Research Article

Qualitative Health Research

2024, Vol. 34(4) 362–373
Structural Factors Contributing to © The Author(s) 2023

Compassion Fatigue, Burnout, and Article reuse guidelines:

sagepub.com/journals-permissions
Secondary Traumatic Stress Among DOI: 10.1177/10497323231213825
journals.sagepub.com/home/qhr
Hospital-Based Healthcare Professionals
During the COVID-19 Pandemic

Ana A. Chatham1 , Liana J. Petruzzi2, Snehal Patel2,3, W. Michael Brode2,3,

Rebecca Cook2,3, Brenda Garza2, Ricardo Garay2, Tim Mercer2,3 , and
Carmen R. Valdez1,2

Abstract
High levels of burnout among healthcare providers (HCPs) have been a widely documented phenomenon, which have
been exacerbated during the COVID-19 pandemic. In the United States, qualitative studies that are inclusive of HCPs in
diverse professional roles have been limited. Therefore, we utilized a qualitative–quantitative design to examine
professional quality of life in terms of compassion fatigue, burnout, and secondary traumatic stress among hospital-based
HCPs, including social workers, hospitalists, residents, and palliative care team members during COVID-19. HCPs (n =
26) participated in virtual semi-structured focus groups or individual interviews and online surveys (n = 30) including the
Professional Quality of Life (ProQOL) Scale. While ProQOL scores indicated low levels of compassion fatigue, burnout,
and secondary traumatic stress, thematic analysis of our qualitative data included rich descriptions of compassion fatigue,
burnout, and secondary traumatic stress. Safety concerns and value misalignment characterized structural stressors
perceived to contribute to HCP compassion fatigue, burnout, and secondary traumatic stress. The discrepancy between
our qualitative and quantitative findings may be indication that modifications to current screenings are warranted. These
findings also suggest a need to identify and implement structural and policy changes that increase HCPs’ physical and
emotional safety and promote better alignment of institutional interests with HCP values.

Keywords
compassion fatigue, burnout, secondary traumatic stress, healthcare professionals, COVID-19

Introduction limited qualitative and mixed-methods studies that in-

clude HCPs in roles other than nurses and physicians
The COVID-19 pandemic has overwhelmed healthcare (Chen et al., 2021; Pearman et al., 2020; Rodriguez et al.,
systems and further exposed healthcare disparities dis- 2020; Shechter et al., 2020).
advantaging historically marginalized populations
(Hooper et al., 2020; Yancy, 2020). Healthcare profes-
1
sionals (HCPs) have been tasked with delivering intensive Steve Hicks School of Social Work at The University of Texas at Austin,
Austin, TX, USA
clinical care on an unprecedented scale while adapting to 2
Population Health Department, Dell Medical School at the University of
the pandemic’s disruption of personal, professional, and Texas at Austin, Austin, TX, USA
social life. Consequently, HCPs’ professional quality of 3
Internal Medicine Department, Dell Medical School at the University of
life has been adversely affected, as evidenced by Texas at Austin, Austin, TX, USA
heightened levels of compassion fatigue, burnout, and
Corresponding Author:
secondary traumatic stress (Alanazi et al., 2022; Ana A. Chatham, Steve Hicks School of Social Work, The University
Braquehais et al., 2020; Koontalay et al., 2021; Lluch of Texas at Austin, 1925 San Jacinto Blvd., Austin, TX 78712, USA.
et al., 2022). In the United States (U.S.), there has been Email: [email protected]
Chatham et al. 363

HCP Compassion Fatigue, Burnout, and Secondary were the top reasons cited by nurses looking to leave the
Traumatic Stress profession (Incredible Health, 2021). The U.S. Surgeon
General has declared HCP burnout a public health crisis
Prior to COVID-19, HCPs in the U.S. were experiencing and warned that failure to intervene will negatively impact
burnout at alarmingly high rates, ranging between 40% all aspects of healthcare as staffing shortages will lead to
and 54% for physicians, 35% and 45% for nurses, and delays in care, costs increases, and worsening disparities
45% and 60% for medical students and residents (National (Office of the United States Surgeon General, 2022).
Academies of Sciences, Engineering, and Medicine
[NASEM], 2019). HCP burnout rates have increased
since 2020 in the U.S., with a report between June and
Theoretical Framework
September of 2020 showing that 76% of sampled HCPs Stamm’s (2010) model characterizes professional quality
had experienced burnout (Mental Health America, 2022). of life or “the quality one feels in relation to their work as a
Another study found that emotional exhaustion increased helper” (p. 8) as influenced by one’s experiences of
for hospital-based HCPs across the pandemic (Sexton compassion satisfaction/fatigue, burnout, and secondary
et al., 2022). traumatic stress. In this model, burnout and secondary
Similarly, secondary traumatic stress has been well traumatic stress have been conceptualized as elements of
documented among healthcare professionals such as compassion fatigue or the low end of the compassion
physicians, nurses, and social workers (Badger et al., satisfaction continuum, which is “about the pleasure you
2008; Nimmo and Huggard, 2013; Zhang et al., 2018). derive from being able to do your work well” (Stamm,
Of 596 nurses who participated in a study assessing 2010, p. 12). Burnout is associated with feeling exhausted,
trauma, burnout, and posttraumatic stress during the frustrated, angry, and unable to effectively do one’s job
pandemic in China and Taiwan, 13.3% reported symp- (Stamm, 2010). Secondary traumatic stress is related to
toms of traumatic stress (Chen et al., 2021). A U.S. study work-related experiences of fear and exposure to indi-
found that 41% of HCPs reported symptoms of secondary viduals who have been traumatized (Stamm, 2010).
traumatic stress, which was higher among those who had
been frontline workers exposed to death (Orrù, 2021). In a
study assessing burnout and compassion fatigue among
The Present Study
hospital-based nurses in one U.S. health system, 86% of It is imperative to have a clear understanding of the factors
emergency-room nurses indicated moderate to high levels that impact professional quality of life among HCPs in the
of compassion fatigue and 82% indicated moderate to U.S., so interventions can be strategically tailored to im-
high levels of burnout (Hooper et al., 2010). prove outcomes. There has been a larger discussion about
Low professional quality of life in terms of compassion the role of structural factors, such as heavy workload,
fatigue, burnout, and secondary traumatic stress has in- administrative burden, inefficient technologies, and inad-
dividual- and systems-level consequences. For example, equate staffing and resources, in HCP burnout (NASEM,
compassion fatigue has been associated with increased 2019; Shanafelt & Noseworthy, 2017). Yet, these structural
irritability, reduced standard of care, negative patient factors have not been widely incorporated into prevention
experiences, or diminished workforce capacity due to programs or burnout interventions at the organizational
early retirement (Dasan et al., 2015). Not only does level. Drawing from a social constructivist epistemology,
burnout translate into poor mental health outcomes for which acknowledges the varied subjective meanings of
HCPs such as substance abuse and suicidality, but it also people’s experiences while taking into account the contexts
adversely impacts clinical care, increasing the incidence in which people exist (Creswell & Poth, 2017), we utilize
of errors, malpractice claims, staff turnover and absen- Stamm’s professional quality of life theoretical model and
teeism, and patient dissatisfaction (NASEM, 2019; screening (Stamm, 2010) to better understand the impact of
Pearman et al., 2020; Shah et al., 2022). COVID-19 among hospital-based HCPs. We draw on the
The implications for staff turnover and early retirement accounts of HCPs from diverse professional backgrounds,
are especially concerning considering staff shortages al- including social workers, nurses, residents, and doctors to
ready afflict the U.S. healthcare system and are expected to assess and describe HCPs’ professional quality of life in
worsen—the American Association of Medical Colleges terms of compassion fatigue, burnout, and secondary
(2020) predicted a shortage of up to 139,000 physicians by traumatic stress during the pandemic. Our research ques-
2033. Another study reported there will be significant tions are: (1) What levels of compassion fatigue, burnout,
shortages of nursing staff throughout the U.S. until 2030 and secondary traumatic stress did HCPs experience during
(Juraschek et al., 2019). Similar projections have been the COVID-19 pandemic? and (2) What factors contributed
made regarding other roles including nursing and medical to HCP compassion fatigue, burnout, and secondary
assistants (Bateman et al., 2021). Burnout and high stress traumatic stress during the pandemic?
364 Qualitative Health Research 34(4)

Methods to the consent form, a survey with demographic questions,

and the ProQOL (Stamm, 2010).
Study Design Thirty HCPs consented, completed the quantitative
A concurrent, explanatory qualitative + quantitative portion of the study, and were invited to participate in a focus
mixed-methods design (Creswell & Creswell, 2018; group. All thirty participants met study’s inclusion criteria of
Morse & Cheek, 2014) was used to provide a thorough being fluent in English and having been an employee or
understanding of HCPs’ professional quality of life during trainee at the institution for at least 6 months. To minimize
the COVID-19 pandemic in terms of compassion fatigue, potential effects of social desirability, community health
burnout, and secondary traumatic stress (Stamm, 2010). workers were not included in this set of focus groups as the
Quantitative and qualitative data were collected and an- primary purpose of this study was the evaluation of a
alyzed separately and integrated through triangulation in community health worker intervention. Taking into con-
the interpretation phase (O’Cathain et al., 2010). sideration HCPs’ limited time availability during the pan-
demic, HCPs who could not attend a focus group were
Author Positionality. The research team was interdisciplinary offered an individual interview in order to maximize par-
and included faculty physicians, social scientists, hospital ticipation. Only two HCPs participated in individual, semi-
staff, and graduate students. During team meetings, the au- structured interviews. Of the thirty HCPs who consented and
thors reflected on their positionality and how it informed their completed the survey, twenty-three participated in one of
perspective on the various stages of research. At the time of five focus groups which were disaggregated by role (hos-
data collection and analysis, the lead author was a social work pitalists, residents, and others) to prevent power dynamics
doctoral student. She had no prior relationship with research from affecting how HCPs participated. No HCP attended
participants and was not an employee or a trainee at the more than one focus group. The number of participants in
institution where the study took place. The second author was each focus group ranged from two to eight. Details about
a social work doctoral candidate who had no prior rela- composition of focus groups can be found in Table 1.
tionship with the participants. To minimize potential effects
of social desirability, authors who were faculty or staff at the Study Procedures
institution where the study took place did not conduct data Quantitative Procedures. Participants were asked their age,
collection but limited their roles to study design, recruitment, gender, race/ethnicity, professional role, and years in
secondary analysis, and manuscript development. healthcare. Professional quality of life, as conceptualized
by Stamm (2010), was measured in terms of compassion
Ethics fatigue, burnout, and secondary traumatic stress via the
ProQOL Scale, a standard measure designed to assess
This study was granted exempt status by the university’s
these outcomes among those in helper roles (Stamm,
Institutional Review Board as it was part of a quality
2010). The ProQOL has been used internationally for
improvement study aiming to evaluate various outcomes
over 25 years (Stamm, 2010). It includes 30 Likert scale
of a community health worker intervention, including its
questions and three subscales: Compassion satisfaction/
impact on HCP compassion fatigue, burnout, and sec-
fatigue, burnout, and secondary traumatic stress. For the
ondary traumatic stress. All participants provided written
compassion satisfaction/fatigue subscale, high scores
informed consent. Given the small sample size and its
indicate compassion satisfaction and low scores indicate
connection to only one institution, to protect participants’
compassion fatigue. For the burnout and secondary
identities, participant quotes were modified by
traumatic stress subscales, high scores indicate high levels
substituting references to specific roles by the descriptors
of burnout and secondary traumatic stress. The ProQOL
‘hospitalist’, ‘resident’, or ‘non-physician’.
has good reliability based on the original normed sample
(Stamm, 2010). We also calculated Cronbach’s alphas
Sampling with our sample across all three subscales (.84).
A purposive, non-probabilistic sampling approach was used
Table 1. Focus Group Attendance (n = 23).
to recruit HCPs from an urban academic safety-net hospital
located in the U.S. South. This setting was selected because Focus group ID Participants role Number of participants
it was the site of a larger project involving community health
FG1 Non-physicians 5
workers addressing COVID-19 impacts on Latinx patients.
FG2 Non-physicians 3
Our team emailed a flyer to hospital listservs that included
FG3 Residents 8
63 HCPs from various departments, inviting them to par-
FG4 Residents 2
ticipate in a focus group and survey about their experiences
FG5 Hospitalists 4
during the pandemic. The recruitment flyer included a link
Chatham et al. 365

Descriptive statistics were calculated in SAS software preliminary findings and invited to participate in a focus
(S.A.S. Institute Inc, 2013) for sociodemographic char- group or provide written feedback regarding their per-
acteristics and the primary outcomes of compassion fa- ceptions of the preliminary findings (Birt et al., 2016).
tigue, burnout, and secondary traumatic stress. Univariate During a 60-minute member checking group, three HCPs
frequency distributions were conducted on all baseline confirmed that the preliminary findings accurately de-
outcome variables. Due to the small sample, only de- scribed their experiences. Another HCP provided positive
scriptive analyses were conducted. feedback regarding the preliminary findings via email. No
significant adjustments to the findings were required as a
Qualitative Procedures. A semi-structured interview guide result of member checking.
was developed with 13 questions designed to elicit partic-
ipants’ constructed meaning of the impact of the COVID-19 Mixed-Methods Procedures. Discrepancies between quan-
pandemic on them. Questions included “How has COVID- titative and qualitative findings were addressed through
19 impacted your role as a healthcare professional?” and the applicable strategies suggested by Moffatt et al.
“How has working in a hospital during the pandemic af- (2006): (1) treating the methods as fundamentally dif-
fected you personally?” A script was prepared to be used at ferent; (2) exploring the methodological rigor of each
the beginning of each focus group and interview clarifying component; (3) exploring dataset comparability; and (4)
the study’s purpose and confidentiality agreement and exploring whether the outcomes of the quantitative and
providing an opportunity for participants to ask questions. qualitative components match.
Utilizing the interview guide, the second author facilitated
five virtual focus groups and two virtual individual inter- Findings
views, each lasting approximately 50 minutes, in October
and November of 2021. Each participant received a $25 Quantitative and qualitative findings are first reported
electronic gift card as compensation. All focus groups and separately and then integrated.
interviews were conducted in English, audio-recorded via
Zoom, and transcribed verbatim. The first and second au- Quantitative Findings
thors checked the transcripts for accuracy and to ensure the
proper identification of participants. Data were then de- All participants (n = 30) were HCPs at an urban academic
identified and loaded into NVivo (QSR International, 2020). safety-net hospital in the U.S. South (refer to Table 2 for
Inductive thematic analysis (Braun & Clarke, 2006; sample demographics). ProQOL scores were within the
Guest et al., 2012) was used as it suited the study’s social moderate range on compassion satisfaction/fatigue (X =
constructivist epistemology (Creswell & Poth, 2017) and 39.7, SD = 4.8) and within the low range for burnout (X =
the study’s purpose of eliciting HCPs’ description of their 25.4, SD = 5.7) and secondary traumatic stress (X = 27.4,
experiences during COVID-19 not based on a hypothesis SD = 5.6; Table 3).
defined a priori. The first author read each transcript,
wrote memos, generated preliminary codes, and formatted
a codebook. Codebook development was an iterative Table 2. Sample Demographics (n = 30).
process of coding a transcript, editing the codebook,
consulting with other team members, and reviewing Variables Number (%)
previously coded data. The codebook became stable after Age (mean) 35.2
five transcripts, indicating conceptual saturation had been Gender (female) 19 (73%)
reached, meaning that no major changes to codes and their Race
definitions were needed (Guest et al., 2012). The result of White 21 (81%)
these activities was 13 stressors grouped in three different Black 1 (4%)
domains. Codes were then analyzed in relation to each Asian 4 (15%)
other. This resulted in two common themes being iden- Hispanic or Latinx 5 (20%)
tified, namely, safety concerns and value misalignment. Spanish speaking 8 (31%)
All coded data was then reviewed to assess whether and Professional background
how stressors related to these two common themes. Physician 6 (23%)
Peer debriefing was utilized on four occasions. Ana- Resident physician 12 (46%)
lytic processes and decisions as well as reflections and Nurse 3 (12%)
feedback from peer debriefing were documented in an Social worker 3 (12%)
audit trail. To further validate this study’s findings, Advanced practice nurse 1 (4%)
Chaplain 1 (4%)
member checking was conducted. All HCPs who signed a
Years in healthcare (mean) 7.5
consent form (n = 30) were emailed a summary of the
366 Qualitative Health Research 34(4)

Table 3. Compassion Fatigue, Burnout, and Secondary Traumatic Stress Among Healthcare Professionals (HCPs) Based on the
ProQOL (n = 30).

Variables Mean (SD) Range Cronbach’s alpha

a
Compassion satisfaction 39.7 (4.8) 29–50 .84
Burnoutb 25.4 (5.7) 13–41 .84
Secondary traumatic stressb 27.4 (5.6) 16–43 .84
a
Lower scores indicate compassion fatigue (22 or less).
b
Higher scores indicate burnout and secondary traumatic stress (42 or more).

Qualitative Findings As she tried to make sense of her experience, this

participant compared her reaction to PTSD, alluding to the
During virtual focus groups and interviews, HCPs (n = trauma she had endured as an HCP, while indicating the
25) described experiences typical of compassion fa- weight of the safety concerns and resulting practices she
tigue, burnout, and secondary traumatic stress, at times had been carrying:
explicitly naming these outcomes. Two major themes
characterized the stressors contributing to HCPs’ self- I honestly was having really dark depressing thoughts. I think
reported compassion fatigue, burnout, and secondary it was definitely like PTSD from seeing everyone dying,
traumatic stress: (1) Safety concerns and (2) value feeling the shame of having COVID. I’ve been so careful all
misalignment. The theme of safety concerns was de- year, I was so careful. I had a low-risk exposure at work, I just
fined as assessing for, worrying about, or taking steps to didn’t expect it and I had gotten tested, but my test got lost.
ensure the physical and psychological safety of self and And I just felt so much shame and anger and defeat. And it
others. The theme value misalignment was defined as a was horrible. It was horrible. (Resident 1)
mismatch between an HCP’s personal and professional
values and those of the hospital or society. Below, we The high mortality rate of COVID-19 patients was a
describe these themes and how they manifested across constant reminder of the safety threat at hand: “We
the 13 stressors, which were categorized as COVID-19 were inundated by deaths on all sides” (Non-physician
specific, institution specific, and society specific 1). Safety was also compromised in the unpredict-
(Tables 4 and 5). ability of the pandemic, leading HCPs to feeling
“scared about the future because we don’t know when
Theme 1: Safety Concerns. Thoughts, feelings, and prac- it’s gonna end” (Resident 2). Unpredictability was also
tices focused on assessing and ensuring physical and relevant in terms of how COVID-19 progressed as a
emotional safety were constantly at the forefront of HCPs’ disease in patients: “I would go in every day not
experiences during the COVID-19 pandemic, contribut- knowing which one of my patients is going to get
ing to HCP compassion fatigue, burnout, and secondary worse, which one of them is going to die” (Resident 3).
traumatic stress. Worrying about and assessing for safety was an ever-
present physical and mental practice for HCPs, which
COVID-19-Specific Stressors. Stressors such as the risk contributed to compassion fatigue, burnout, and sec-
of spreading the infection and its high death rate posed ondary traumatic stress.
concerns for physical safety. Paradoxically, the safety
measures needed to prevent spread, namely, HCP and Institution-Specific Stressors. Safety concerns were present
patient isolation, posed concerns for psychological safety in two of the three institution-specific stressors: Heavy
and wellbeing. Chronically having to assess and mitigate workloads and toxic work environment. Worrying about
issues of basic safety negatively impacted HCPs’ psy- keeping everyone safe while being overextended con-
chological wellbeing. One participant described her in- tributed to burnout: “Everyone was burnt out at some
tense emotional reaction to realizing she had exposed point during my second year because we were forced to
others to COVID-19: do so many extra shifts” (Resident 4). Residents reported
doing several extra weeks of ICU rotation and taking
I had a full mental breakdown thinking that I could have additional responsibilities to meet patients’ needs and
possibly given it to my family. It had been when I was support faculty mentors.
wedding-dress shopping that weekend, (…) I was masked Negative interpersonal dynamics among HCPs and
and stuff, but still the thought that I could have given it to between HCPs and hospital leadership added a sense of
someone just petrified me. (Resident 1) feeling emotionally unsafe. One participant elaborated
Chatham et al. 367

Table 4. Definitions and Categorization of Stressors Experienced by HCPs During the COVID-19 Pandemic Contributing to
Compassion Fatigue, Burnout, and Secondary Traumatic Stress.

COVID-19-specific stressors Institution-specific stressors Society-specific stressors

Unpredictability: Being unable to predict the Heavy workload: Having a workload that Neglect of public health safety measures: To
future regarding patient outcomes as well cannot be completed within normally perceive COVID-19’s impact as small, not
as the pandemic itself scheduled hours or with reasonable significant. To be neglectful of taking
effort precautions such as masking and avoiding
social gatherings
High death rate: High number of patients Compensation and benefits: Issues related Vaccine hesitancy: To hesitate or refuse to get
dying from COVID-19 to pay rates and benefits a COVID-19 vaccine
Difficult conversations: Communicating with Toxic environment: Negative interactions COVID-19 denialism: To deny that COVID-
patients’ loved ones about no-visitor or feelings between employees and/or 19 is real, to attribute it to a political
policy, patients’ poor health, worsening between employees and leadership movement or agenda
condition, end-of-life decisions, and death
Patient isolation: Witnessing and/or mitigating Healthcare disparities: Patients’ treatment
patient isolation by being present with quality varying according to their
patients and/or facilitating patient socioeconomic status
communication with loved ones
HCP isolation: Physical and psychological
isolation fueled by limited in-person social
interactions as well as a heightened
awareness of COVID-19’s impact
Risk of spread: Chance of catching COVID-19
at work; chance of exposing others to
COVID-19

Table 5. Presence of Safety Concerns and Value Misalignment Within Stressors Experienced by HCPs During the COVID-19
Pandemic.

Category Stressor Safety concerns Value misalignment

COVID-19 specific Unpredictability X X

High death rate X X
Difficult conversations X
Patient isolation X
HCP isolation X X
Risk of spread X
Institution specific Heavy workload X X
Compensation and benefits X
Toxic environment X X
Society specific Neglect of public health safety measures X X
Vaccine hesitancy X X
COVID-19 denialism X X
Healthcare disparities X X

on the increased potential for errors resulting from the compassionate who also know that that we are never the
hospital’s challenges in hiring and retaining staff and its people that receive extra compensation or bonuses. It’s
implications for care. She commented, “The staff that a really complicated time around staffing and pay”
work here want to do a good job, but sometimes we feel (Non-physician 2). Another participant reflected, “We
almost restrained by our own administration” (Non- used to pride ourselves on the relationships [among
physician 1). Pay disparities were also mentioned as a providers] […] it’s now almost a toxic environment
component of the toxic work environment: “There are with much more mistrust, a lot of finger-pointing”
people who are working to be understanding and (Hospitalist 1).
368 Qualitative Health Research 34(4)

Society-Specific Stressors. All society-specific stressors up the iPad, so his family can see him. (…) I have this
identified were underpinned by safety concerns. HCPs felt firsthand view to their active grieving and I can’t, I can’t
unsafe both at work and outside of work, which was per- leave. If I leave, they end the call. I need to be there, and it’s
ceived to contribute to compassion fatigue, burnout, and just so traumatizing. (Non-physician 1)
secondary traumatic stress. Beyond the obvious concern for
the safety of the community related to transmission, neglect Likewise, when talking about the high number of
of public health safety measures, vaccine hesitancy, and patient deaths and difficult conversations she had to
COVID-19 denialism also brought a concern for personal navigate, a participant said, “One adjective that I often use
safety, as HCPs were often viewed antagonistically by a to describe it when talking about it with other people is
segment of society. One participant mentioned, “We have had that it’s been traumatic” (Resident 7). The very procedures
more anger directed at us about any of a number of things in place to ensure safety, at times, were perceived to
related to COVID. And I know providers that have had been contribute to compassion fatigue, burnout, and secondary
in scrubs at gas pumps getting yelled at” (Non-physician 2). traumatic stress among HCPs.
Finally, healthcare disparities among marginalized
patients were another society-specific stressor character- Institution-Specific Stressors. HCPs reported inade-
ized by safety concerns. One participant reflected, “I very quate financial compensation and benefits coupled with
rarely have any confidence that the person that I’m dis- excessive workloads and increased roles and respon-
charging from the hospital is going to actually get the type sibilities during the COVID-19 pandemic. One par-
of follow-up and services that I think they need” (hos- ticipant stated, “[COVID-19] added probably 10 more
pitalist 3). Another participant recounted: hours of meetings and work a week and a leadership
role that wasn’t compensated or accounted for by the
Simple things like in the beginning, we knew patients needed hospital” (Hospitalist 4). Reflecting on the increased
oxygen to go home safely, because that was one of the few amount and intensity of the work, another participant
therapies that works [for COVID-19], and having to argue stated, “It’s been incredibly taxing on our hospitalist
with our hospital systems that oxygen should be provided, group, our group of infectious disease doctors, and our
(…) to me just seemed crazy. (Hospitalist 2) residents to the point where people are pretty much
burnt out” (Hospitalist 1). He later described how
The exacerbation of healthcare disparities among un- burnout manifested in the team and its potential
derserved patients during the COVID-19 pandemic was consequences:
perceived to directly contribute to HCPs’ low professional
quality of life. [HCPs are] not interested in any more change or innovation
or additional responsibilities. Getting faculty to step up now
Theme 2: Value Misalignment. Due to a variety of insti- to do additional faculty type work, you might expect as part
tutional and societal circumstances, HCPs were prevented of being faculty, it’s just hard, people just don’t really want to
from living and working according to their values, which give more. (Hospitalist 1)
HCPs related to compassion fatigue, burnout, and sec-
ondary traumatic stress. This participant speculated that the generalized burn-
out may generate additional institution-specific stressors
COVID-19-Specific Stressors. Restrictions, such as not such as potential challenges around opportunities for
permitting in-person visitors, required HCPs to deliver student mentoring and learning.
care in ways that, in addition to being different from what The pay gap between travel nurses and staff nurses
they were used to and trained for, were also misaligned played a role here, too, as voiced by one participant: “It
with their values for patient care. For example, HCPs does feel like a slap in the face when someone who could
talked about how impersonal it felt to discuss end-of-life have left for more money, stayed out of loyalty, and then
issues with patients’ families over the phone: “It was didn’t get rewarded financially for that” (Non-physician
almost trying to convince them (loved ones) ‘he’s really 1). The hospital’s practice of offering a competitive pay to
sick, I’m not lying to you’. It was really challenging” attract travel nurses and alleviate workload issues trans-
(Resident 3). They also talked about the hardship of lated into an undervaluing of staff nurses’ loyalty to the
witnessing patients dying alone. Facilitating a patient’s institution.
goodbye to his family via video call felt like a trauma- Another participant described how assisting socio-
tizing moral obligation to this participant: economically vulnerable patients and loved ones required
much time and energy and expressed, “It just feels like the
I was in a COVID room, geared up head-to-toe, super-hot, whack a mole, you can’t come up for air without being
sweaty, tired. And the last two hours of this man’s life, I held pushed down. It’s just very, very PTSD” (Non-physician
Chatham et al. 369

1). Yet, additional patient demands did not elicit additional The misalignment between HCPs and societal
institutional support in terms of increased benefits or pay. values was also made evident by the fourth of society-
One participant talked about how HCPs were not provided specific stressors, healthcare disparities. HCPs agreed
extra sick leave when they or their dependents contracted that the pandemic made pre-existing inequities in the
COVID-19, forcing HCPs to use their paid time off for healthcare system undeniable, creating a moral
this purpose. She reflected “We’ve been compensating for struggle for HCPs. One participant stated, “The
a system that’s not really taking care of us” (Non- number of disparities that we knew about, and became
physician 3). Agreeing with the structural nature of the worse, was really striking and demoralizing” (Hospi-
stressors contributing to compassion fatigue, burnout, and talist 2). One participant highlighted the emotional toll
secondary traumatic stress, another participant stated, this value misalignment took:
“I’m not just a couple of yoga classes away from feeling
top-notch, it’s way more systemic than that” (Non- Knowing what the right thing to do or to give or what
physician 2). someone needs and then not being able to deliver that causes
It is important to note that while safety concerns stood not just dissatisfaction, but it leads to feeling upset, feeling
out as a theme on its own, safety as a value that could not inadequate, feeling mad at the system, feeling helpless, I, you
always be upheld to a desired level also played a role in the feel hopeless a lot about being victims of the way the system
misalignment of HCP values. One participant summarized: is set up. (Hospitalist 3)

There are providers that have had (patient) numbers that if we In practice, this translated into HCPs grappling with the
had more staffing would not be anybody’s choice (…). And dissonance between their values and what the healthcare
that is an added layer of stress, concern, fear, burnout, system allowed them to do, which was perceived to
anxiety, a sense of not being valued, appreciated or seen, contribute to low professional quality of life.
right? For the folks who are there to feel like they’re in a place While our quantitative findings indicated moderate
to not deliver the care they want to and feeling worried that to low levels of HCP compassion fatigue, burnout, and
it’s unsafe. (Non-physician 2) secondary traumatic stress, our qualitative data re-
vealed clear examples of HCP compassion fatigue,
Heavy workload, in addition to being physically ex- burnout, and secondary traumatic stress which were
hausting, included layers of safety concerns and value connected to stressors characterized by safety concerns
misalignment at the institutional level. and value misalignment. The application of Moffatt
et al.’s (2006) strategies indicated that this discrepancy
Society-Specific Stressors. HCPs had to grapple with the could be attributed to a mismatch between how the
dissonance between their own values and the values of outcomes were operationalized and measured in the
members of society who (1) neglected public health safety ProQOL survey versus how the real-life experience of
measures, (2) hesitated or declined to get vaccinated, and/ these outcomes was felt and described by HCPs. Of
or (3) denied the existence of COVID-19. One participant note, most of the stressors described by HCPs as
recalled, “I posted a picture on social media of my first contributing to their compassion fatigue, burnout, and
dose of the COVID vaccine, I had a lot of people almost secondary traumatic stress were at the societal and
attacking me like, ‘Oh, my goodness, why would you get structural levels, while the ProQOL focuses largely on
this? Do you know what’s in this?’” (Resident 5). Soci- individual-level feelings, cognitions, and behaviors.
ety’s disregard for scientific knowledge was viewed as an This suggests that the quantitative measure was not
obvious misalignment of values by most HCPs: “The sensitive enough to capture compassion fatigue,
vaccine is free, it’s available, you could have easily gotten burnout, and secondary traumatic stress among HCPs
it. It was just a bit more challenging, to share the same in the context of the COVID-19 pandemic.
compassion I had during the first surge” (Resident 3).
Another participant captured the emotional toll this dis-
Discussion
sonance had taken, alluding to an experience of com-
passion fatigue and burnout: Our study’s contributions are threefold: (1) We describe
safety concerns and value misalignment as factors char-
I’m running out of the patience, the empathy, the under- acterizing stressors perceived to contribute to HCP
standing, to try to sit there and hear more conspiracy theories, compassion fatigue, burnout, and secondary traumatic
hear more people denouncing my profession, my work. I’m stress during the COVID-19 pandemic; (2) we highlight
willing to work 80 hours a week and get training to help the salience of societal and system stressors in HCPs’
people and then people just write it off with something they experiences. Although this does not negate the potential
read on the internet. (Resident 6) existence of individual-level stressors, these were not
370 Qualitative Health Research 34(4)

emphasized by HCPs in this study. And (3) the dis- framework is limited, and the ways in which COVID-19
crepancy between our qualitative and quantitative find- fits within this model remain to be studied.
ings calls attention to the challenges of clearly defining Further, the discrepancy between our qualitative and
and accurately capturing and measuring compassion fa- quantitative findings suggests the prevalence and severity
tigue, burnout, and secondary traumatic stress, especially of HCP compassion fatigue, burnout, and secondary
in light of the changes caused by the COVID-19 traumatic stress may have been underestimated. This may
pandemic. be partially due to the focus on individual-level factors
These findings add to the body of evidence that un- among existing measures that insufficiently capture the
derscores HCP compassion fatigue, burnout, and sec- structural components of burnout at the institutional or
ondary traumatic stress as significant challenges in the societal levels. An analysis of the psychometric properties
U.S. healthcare system, which have been exacerbated by of the ProQOL suggested validity and reliability concerns
the COVID-19 pandemic (Alanazi et al., 2022; with the burnout and secondary traumatic stress scales
Braquehais et al., 2020; Koontalay et al., 2021; Lluch (Hemsworth et al., 2018), which could help explain our
et al., 2022). Additionally, our qualitative findings align participants low scores on these outcomes. Future re-
with previous research indicating that COVID-related search could utilize robust measures to augment quanti-
stressors such as the unpredictability of the pandemic, tative prevalence studies with qualitative data so that they
institutional stressors such as inadequate staffing, and are sensitive to the current realities affecting HCPs, es-
societal stressors such as healthcare disparities are some of pecially post-COVID-19.
the underlying factors contributing to low HCP wellbeing Likewise, the focus of wellbeing measures and studies
(Shah et al., 2022; Zerden et al., 2022). on HCP individual-level factors has most likely informed
These findings carry important implications for prac- suggested interventions that are individual in nature such
tice, policy, and research, as HCP compassion fatigue, as self-care or mindfulness (Babineau & Thomas, 2019;
burnout, and secondary traumatic stress are associated Sharifi et al., 2021). Interventions that fail to address the
with HCPs’ mental health, quality of patient care, error systemic challenges discussed by participants, such as
rate, malpractice claims, staff turnover, and patient dis- inadequate staffing, would mean an incomplete and
satisfaction (Dasan et al., 2015; Pearman et al., 2020; temporary relief to a problem that is much more deeply
Shah et al., 2022). Because of the profound impact the rooted. Additionally, it would also risk overburdening the
COVID-19 pandemic has had on all sectors of society individual HCP with the responsibility of surviving a
globally, it is critical to revisit the theoretical models used system that is not structured in a supportive way. Existing
to explain and assess HCPs’ wellbeing. evidence supports this recommendation, as interventions
Much has been written about the role of social and focused on workload or scheduling changes have been
structural factors on health and health disparities found more effective at reducing burnout than physician-
(Braveman & Gottlieb, 2014; Green et al., 2021; Singu level interventions focused on mindfulness or stress re-
et al., 2020). Studies specifically focused on how social duction (De Simone et al., 2021; Shanafelt & Noseworthy,
and structural factors, during the COVID-19 pandemic, 2017). Therefore, any meaningful effort to decrease the
impacted HCPs are still few (Browne et al., 2023; current rates of HCP compassion fatigue, burnout, and
Pathman et al., 2022). NASEM’s model of clinician secondary traumatic stress must consider the values and
burnout includes similar factors affecting HCPs’ policies embedded in what the system asks of HCPs,
wellbeing as this study (NASEM, 2019). This model particularly when caring for patients suffering from health
includes three system levels: (1) External environment, inequities.
which includes the healthcare industry, laws and reg-
ulations, and societal values; (2) Healthcare organiza-
tion, which includes leadership and management,
Limitations
governance, rewards, and benefits; and (3) Frontline This study is not without limitations. First, due to it
care delivery, which includes the physical environment, being part of a program evaluation that used purposive
technologies, activities, and the people involved (cli- sampling, quantitative findings are not considered
nicians, staff, learners, patients, and families). Addi- generalizable beyond the HCPs that participated in this
tionally, it incorporates work system factors (job study. Second, we were unable to compare ProQOL
demands and job resources) and individual-level factors scores of compassion fatigue, burnout, and secondary
(NASEM, 2019). However, it is possible that by traumatic stress across healthcare professions due to the
identifying societal values as a distal factor, it may be small sample size. Third, the sample lacked racial di-
minimizing the central role that safety concerns and versity, and although it included HCPs from diverse
value misalignment have had on HCPs’ wellbeing professional backgrounds, it was overrepresented by
during the pandemic. Literature that utilizes this physicians. The variability in focus group size and the
Chatham et al. 371

inclusion of interviews in the focus group data are Ethical Statement

additional limitations, which resulted from the chal- Ethical Approval
lenges of recruiting HCPs during the COVID-19 pan-
demic. Future studies should include a larger, more This study was granted exempt status by the University of Texas
representative sample of healthcare professionals from at Austin Institutional Review Board.
a variety of departments and disciplines, as well as more
racially and ethnically diverse sample. Further, future Informed Consent
studies should consider including several measures for All participants provided written informed consent.
burnout, compassion fatigue, and secondary traumatic
stress to compare their efficacy at identifying and ORCID iDs
measuring structural factors such as systems-level or Ana A. Chatham  https://orcid.org/0000-0003-4068-0461
institutional-level stressors. Tim Mercer  https://orcid.org/0000-0002-8831-0569
The lack of clear, shared definitions of compassion
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for the research, authorship, and/or publication of this article: Journal of the Association of Physicians, 113(9),
This work was supported by the Michael and Susan Dell 613–617. https://doi-org.ezproxy.lib.utexas.edu/10.
Foundation and Texas Mutual. 1093/qjmed/hcaa207
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