appendix B). The content of this questionnaire related to participants' feedback regarding the efficacy, applicability, and 14 format of the workshop. It used Likert-type scale questions related to participants' personal beliefs about CF and its impact in their lives. Additionally, free text questions were administered, allowing participants to anonymously rate and give feedback regarding the CF workshop. This feedback will be reviewed and incorporated into future CF workshops. Ethical Considerations This project was determined to be a quality improvement project and therefore did not require review and approval by the University of Utah IRB. Participants were informed that participation was voluntary and were free to stop participation at any time if they desired. All questionnaire responses were coded for participants to de-identify data. Codes were kept in a password-protected computer to which only the project leader had access. Data were reported in aggregate format to prevent the identification of individual responses. Discussion Results The CF workshop was held on January 2, 2020, in a conference room at the project site. The workshop lasted one hour. Content of the CF workshop consisted of a one-hour discussion-aided PowerPoint that targeted prevention and treatment of CF. Ten participants attended the CF workshop and of those 10, only four completed the requisite pre- and post-survey material due to scheduling conflicts. The small sample size made use of inferential analyses of the data untenable regarding the effect of the workshop. The Pro QoL divides its results into three sections, analyzing a Compassion 15 Satisfaction Score (CSS), a Burnout Score (BS), and a Secondary Traumatic Stress Score (STSS). Participants who completed the Pro QOL at the implementation site had a mean CSS of 38.83. This score is associated with an average level of compassion satisfaction among participants at the implementation site (Table 2). Therapists at the implementation site had a mean BS of 21.09, indicating a low level of burnout among clinicians at the implementation site (Table 2). Participants had a mean STSS sum of 20.55, indicating low STSS levels among clinicians at the clinic (Table 2). The short survey questionnaire used a five-point Likert-style format, with a score of "1" indicating "not important at all or does not affect me on a personal level" and a score of "5" indicating "very important or significantly affects me on a personal level." Results showed that participants rated CF as an important concern with a mean score of 4.79 (n=13). They also indicated that CF significantly affected them on a personal level with a mean score of 3.24 (n=13) (Table 3). Results indicate that therapists at site are managing their CF reasonably well. Short answer free text questions were provided for comments and responses from participants in the workshop (Appendix D). These questions related to self-care skills and techniques to prevent compassion fatigue and were included in the questionnaire in order to catalog skills employed by clinicians at implementation site as well as determine the presence of deficits in self-care techniques for CF. Analysis of these questions showed that participants were already using many positive skills. These skills included exercise, healthy eating, healthy sleep habits, talking with family/friends/co-workers, mindfulness meditation, and healthy work-life boundaries. One deficiency observed was the lack of 16 therapists utilizing therapy in their personal lives. Only one participant reported utilizing therapy in their personal life. Feedback gathered regarding the workshop was mostly positive. One participant stated it would have been ideal to have had more time to discuss coping strategies. Summary Data gathered through the pre-intervention Pro QoL indicate that therapists at the implementation site are at low risk for CF. With the exception of one participant, all others endorsed having friends at work with whom they could discuss problems and indicated that they felt they could talk to their supervisor if they were struggling with CF. Free text answers related to activities and skills used to promote self-care and prevent CF showed that therapists at the implementation site are using a variety of skills to manage CF's effects on their lives. Participant feedback (n=6) indicated the workshop was beneficial, with a mean score of 4.5 on a 5-point Likert-type scale where "1" represents "not beneficial" and "5" represents "very beneficial" (Table 4). Interpretation Of the 29 studies that reported prevalence related to CF in the meta-analysis conducted by Sinclair et al. (2017), none of them include a population of therapists similar to the one studied in this project. Findings in those studies showed that 7%-61% of participants were at high risk for compassion fatigue, depending on their field of healthcare work. Laverdiere et al. (2019), conducted a study of 240 psychotherapists using the Pro QoL to measure the prevalence of CF. These results showed CS mean score of 41.45, BS mean score of 19.87, and STS mean score of 19.21, all of which were 17 similar to findings in this project. The Pro QoL divides its results into three sections, analyzing a Compassion Satisfaction Score (CSS), a Burnout Score (BS), and a Secondary Traumatic Stress Score (STSS). The Compassion Satisfaction Score (CSS) measures the pleasure one derives from his or her ability to accomplish one's work well. The ProQoL divides individuals into three levels of compassion satisfaction: low, average and high. A score of 22 or less equates to low levels of Compassion Satisfaction (CS). A score between 22 and 41 equates to average levels of CS. A score of 42 or more equates to high levels of CS. Individuals scoring in the high levels of CS derive a good deal of professional satisfaction from their position. Individuals scoring in the low levels of CS are not satisfied with their jobs, or they derive greater satisfaction from activities other than their jobs (Appendix A). Participants who completed the Pro QOL at the implementation site had a mean CSS of 38.83. This score is associated with an average level of compassion satisfaction among participants at the implementation site (Table 2). The Burnout Score (BS) measures one of the elements of CF. The BS is associated with feelings of hopelessness and difficulties in dealing with work or in doing one's job effectively. These negative feelings usually have a gradual onset. They can reflect the feeling that one's efforts make no difference. These negative feelings may also be reflective of a very high workload or a non-supportive work environment. Higher scores on this scale indicate a higher risk for burnout. The Pro QoL divides individuals into three levels of burnout: low, average and high. A score of 22 or less equates to low levels of burnout. A score between 22 and 41 equates to average levels of burnout. A 18 score of 42 or more equates to high levels of burnout. The average score for the BS is 50 (SD 10; alpha scale reliability .75). A score in the low level of burnout indicates more positive feelings about one's ability to be effective in one's work. A score in the high level of burnout indicates a lack of feeling effective at one's work. An individual's score may reflect their mood; perhaps he or she was having a "bad day" or in need of some time off. If the high score persists or if it is reflective of other worries, it may be a cause for concern (Appendix A). Therapists at the implementation site had a mean BS of 21.09, indicating a low level of burnout among clinicians at the implementation site (Appendix A). The Secondary Traumatic Stress Score (STSS) measures one's work-related, secondary exposure to extreme stress and trauma in the course of one's work. Developing secondary trauma from exposure to another's trauma is somewhat rare but does happen to many people who care for those who have experienced trauma. The phenomenon of vicarious traumatization occurs in persons who are repeatedly exposed to patients recounting traumatic events in their lives. This is not uncommon among therapists and emergency workers. The symptoms of secondary traumatic stress (STS) are usually rapid in onset and associated with a particular event. They may include being afraid, having difficulty sleeping, having images of the upsetting event pop into your mind, or avoiding things that remind you of the event. The average score on STSS is 50 (SD 10; alpha scale reliability .81). The Pro QoL divides individuals into three levels of STS: low, average and high. A score of 22 or less equates to low levels of STS. A score between 22 and 41 equates to average levels of STS. A score of 42 or more equates to high levels of STS. 19 While higher scores do not necessarily indicate a problem with the respondent, some introspection about one's work environment and feelings about the work one does may need to be examined. The therapist may wish to discuss this with their supervisor, a colleague, or a healthcare professional (Pro QoL, appendix A). Participants had a mean STSS sum of 20.55, indicating low STSS levels among clinicians at the clinic (Table 2). Questionnaire results showed that none of the participants were at high risk for compassion fatigue when compared to previous studies of psychotherapists (De La Rosa et al., 2018). High levels of Compassion Satisfaction were found in 31% of participants and 69% had average levels of Compassion Satisfaction. Burnout Risk was found to be low in 75% of workshop participants and 56% were at low risk for Secondary Traumatic Stress. Before this project, there was no definitive measure of data to indicate how therapists at the implementation site were managing CF or to what extent they were affected by it. These findings were reassuring from the standpoint that therapists at the site were managing professional burnout reasonably well. One surprising observation was the lack of therapists who reported using individual therapy in their personal lives. Only one participant reported engaging in individual therapy in their personal life. It is impossible to determine the effect of the workshop on participants as a whole due to a lack of participants who completed both the pre- and post-Pro QoL assessments and also participated in the workshop. Although 10 therapists attended the workshop, only four participants completed all three components of the project. This sample is too small to draw conclusions about the efficacy of the workshop. 20 The costs of this project were primarily opportunity costs. These opportunity costs were relatively minimal as the CF workshop was held during a regularly scheduled meeting time for the purpose of staff improvement. An additional time cost was placed on participants to fill out the required questionnaire data. This requirement amounted to a total time investment of approximately 20-30 minutes. Limitations Multiple factors made it difficult to assess for change related to the CF workshop. The biggest statistical limitation is seen in the small number of participants who completed the pre- and post-survey material and attended the workshop. Unfortunately, many individuals who completed the pre-workshop survey material were unable to attend the workshop. Ten participants attended the CF workshop and of those 10, only four completed the requisite pre- and post-survey material. A sample size of four was insufficient to show change or infer any benefit from the intervention. This problem was exacerbated by the constrained timeframe over which the project was able to be conducted. With more time, the CF workshop could have been held multiple times to accommodate the schedules of more participants. Another factor that limited the ability to assess for change related to the CF workshop was the relatively positive overall mental health of the therapists practicing at this site. The Pro QoL showed high or average level of compassion satisfaction and low levels of both burnout and secondary trauma. It may be difficult to show change in participants related to the CF workshop who already perceive low levels of CF. This does not necessarily mean that the CF workshop was without value. Its value is evident from participants' feedback, the majority of which 21 reported the experience as positive and helpful. In this context and setting with this group, the CF workshop may serve as a preventative measure. While there is a large body of research related to CF in medical provider populations (nurses, doctors, first-responders), there is a paucity of studies that explore the effect of CF on therapists specifically. Compassion fatigue does not have a uniform definition, nor are there established diagnostic criteria for CF (Huggard, 2016; Mathieu, 2008), creating difficulty when developing educational material targeted at treating CF. While best efforts were made to draw from academic research in the development of the CF workshop, it is unknown if the educational techniques used in this workshop were effective in treating or preventing CF. The Pro QoL tool provided some objective measure of CF, but inferences drawn from the brief survey were more subjective in nature. Conclusions The usefulness of this project can be explored in terms of its value for therapists at the implementation site and in terms of its contribution to the academic study of CF, specifically CF among practicing psychotherapists. Results served to demonstrate to this group the extent to which CF is a problem in their practice setting. Findings should be considered reassuring to the group. While the effectiveness of the CF workshop cannot be confirmed from project findings, this project does provide valuable information regarding the prevalence of CF amongst therapists, in an outpatient clinic, working with pediatric clients of low socioeconomic status. Findings from this project may be compared to other similar 22 populations if such studies exist, but these findings cannot be generalized due to the small sample size. One would also have to explore characteristics of this particular group of participants that may be contributing to low levels of CF within the practice, which may be accounted for by such factors as staffing composition, scheduling load of patients, type and characteristics of patients seen, the leadership style of administration within the practice, a healthier culture within the practice, and healthier interpersonal relationships among the staff at the selected clinical site. This project is not sustainable at this time, primarily because there is no one currently assigned to manage the continuation of this project. However, the continuation of this project is certainly feasible and would only require a minimal commitment from staff at the implementation site. Leadership at the clinical site would have to determine the value of this project and define how often they would need to assess and educate staff about CF. With this parameter established, a project manager would have to be assigned to disseminate, collect, and analyze the Pro QoL and brief survey. Additionally, the assigned project manager would have to incorporate feedback from the previous CF workshop in order to improve the educational experience. Lastly, the project manager would be responsible for teaching the workshop at intervals designated by implementation site leadership. Acknowledgments Pamela Phares helped in the development of the design and methodology of this project. She was also the primary editor and writing consultant. Candace Barrett aided in the statistical analysis of data. Kristin Gibson served as editor. 23 24 References Baggerly, J., & Osborn, D. (2006, February). School counselors' career satisfaction and commitment: Correlates and predictors. Professional School Counseling, 9(3), 197-. Bride, B.E., Radey, M., Figley, C.R., 2007. Measuring compassion fatigue. Clin. Soc. Work J. 35, 155e163. 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Med. 180 (3), 290-295. 27 Table 1 Summaries on Demographics Number of responses for gender, ethnicity, and job title types: Gender Total Number Completed Both Pre & Post Female 4 1 Male 9 3 Non-binary 0 0 Ethnicity African American Asian Asian/Caucasian Caucasian Hispanic Native American Polynesian Other 0 0 1 11 1 0 0 0 0 0 0 4 0 0 0 0 Job Title/Degree (Blank) APRN-I Therapist Therapist Intern 1 1 10 1 0 0 4 0 Summaries of Age: Total Completed Pre & Post Min 25 40 Mean 40.85 49.25 Median 40.0 47.5 28 Mode 40 42 Max 62 62 Table 2 Non-paired Wilcoxon Test (i.e., Mann-Whitney Test) (pre: n = 9, post: n = 7) Median Difference (Post - Pre) Wilcoxon Statistic p-value CSS 4 45.0 0.1675 BS 0 33.0 0.9151 STSS 5 39.5 0.4238 This section tests to see if there is a difference in median score between those that took the pre survey (n=9) and those that took the post survey (n=7). The "median difference" is the difference between the median post-score and the median pre-score. There is no evidence that the average pre-survey Compassion Fatigue scores are different than the average post-survey scores. Non-paired t-tests (pre: n = 9, post: n = 7) Mean Difference (Post - Pre) t Statistic p-value CSS 3.2063 1.6034 0.1334 BS -0.4762 -0.2382 0.8159 STSS 1.8889 0.8498 0.4100 The sample size of the non-paired survey participants (individuals that completed surveys before or after the workshop but not both) was 13. This section tests to see if there is a difference in score between those that took the presurvey (n=9) and those that took the post-survey (n=7). The "mean difference" is the difference between the mean post score and the mean pre score. There is no evidence that the average pre-survey Compassion Fatigue scores are different than the average post-survey scores. Pro QoL Scores (pre: n = 9, post: n = 7) Pre-Survey Post-Survey Mean Mean CSS 37.2222 40.4286 29 Pre-Survey SD 5.1181 Post-Survey SD 2.7603 BS STSS 21.3333 19.1111 20.8571 21.0000 5.3385 4.7551 2.4103 4.1231 Table 3 Compassion Fatigue Perceptions (Short Survey Responses) Pre Survey Median (Mean/Mode) Post Survey Median (Mean/Mode) Difference Median (min, max) Importance of Compassion Fatigue Total (pre: n=11, post: 5 (4.73/5) 5 (4.86/5) NA n=7) Completed Pre & Post 5 (4.75/5) 5 (5/5) 0 (0,1) (n=4) Affects of Compassion Fatigue Personally Total (pre: n=11, post: 3 (3.27/4) 4 (3.71/4) NA n=7) Completed Pre & Post 3.5 (3.5/4) 4.5 (4.25/5) 0.5 (0,2) (n=4) Note that "difference" is the post-survey response minus the pre-survey response and only applies to those that completed both the pre- and post-surveys fully. Table 4 Compassion Fatigue Workshop Beneficial Min Mean Median Total (n=6) 3 4.5 5 30 Mode 5 Max 5 Appendix A Professional Quality of Life Scale 31 32 33 34 Appendix B Compassion Fatigue Questionnaire Demographics Gender- Circle your answer: (optional) Male Female Non-binary What is your ethnicity? Circle your answer: (optional) Asian Caucasian African American Native American Hispanic Other_________________ Polynesian What is your age?______ (optional) What is your Job Title/Degree?_________________ Questions: Have you ever heard of the term Compassion fatigue? Yes No How important is it to understand Compassion Fatigue in your line of work? Circle your answer. (1=not at all; 5=very important) 1 2 3 4 5 How much do you think Compassion Fatigue affects you personally? Circle your answer. (1=not at all; 5=causes significant problems in my personal/professional life) 1 2 3 4 5 Do feel like you have friends at work you can talk to if you are struggling? Yes No Do you feel you could approach your supervisors for help if you were struggling with stress, depression or compassion fatigue? Yes No What skills or techniques do you use to promote self-care in your life? (free text your answer below) What skills or techniques do you use to treat, prevent, or manage Compassion Fatigue in your life? (free text your answer below) 35 Complete After Attending the Compassion Fatigue Workshop Did you find the Compassion Fatigue Workshop beneficial? Circle your answer. (1=not at all; 5=very beneficial) 1 2 3 4 5 Do you have any feedback, questions, concerns, or comments regarding the Compassion Fatigue Workshop? (free text your answer below) 36 Appendix C Presentation Handout Compassion Fatigue Warning Signs Arousal Intrusion Avoidance Depression Dissociative Wellness Program Self-Care 37 Be Self-Managed Develop Awareness Seek Professional Assistance Connect With Others Intentionality Meditation 38 Appendix D Free Text Answers from CF Short Questionnaire What skills or techniques do you use to promote self-care in your life? Participant Responses: Regular exercise, healthy eating, talking to other therapists, vacations Running, talking to friends and family, sex Pre: Try to maintain balance between work and non-work. Exercise. Post: Set good boundaries between work and home life balance and know limits. Exercise Pre: Do many things with family. Community activities. Sports. Talk to outside professionals. Post: Meditation, Talk to family, Seek professional help. Mindfulness- being present at work and at home. Intentionality- Plan things to look forward to at the end of each day. Connect with friends and Family. Mindfulness. Recreational activity Ensuring that I have at least 1 hour a day for paperwork. Finding a way to best help the client so you both don't feel helpless. Having goals seems to help all involved. Pre: Exercise, reading, relaxation, guided meditation. Post: Knowing limits. Reducing or balancing expectations Pre: I used to have a good cry at the end of each day while thinking about my clients that I saw that day that helped. Now, however, I feel that the model of therapy I use constantly (in session) reminds me to carefully watch my triggers and deal with/comfort myself as they come up so I can be more present and calm in the moment. I take some time, when needed, to show self-compassion, breath, and calm my inner system. Pre: My primary self-care comes from doing daily check-ins with myself (e.g. stress levels, emotions) and depending on levels, engaging in self-care practices to meet that need. I mostly use mindfulness, grounding, thought modification, and music... but for special instances I have other skills that fit for specific needs. 39 Post: I set aside time to take care of myself. I regularly keep up with friends and family. For me what is most important is that it is intentional. Within that, I enjoy a variety of activities and the length of time is inconsequential. Post: Mindfulness, Gardening, Family time, Use time off, vacations, Dates What skills or techniques do you use to treat, prevent, or manage Compassion Fatigue in your life? Participant Responses: Pre: monitor; sleep, blood pressure, fatigue, physical pain. Post: spending time with family. Not talking about work. Mindfulness to leave work at work. Spiritual guidance. Pre: Talk to coworkers and boss when needed. Maintain good mental healthcare. Post: (Blank) Mindfulness. Recreational activity. De-brief with co-worker. Leave work at work. Get/take time to rest. Spend time with family. Exercise, eat well, and get enough sleep. Pre: (blank) Post: Reading, Walking, Watching a good movie. I carefully take time to sincerely listen to my inner system when I feel tired, exhausted or triggered and then respond appropriately. I do this daily and do self-therapy frequently. I use my coworkers, talking with them, letting them know if I'm okay. I also focus my efforts on positive self-talk and self-compassion. Additionally I will use distractions for a mental break. Regular self-care, also healthy coping, have people I can talk to. I've made a list of warning signs for compassion fatigue and for recognizing when I need a self-care break. Post: Exercise Yoga, Weight lifting, Gardening, Building things, talking with friends and wife. Feedback: Participant Responses: 40 I've been aware of compassion fatigue my whole career so I wasn't expecting this workshop to be as helpful as it was. It was very helpful to me as a professional. It also got me thinking about how we can better incorporate self-care/compassion fatigue prevention into life here at IMPLEMENTATION SITE. Thank you so much! I would like to have had more time to talk about coping strategies. It was a nice discussion and presentation balance. Well done. Good information Good to remember self-care and things that can happen that cause burnout or compassion fatigue. 41 Appendix E Health Belief Model Individual Perceptions Modifying Factors Modifying Factors ⦁ Knowledge Likelihood of Action Perceived Benefits/Barriers ⦁ Pre/Post-workshop survey Perceived Susceptibility ⦁ Pre/Post-workshop survey Perceived Threat ⦁ Pre-workshop perception/knowledge of Compassion Fatigue Cues to Action ⦁ Compassion Fatigue Workshop 42 Likelihood of Change ⦁ Pre/Post-workshop survey