The Mental Health and Wellbeing of Healthcare Practitioners. Группа авторов
(GMC ), [1]). The terms usually used to describe the experience of being affected by healthcare work have often been borrowed from other areas of practice and it is worth tracing their various histories here.
Compassion Fatigue: Sinclair et al.'s [2] review of the use of the term compassion fatigue provides us with a useful frame for considering how we talk about the psychosocial effects of working in healthcare. Compassion fatigue refers to the gradual erosion of compassionate feelings towards, for example, patients, because of the high demands and stressful nature of the job. The point that Sinclair and colleagues are trying to make, though, is that the term ‘compassion fatigue’ like many similar terms in healthcare, is used without due care or appropriate rigour. Ledoux [3] points out that rather than trying to connote a lessening of compassion, as if compassion were a finite resource running in only one direction, it could be worth noting that much of the difficulty in maintaining compassionate attitudes is related to those things which thwart the expression of compassion such as long working hours, too few staff for too many patients, lack of rest for staff or opportunities to offload concerns. This conceptualisation is much closer to that of moral distress which has also been extensively explored in nurses and which is discussed below. Interesting observations can be made about those factors which might explain how they occur, it may be that some caring strategies are simply more prone than others to result in compassion fatigue, for example, a tendency to have a ‘rescuing’ style of caring will result in difficult feelings if the patient cannot be ‘rescued’; a sense that perhaps the patient's illness is in part self‐inflicted will interfere with compassionate feelings; difficult or disrupted patient interactions might mean that satisfaction cannot so easily be gained from the encounter and thus the good feelings which might offset the difficult or depleting feelings cannot necessarily be accessed.
An alternative conceptualisation of compassion fatigue is proposed by Charles Figley in his 1995 book ‘Compassion Fatigue: Coping with Secondary Stress Disorder in Those Who Treat the Traumatised’ in which compassion fatigue is a form of distress which arises from being exposed to the traumatic experiences of others’. The book focuses on the experiences of psychotherapists, trauma counsellors and others in the business of addressing the psychological needs of people who have undergone trauma. The term ‘compassion fatigue’ itself was borrowed from psychotherapists' experiences, as many of the terms used in understanding the emotional experiences of healthcare professionals have been borrowed. References to compassion fatigue as conceptualised by Figley, appear in papers about healthcare workers having been lifted wholesale and without further explanation in the text (see, for example, [4]). This is by no means a strange occurrence, in fact, in healthcare, the borrowing of learning from other industries is commonplace, with probably the most well‐known example being the borrowing of safety and quality assurance techniques such as checklists, and learning on human factors from aviation. The learning from organisational psychology or other systems‐based work, though, reminds us that it is not usually effective to take a concept wholesale from one area and apply it to another. It would be wiser to verify the appropriateness of the concept first. I have often wondered if the scientific background of much of medical practice has done it a disservice, in the end, meaning that concepts from social science do not look so credible as those from the physical sciences and are thus appropriated without much rigour, seeming ‘good enough’ or maybe ‘harmless enough’.
Burnout: The concept of burnout was described by Christine Maslach in 1981 [5], as ‘a psychological syndrome of emotional exhaustion, depersonalisation and reduced personal accomplishment’ which can be the result of work demands which are principally relational in nature and where there is no opportunity to recharge. The term was developed to capture the experience of any person who worked ‘in an intense involvement’ with others, rather than those specifically in helping professions, this includes the criminal justice system and education. The result for workers is the sense that they are unable to do a good job, but also a disengagement from the people they had set out to serve, meaning that they are unable to access the potential good feelings which could be part of working with people. The concept is now very widely used in healthcare, a Google Scholar search in September 2020 of ‘burnout healthcare professionals’ returns 330 000 results.
Moral Distress: this concept was outlined by Jameton in 1984 in his book ‘Nursing Practice: the ethical issues’ [6] and refers to the effects of knowing what should be done for a patient, but being unable to do it because of situational and organisational constraints such as lack of time, staff or equipment. Most of the research in moral distress relates to nursing practice. The concept is of interest in this chapter since it highlights the relationship between organisational issues and personal, moral issues. This allows us to think of the healthcare professional's own agency in the workplace. Later work shows that to thrive at work, people need a sense of autonomy, belonging and competence and that this is as true for healthcare workers as for anyone else [7].
Secondary Trauma: refers to the stress experienced by helping those who have been traumatised. It is now listed in the Diagnostic and Statistical Manual of the American Psychiatric Association 5th Edition (DSM‐5) as a potential aetiology for post‐traumatic stress disorder (PTSD ) (see below). This is an important development because it shows that there is a recognition of the powerful negative effects of helping work now. It would produce symptoms like hyperarousal, avoidance, intrusive thoughts and depression and anxiety type symptoms [8] and its effects have been explored in various professions, including healthcare.
Vicarious Trauma: describes the trauma that occurs from hearing the traumatic events that another has suffered, or in other ways being exposed to this trauma, including, one might assume, treating their physical injuries [8].
Note: The terms ‘vicarious trauma’ and ‘secondary trauma’ tend to be used exclusively from one another, sometimes the term secondary trauma is used to describe the after‐effects of a primary trauma, for example, the loss of employment or relationship subsequent to primary trauma (such as domestic violence, violent crime, terrorism etc.).
Post‐traumatic stress disorder (PTSD): this is a mental disorder that results from exposure to traumatic events that threaten the self or others [9]. The disorder is listed in the DSM‐5 [10] and the symptoms include: intrusive memories and flashbacks, sleep disturbance, avoidance of places, people or things which remind the person of the event, possible dissociative symptoms, irritability, self‐destructive behaviour and so forth. These symptoms need to have lasted for a month or more in order to meet diagnostic criteria. The inclusion, in the DSM‐5, of PTSD caused by threats to others as well as self, recognises the effects of working as, for example, an emergency responder or in other areas where there is exposure to accidents and acts of violence, while not necessarily being the target of these acts of violence. The revised definition also recognises that one of the symptoms of PTSD will be persistent negative appraisals of the world, the self and the future [11].
Post‐traumatic Growth: the idea that people can grow and develop as a result of adverse circumstances is not a new one and much has been written on the topic, especially by positive psychologists such as Maslow, Caplan and Csikszentmihalyi. Since the 1980s and 1990s much more research has been undertaken to explore this idea in a variety of areas such a bereavement, illness and accidents [12]. It describes profound transformative changes in relation to quite serious trauma, not just a resilience to these or maintenance of baseline wellbeing. It is an important consideration in a book about the mental health and wellbeing of healthcare practitioners given the likelihood of their exposure to traumatic events is so much greater.
Moral Injury: Moral injury, then, has been described in two ways, firstly, by Jonathan Shay as: the betrayal of what's right by someone who holds legitimate authority, in a high stakes situation [13] and as the result of: ‘perpetrating, failing to prevent, bearing witness to or learning about acts that transgress deeply held moral beliefs or expectations’ [14]. Shay's observations of veterans recovering from their experiences in the theatre of war highlighted the tenacious nature of the emotional reactions to these experiences. He spoke of their struggles to recover from the events which had rocked their view of themselves and of the world; even though they had undergone effective, evidence‐based