Working with the traumatized− i.e., those wounded in battle− can have both negative and positive influences on those who are responsible for their care. Studies have documented the impact of caring on helping professionals.^{7, 8} Some researchers suggest that there is a cost to caring that can occur when a clinician is exposed to traumatic events that occur within the lives of their patients. Experiencing the impact of working with the war wounded often creates a constellation of responses− some positive and some negative− from the medical community’s immersion in a soldier’s suffering.⁷ This phenomenon is not unique to those health care professionals working in a war environment. However, when working in a war environment, the potential for burnout and compassion fatigue rises as staff joins empathically with the wounded and their family.

Burnout and compassion fatigue (CF) are two possible outcomes for those that work with the war wounded. Compassion fatigue is a negative aspect of our work as helpers. CF is to be seen as an expression of a negative feeling driven by fear and work related trauma. It is an outgrowth of hearing some of the most painful and difficult stories told to helpers by their clients.⁹ Burnout differs from compassion fatigue in that compassion fatigue is the direct result of hearing emotionally shocking material from clients; burnout is a problem of the social environment in which people work. Issues such as workload, lack of control, insufficient rewards, unfairness, low pay, etc., all are potential causes of burnout.¹⁰ Burnout is associated with feeling of hopelessness, and difficulties in dealing with work and doing your job effectively. These negative feelings usually have a gradual build up and often reflect the feeling that one’s efforts make no difference.⁹ Empirical studies of burnout note that it is an especially prevalent condition among the helping professionals.¹²

In a study of disaster response teams, levels of secondary traumatic stress (compassion fatigue), were above levels of 20%.¹¹ In another study, following the 1995 Oklahoma City bombing, 64.7% of trauma workers noted significant levels of compassion fatigue and 54% of responders to the 9/11 attacks were at moderate to high risk for compassion fatigue.¹²

Conrad and Kellar-Guenter¹³ found a positive relationship between burnout and compassion fatigue and found high levels of compassion satisfaction− the pleasure derived from being able to do one’s work well− in individuals with low levels of burnout. A study among international aid workers found similar result.¹⁴ These findings support a positive relationship between compassion fatigue and burnout and an inverse relationship between compassion satisfaction and burnout.

The Department of Defense reports that nearly one-third of military personnel deployed in OEF/OIF have experienced extended tours and/or repeated deployments and it is assumed that extensions and repeated deployments are likely to continue.¹⁵ Military induced separations create stress due to the exigencies of departure, increased caretaking and household responsibilities for family members that remain at home, disconnected relationships, loss of emotional support, fear and readjustment of roles.¹⁶ Recognizing that the average age of active duty service members is 23 years and that 44% of active duty troops have children many young families have been impacted by the war effort and multiple deployments.¹⁷

Several studies document the depth and extent of the impact of deployment, anecdotal press and media coverage suggests that deployment puts a particular strain on military families. In one study, 798 spouses of active duty personnel were assessed. Findings showed that spouses who experienced extensions and/or multiple deployments fared worse on an array of measures. These included mental well-being, household strains and some areas of their jobs; these spouses were more likely to view the Army negatively.¹⁵ Similarly, Eaton in a survey of 940 military spouses found that spouses have similar rates of mental health problems as soldiers.¹⁸ A study of 872 military spouses by Warner and colleagues found that approximately 1 out of every 10 respondents noted symptoms of severe depression and nearly half met the clinical criteria for depression.¹⁹

Based on the existing literature, it is assumed that the impact of deployments on family members is considerable and thus became a factor to be evaluated in the responses to the ProQoL. Research suggests that it potentially would impact the three domains of measurement within the survey: compassion satisfaction (CS), compassion fatigue (CF) and burnout (BO).

The ProQOL is comprised of three 10-item scales− CS, BO and CF. Items are scored on a Likert scale, in which 0 equals “never”, and 5 equals “very often” For each of the three scales, the ten item ratings are totaled to arrive at a score. The ProQOL has good construct validity and is well validated with over 200 articles noted in the peer review literature; the alpha reliabilities of the scale are compassion satisfaction =0.87, compassion fatigue=0.80 and burnout=0.70.²⁰

Compassion Satisfaction (on the ProQOL: mean 37, SD 7) measures the pleasure derived from being able to do one's work well. Staff often finds pleasure in helping others through their work. They may feel positive about the work they accomplish with their colleagues, the care and help given to someone in need or the changes they may make for their community. Higher scores on this scale indicate a greater satisfaction in their ability as caregivers. About 25% of people score higher than 41.0 and about 25% of people score below 32.0. A score over 37.0 suggests positive satisfaction.²⁰

Burnout (on the ProQOL: mean 22.0, SD 6) is associated with feelings of hopelessness and inefficacy/frustrations related to work. While generally understood, the onset of these negative feelings may be so gradual that it is not obvious until the feelings become overwhelming. BO can reflect the feeling that the staff’s efforts make no difference, or it can be associated with a very high workload or a non-supportive work environment. Generally burnout reflects distress at administrative and work environment concerns. Higher scores on this scale indicate one is at a higher risk for BO. About 25% of people score above 28.0 and about 25% of people score below 19.0. A score of above 23.0 suggests the presence of burnout.²⁰

Compassion fatigue occurs when staff is exposed to other people's traumatic experiences. Often, the staff internalizes the patients’ trauma. The exposure is secondary; one is not in direct physical danger like a soldier or a humanitarian aid worker. Thus, CF is often called secondary trauma and related to vicarious trauma. Compassion Fatigue symptoms are usually rapid in onset and associated with a particular event. Higher scores above 17.0 on this scale indicate one is at a higher risk for CF. About 25% of people score below 8 and about 25% of people score above 17.0. A score of above 13 suggests compassion fatigue.²⁰

The 30 question ProQOL was administered hospital-wide in May 2008. A total of 481 (22%) staff responded. Participants provided demographic information including gender, rank, employment status, skill type and department. Staff was also asked if they or a family member had been deployed within the previous 12 months.

Participant characteristics were compared using means, standard deviation (SD) and confidence intervals (CI). All analyses were performed using SPSS statistical software (version 16, SPSS Inc. Chicago, IL). A P value of <.05 was considered statistically significant.