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Provider Fatigue and Provider Resiliency Training

Chapter 23

PROVIDER FATIGUE AND PROVIDER 

RESILIENCY TRAINING

MARY ANN PECHACEK, PsyD, LMFT*; GRAEME C. BICKNELL, PhD, LISW†; and LISA LANDRY, PhD‡

INTRODUCTION

TERMS AND DEFINITIONS

FIGLEY’S COMPASSION FATIGUE MODEL

FACTORS CONTRIBUTING TO COMPASSION STRESS 

SYNERGISTIC EFFECTS OF PROVIDER FATIGUE

WAYS TO IDENTIFY PROVIDER FATIGUE

Markers

Behavior Changes After Exposure to Trauma

US Medical Command Use of the Professional Quality of Life Scale

WAYS TO COMBAT PROVIDER FATIGUE

The EAT Model

Building Resiliency

A Holistic Approach to Renewal 

Leadership

SUMMARY

*Psychologist and Instructor/Writer, Department of Behavioral Health Sciences, Special Subjects Branch, Army Medical Department Center and School, 

3151 Scott Road, Building 2840, Fort Sam Houston, Texas 78234

†

Lieutenant Colonel, Medical Service Corps, US Army; Deputy Chief, Behavioral Health Division, US Medical Command, 2050 Worth Road, Building 

2792, Fort Sam Houston, San Antonio, Texas 78234-6010s 

‡

Instructor/Writer, Department of Behavioral Health Sciences, Army Medical Department Center and School, 3151 Scott Road, Building 2840, Office 

#32, Fort Sam Houston, Texas 78234 
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Combat and Operational Behavioral Health

INTRODUCTION

The effects of caring for traumatized individuals 

have been characterized in numerous ways and given 

different names over time during many traumatic 

events. Although each of these concepts was originally developed in a specific context with individual 

nuances, they have also been used interchangeably 

in connection with the phenomenon of secondary 

trauma—the reaction of caregivers to the traumatic 

events experienced by those they serve. Current military behavioral healthcare providers have built on the 

efforts of their predecessors, who have attempted to 

capture and understand the effects of trauma through 

the years. Providers are resilient by nature and military 

providers are especially so, as seen in their focusing, 

building, and reinforcing the resilience in achievable 

balanced health.

All members of the Department of Defense—

soldiers, sailors, airmen, marines, and civilians—have 

been affected by the global war on terror. The US 

military has developed many programs and services 

to aid military personnel and their families, addressing psychological, spiritual, and physical recovery; 

however, only a few programs are directed toward 

caregivers. One such program is Provider Resiliency 

Training (PRT), created and implemented by the Soldier and Family Support Branch at the Army Medical 

Department (AMEDD) Center and School at Fort Sam 

Houston, Texas. 

PRT has three phases. During the first phase of 

training, all care providers throughout the medical 

command (MEDCOM) watch a video on PRT and take 

the Professional Quality of Life (Pro-QOL) Scale (discussed in detail in this chapter). This phase takes approximately 30 minutes to complete. The second phase 

of PRT involves the development of initial self-care 

plans by all MEDCOM medical treatment facilities’ 

staff, and takes about 2 hours to complete. The third 

phase—annual maintenance of the plan—is completed 

during the care provider’s birth month and is used to 

readminister the Pro-QOL screening tool completed 

during the first phase. This allows trainers to review 

those results with individual participants. This third 

and final phase takes about 1 hour to complete.

PRT is a comprehensive course in definitions, concepts, models, and methods for dealing with provider 

fatigue. This training is designed for audiences at all 

levels of care provision. The first half of the introduction to PRT defines and clarifies the challenge of compassion fatigue/provider fatigue and the “cost of caring,” as well as principles of practical holistic renewal. 

The second half is focused on strength and resiliency: 

How do individuals stay strong? Where does resiliency 

come from? How might resiliency be encouraged in 

self, colleagues, systems, and soldiers? 

Like a mental gymnasium geared toward the 

overall fitness of caregivers and the development of 

their resiliency in the face of challenges, PRT aims 

to help providers find the inner strength to face fear 

and adversity with courage. Furthermore, PRT is focused on military providers who care for those who 

have experienced suffering and trauma. The stress of 

contemporary combat and operational environments 

is unlike that experienced by physicians, nurses, or 

chaplains in the civilian sector. 

TERMS AND DEFINITIONS

A number of terms have been used to capture 

secondary reactions to trauma, including “burnout,”1

“secondary victimization,”2

 “secondary traumatic 

stress disorder,”3–7 “secondary survivor,”8 “vicarious 

traumatization,”9,10 “traumatic countertransference,”11

and “compassion fatigue.” A similar concept, “emotional contagion,” is defined as an affective process in 

which “an individual observing another person experiences emotional responses parallel to that person’s 

actual or anticipated emotions.”12(p338) Furthermore, 

“rape-related family crisis”13,14 and “proximity effects” on female partners of war veterans15 are related 

concepts. The generational effects of trauma16,17 and 

the need for family “detoxification” from war-related 

traumatic stress18 have been noted. Finally, difficulties with client problems have been considered as 

simple countertransference and discussed within 

the context of posttraumatic stress disorder (PTSD) 

treatment.2,11,19,20 However, the concept is difficult to 

measure or to separate from other factors of clienttherapist transactions. 

Historically, compassion fatigue, compassion stress, 

vicarious traumatization, secondary PTSD, and the 

current military concept of provider fatigue all involve 

the empathic connection with people experiencing the 

emotions of trauma, resulting in the provider experiencing the same emotions. Provider fatigue is related 

to the other concepts, primarily compassion fatigue, 

previously the latest in an evolving concept known 

in the field of traumatology as “secondary traumatic 

stress.” Most often this phenomenon is associated with 

the “cost of caring”3 for others in emotional pain. 

The term “provider fatigue” was first used in 1992 

by Joinson,21 who described nurses worn down by 
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daily hospital emergencies. The same year, in his book 

Compassionate Therapy, Kottler22 emphasized the importance of compassion in dealing with extremely difficult 

and resistant patients. However, neither publication 

adequately defined “compassion.” Most past research 

emphasized only why practitioners lose compassion 

as a result of working with the suffering. On the other 

hand, some people, including military care providers, 

may feel that it is wrong for a practitioner to have deep 

feelings of sympathy and sorrow for a client’s suffering. And practitioners certainly must understand their 

limitations in helping to alleviate the pain suffered by 

patients.

The American Psychiatric Association’s Diagnostic 

and Statistical Manual of Mental Disorders (4th ed)23 notes 

that PTSD is possible when one is traumatized either 

directly (in harm’s way) or indirectly, for example, as 

a parent witnessing a child’s injury. Those involved 

in both types of incidents may experience trauma, 

although through different social pathways. The latter 

pathway is called ”secondary traumatic stress.” Few 

reports of the incidence and prevalence of this type 

of stress reaction exist; however, based on secondary 

data and theory analysis, it is possible that burnout, 

countertransference, worker dissatisfaction, and other 

related concepts may have masked this common problem.2

 Vicarious traumatization, for example, refers to 

a transformation in the therapist’s inner experience 

resulting from empathic engagement with clients’ 

trauma material. These effects are cumulative and permanent, and evident in both a therapist’s professional 

and personal life.10 Compassion or provider fatigue is a 

more user-friendly term for secondary traumatic stress 

disorder, which is nearly identical to PTSD except that 

it affects those emotionally affected by the trauma of 

another (usually a client or a family member). Terms 

as used in this chapter are defined as follows:

	 •	 Primary traumatic stress results from stressors inherent in an extreme event—what 

was immediately experienced or witnessed, 

especially things that contributed most to a 

traumatic response. For example, the military 

healthcare provider may be in danger of direct 

fire while assisting fellow soldiers. 

	 •	 Compassion stress is the residue of emotional 

energy from the empathic response to the client, as well as the ongoing demand for action 

to relieve the client’s suffering. It flows from 

having an empathic, caring response. Together 

with other factors it can contribute to provider 

fatigue unless the provider acts to manage the 

stress. 

	 •	 Compassion or provider fatigue is the emotional residue or strain of exposure from working with those suffering the consequences 

of traumatic events. A form of secondary 

traumatic stress—compassion or provider 

fatigue—is the result of a healthcare provider 

engaging in the treatment of individuals exposed to various traumas. It is natural and 

normal for providers to experience compassion fatigue; if a provider is doing a job well, it 

is normal to feel fatigued, similar to an athlete 

feeling fatigued after a good workout. Provider fatigue should be expected, mitigated, and 

processed by every professional caregiver.

	 •	 Burnout is a cumulative process marked 

by emotional exhaustion and withdrawal 

associated with increased workload and institutional stress. Burnout is not necessarily 

trauma-related; it can occur in any job with 

an ongoing overwhelming workload. Burnout occurs when a person loses the ability to 

care.

	 •	 Resiliency is the ability to recover rapidly 

from illness, change, or misfortune. (In objects, 

it is the ability to regain the original shape 

after being bent, stretched, or compressed.) 

Resiliency occurs on a continuum (it is not 

an either/or proposition) and relates to a 

person’s overall growth and development. 

Resiliency is about who the person is, while 

stress management is about what that person 

is doing; however, a provider’s level of resiliency is evident in how he or she responds to 

stressors. Resiliency grows through healthy 

responses to stressors. 

FIGLEY’S COMPASSION FATIGUE MODEL

In 1995, Charles Figley, a former Marine and leader 

in the field of traumatology, created a model of compassion fatigue delineating how exposure to suffering 

and an empathic response can lead to compassion 

stress and compassion fatigue.24 The same experiences 

can be seen in the area of provider fatigue, and will be 

further discussed in the next section. Elements in the 

model include the following:

	 •	 Emotional contagion is experiencing the feelings of the sufferer as a function of exposure 

to the sufferer. 

	 •	 Empathic concern is the motivation to respond to people in need. 
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	 • Empathic ability is the aptitude for noticing 

the pain of others. 

	 • Empathic response is the extent to which the 

helper makes an effort to reduce the suffering 

of the sufferer. 

	 • Disengagement is the extent to which helpers can distance themselves from the ongoing 

misery of the traumatized person. 

	 • Sense of achievement is the extent to which 

helpers are satisfied with their efforts to help 

the client/sufferer. 

	 • Compassion stress is the compulsive demand 

for action to relieve the suffering of others. 

	 • Prolonged exposure is the ongoing sense of 

responsibility for the care of the suffering, over 

a protracted period of time. 

	 • Traumatic recollections are memories that 

trigger the symptoms of PTSD and associated 

reactions, such as depression and generalized 

anxiety. 

	 • Life disruption is the unexpected change in 

schedule, routine, and managing life responsibilities caused by experiences that demand 

attention (eg, changes in health, lifestyle, 

social status, or professional or personal circumstances). 

	 • Compassion fatigue is the state of tension 

and preoccupation with the traumatized by 

(a) reexperiencing the traumatic events; (b) 

avoidance/numbing of reminders, and (c) 

persistent arousal. It is a natural consequence 

of behaviors and emotions resulting from 

knowing about a traumatizing event experienced by another. 

	 • Compassion trap is the inability to let go of 

the thoughts, feelings, and emotions useful in 

helping another, long after they are useful.24

It is thought that “other-centered” people, who are 

good at providing care, are vulnerable to compassion 

fatigue. Those without as much compassion suffer 

these effects less dramatically. The first author of this 

chapter conceptualizes this as follows: “the caregivers’ 

gift is their burden.” Being a compassionate person 

is helpful in the healing process, but that compassion may become a challenge if it is not balanced by 

resiliency. 

Providers who are strongly empathetic may be most 

at risk of provider fatigue. No provider witnesses 

trauma in the abstract; for those who are strongly 

empathic it can be, and is, personal. The actual experience is felt vicariously as pain, with a consequential 

psychological impact. Often providers do not see 

self-care as a priority, which places them in jeopardy 

of burning out. 

Another factor that puts the provider at risk for 

secondary traumatization is a personal history of 

trauma. When providers have experienced a significant loss in their own lives, the experiences and 

images of trauma may trigger those memories and 

stimulate fresh grief. Many providers are secondary 

witnesses to trauma on a regular basis. As witnesses 

and providers, they are vulnerable to the emotional 

pain of victims. Providers picture bits and pieces of 

the trauma in their minds and may experience intense 

feelings in their bodies. 

Many military providers are both participants in 

the trauma (eg, being shot at) and caregivers of others affected. Figley summarized these experiences by 

noting that helping the traumatized can itself be quite 

traumatizing. An Army chaplain related the story 

of being part of a convoy in which a vehicle in front 

of him was blown up. He was in imminent danger 

himself. As he participated in helping his comrades 

through the trauma and debriefing that followed it, 

he found himself alone, wondering who would help 

him. He turned to his God and returned to camp. 

The next day was Sunday and his job took him to the 

pulpit, where he delivered an inspiring sermon to the 

soldiers he served.25 The point made is that one may 

be in the face of danger, help those in danger, be alone 

in danger, and then rise the next day to serve those in 

danger. This situation occurs in the life of the military 

care provider on a regular basis.

FACTORS CONTRIBUTING TO COMPASSION STRESS 

Empathic responses in the provider occur when 

the ability and desire to help others converges with 

exposure to suffering. Compassion stress flows from 

having an empathic, caring response to the work or 

to those who suffer. It is how providers feel (physically and/or emotionally) the trauma of the patients 

with whom they are working. For example, hearing 

of terrible abuse stirs within the provider a feeling of 

disgust and gastrointestinal upset. The level of stress 

is determined by how much the provider relates to or 

identifies with another’s suffering and trauma. The following characteristics, based on Figley’s model, often 

propel people to become healthcare providers, yet also 

predispose them to experience compassion stress: (a) 

the ability to be empathic, (b) the desire to help, and 

(c) the level of exposure to suffering. The chances of 

experiencing compassion fatigue are reduced to the 

degree that these features are lacking.2,24
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Provider Fatigue and Provider Resiliency Training

	 •	 Empathic ability is the aptitude of the provider for noticing the pain of others. Figley’s 

model suggests that without empathy, providers experience little if any compassion 

stress and no compassion fatigue. However, 

without empathy they feel little if any empathic response to suffering clients. Thus, the 

ability to empathize is key both to helping 

others and being vulnerable to the costs of 

caring.

	 •	 Empathic concern is the motivation to respond to people in need. The ability to be 

empathic is insufficient unless motivation exists to help others who require the services of 

a concerned psychotherapist. With sufficient 

concern, the empathic provider draws upon 

his or her talent, training, and knowledge to 

deliver the highest quality of services possible 

to those who seek it.

	 •	 Exposure to the client is experiencing the 

emotional energy of client’s suffering through 

direct exposure. Mental health professionals 

directly employed in human services may 

decide to become supervisors, administrators, or teachers because of the costs of direct 

exposure to clients (of course, determining 

individual motivation is difficult, and some 

make the shift from direct practice because of 

additional pay, improved working conditions, 

and higher status).24

	 •	 Empathic response is the extent to which the 

provider makes an effort to reduce the suffering of the client through empathic understanding. This insight into feelings, thoughts, 

and behaviors of the client is achieved by 

projecting one’s self into the perspective of 

the client. In doing so, the provider might experience the client’s hurt, fear, anger, or other 

emotions. Therein lie both the benefits and the 

costs of such a powerful therapeutic response. 

The benefits are immediately obvious to every 

provider who practices his or her skills with 

another. The benefit for the provider is that 

a sense of bonding and understanding with 

the hurting person may emerge. This may be 

demonstrated by the latter feeling understood 

and having the pain/trauma be normalized 

by the provider’s expression of empathy. The 

costs, rarely discussed, must be experienced 

for the provider to guard against or mitigate 

the effects.

	 •	 Compassion stress, the residue of emotional energy from the empathic response, 

is experienced as an ongoing demand for 

action to relieve the client’s suffering. As 

with any stress, compassion stress with sufficient intensity can have a negative effect 

on the immune system and quality of life. 

Together with other factors, this stress can 

contribute to compassion fatigue unless the 

psychotherapist acts to control it. Two major 

types of coping actions appear to help control 

compassion stress:

 ° A sense of achievement, the extent to 

which providers are satisfied with their 

efforts to help the client, can lower or prevent compassion stress. Having a sense of 

achievement involves a conscious, rational 

effort to recognize where the provider’s responsibility ends and the client’s begins.

 ° Detachment, the extent to which providers 

can distance themselves from the ongoing 

misery of the client between treatment 

sessions, can lower or prevent compassion 

stress. The ability to disengage also requires 

a conscious, rational effort to recognize that 

to live their own lives providers must “let 

go” of the thoughts, feelings, and sensations 

associated with clients. Disengagement 

is the recognition of importance of selfcare.24

Compassion stress can also be mitigated by both 

individual and unit management of stressors. If there is 

a sense of achievement, an ability to disengage, and the 

stress is well managed, the stress will be maintained 

at normal levels. If these are insufficient or not present, 

then the level of stress will rise. If compassion stress 

is permitted to build, despite the provider’s effort at 

disengagement and a sense of work satisfaction, the 

provider is at a greater risk of compassion fatigue. 

Three other factors play a role in increasing compassion/provider fatigue:

1. Prolonged exposure is the ongoing sense of 

responsibility for the care of the suffering, 

over a protracted period of time (eg, multiple 

sessions with one individual or multiple 

contacts from large-scale disasters such as the 

2004 tsunami in Asia). To prevent prolonged 

exposure, providers should have regular 

breaks from client appointments, lasting from 

a day off to a week’s vacation.

2. Traumatic recollections are memories that 

trigger symptoms of PTSD and associated 

reactions, such as depression and anxiety. 

These memories may be from the provider’s 

experiences with either demanding or threat-
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ening clients, clients who were especially 

sad or suffering, or clients with experiences 

that have a connection to traumatic events 

experienced by the provider.

3. Life disruptions are unexpected changes 

in schedule, routine, and managing life 

responsibilities that demand attention (eg, 

personal home-front concerns while at war; 

illness; or changes in lifestyle, social status, 

or professional or personal responsibilities). 

Normally such disruptions would cause a 

certain but tolerable level of distress. However, when combined with the other factors, 

these disruptions can increase the chances 

of the provider developing compassion fatigue.24

SYNERGISTIC EFFECTS OF PROVIDER FATIGUE

For the military healthcare provider, numerous 

sources of stress may come together to bring about 

provider fatigue. Although the primary ingredient 

of provider fatigue is unmanaged compassion stress, 

operational stress also contributes to the provider 

fatigue of military healthcare providers, as well as 

chaplains, support staff, and family members. Unresolved primary traumatic stress, secondary traumatic 

stress, and burnout, when added to unmanaged 

compassion stress, directly affect the overall level 

of provider fatigue. For example, providers may 

experience burnout from a continuously heavy 

workload (unrelated to trauma); secondary trauma 

from repeated exposure to the suffering of coworkers 

or family members; or primary trauma in the form 

of direct or indirect fire in a war zone, or the sights, 

smells, and sounds of providing direct humanitarian care. The interactive effect of different types 

of stressors can shape the overall development of 

provider fatigue. Military healthcare providers are 

at increased risk of provider fatigue because of both 

exposure to others’ suffering and the risk of personal 

injury or death.

For many military providers, symptoms of secondary traumatization have a delayed onset. Many 

providers also have prior traumatic experiences that 

may cause no symptoms until associated with the 

stressors of working with traumatic material presented 

by patients. Some may develop clinical PTSD-like 

symptoms associated with their previously “benign” 

historical experiences. It is often necessary to resolve 

primary traumatic stress before addressing any issues 

of secondary stress or burnout. 

Primary stress, secondary stress, operational stress, 

and burnout symptoms have a synergistic or interactive effect with compassion stress (Figure 23-1). Experiencing symptoms from any one of these sources 

appears to diminish resiliency and lower thresholds 

for the adverse impact of the stressors, which can in 

turn lead to a rapid onset of severe symptoms that can 

become debilitating to the provider within a very short 

period of time. The experiences of military providers 

differ from those of civilian providers because of danger while delivering service, multiple deployments, 

working with detainees, cultural differences, and lack 

of time for reprieve. Military-specific operational stress 

includes 

	 •	 lack of reprieves, breaks, and exits during

operations;

	 •	 experience of primary trauma while helping

others;

	 •	 a cumulative effect of the provider’s and clients’ repeated deployments;

	 •	 isolation and relational issues;

	 •	 ethical issues, such as determining who the

client is; and

	 •	 competing demands fortreatment ofthe client

versus the provider. 

Burnout

Secondary

Traumatic

Stress

Operational Stress,

Military-Unique

Components

PROVIDER

Primary

Traumatic

Stress

Figure 23-1. Synergistic effects of primary, secondary, and 

operational stress, combined with burnout symptoms, on 

providers.
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Provider Fatigue and Provider Resiliency Training

WAYS TO IDENTIFY PROVIDER FATIGUE

Symptoms of provider fatigue may include withdrawal from family and friends; emotional numbing; 

loss of interest in things usually enjoyed; persistent 

thoughts and images related to the problems of others; 

physical symptoms such as headaches, gastrointestinal 

disturbances, and muscle tightness; sleep disturbance; 

and jumpiness. 

Markers 

Healthcare providers must monitor themselves 

and coworkers for the following markers. The more 

markers observed or felt, the greater the risk of provider fatigue. The markers fall into the categories of 

cognitive, emotional, behavioral, spiritual, somatic, 

and social.2

Cognitive Markers

	 •	 Intrusive thoughts and disturbing memories

	 •	 Preoccupation with trauma

	 •	 Lowered concentration

	 •	 Disorientation

	 •	 Thoughts of self-harm or harm to others

	 •	 Reduced sense of safety

Emotional Markers

	 •	 Powerlessness

	 •	 Anxiety or fear

	 •	 Anger

	 •	 Survivor’s guilt

	 •	 Numbness or inability to feel emotions

	 •	 Sadness

	 •	 Emotional roller coaster

	 •	 Feelings of depletion, being run down, or out

of steam

	 •	 Irritability

	 •	 Decreased self-esteem

Behavioral Markers

	 •	 Impatience

	 •	 Being snappy or short tempered with others

	 •	 Poor sleep

	 •	 Nightmares

	 •	 Appetite changes, eating more or less than

normal

	 •	 Being jumpy or on edge; startling easily

	 •	 Being accident prone

	 •	 Losing things

	 •	 Being rigid orinflexible, wanting to do everything the same way 

	 •	 Using ineffective or harmful self-care practices

Spiritual Markers

	 •	 Loss of hope

	 •	 Loss of purpose

	 •	 Anger at God

	 •	 Questioning prior religious beliefs

	 •	 Skepticism toward religion

	 •	 Reduced joy and sense of purpose with career

	 •	 Loss of compassion

Somatic Markers

	 •	 Shock

	 •	 Rapid heartbeat and sweating

	 •	 Breathing difficulties

	 •	 Aches and pains

	 •	 Dizziness

	 •	 Impaired immune system; being more prone

to illness

	 •	 Exhaustion

	 •	 Gastrointestinal problems and headaches

Social Markers

	 •	 Decreased interest in emotional intimacy

	 •	 Mistrust and isolation

	 •	 Being overprotective as a parent or as a leader;

not allowing others to have normal activities

	 •	 Loneliness

	 •	 Increased interpersonal conflicts

	 •	 Trouble separating work from personal life

Behavior Changes After Exposure to Trauma

Numerous problems including absenteeism have 

been documented after exposure to trauma. This is a 

real phenomenon that can affect military healthcare 

providers and their ability to do their jobs. In a mixed 

method study by Regehr, Goldberg, and Hughes,26

emergency workers routinely exposed to pain and 

suffering were examined to better understand factors 

leading to higher levels of distress within the theoretical 

framework of emotional and cognitive empathy. Researchers found a significant increase in alcohol-related 

problems, an increase in mental health stress leave, 

and an increase in use of psychiatric medications after 

these providers were exposed to a traumatic event. The 
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study concluded that paramedics, who are exposed to 

many events outside the everyday experiences of the 

average person, have for the most part learned to deal 

with the events and take them in stride. A coping technique commonly used by paramedics is to deal with the 

events cognitively and technically while maintaining 

an emotional distance. At times, however, certain circumstances lead workers to develop an emotional connection with events based on their awareness of other 

aspects of the patient’s experience. Aspects that can 

trigger this connection include the victim’s alienation 

from others, profound loss, or the abuse of an innocent 

child. When this connection occurs, paramedics report 

increased symptoms of traumatic stress.26

Provider fatigue can be recognized on the job by its 

effects on work performance, morale, behavior, and 

relationships.2

Effects on Work Performance

	 •	 Decreased quality

	 •	 Decreased quantity

	 •	 Low motivation

	 •	 Avoidance of tasks

	 •	 Increased mistakes

	 •	 Setting perfectionist standards

	 •	 Obsession about details

Effects on Morale

	 •	 Decrease in confidence

	 •	 Loss of interest

	 •	 Dissatisfaction

	 •	 Negative attitude

	 •	 Apathy

	 •	 Demoralization

	 •	 Lack of appreciation

	 •	 Detachment

	 •	 Feelings of incompleteness

Effects on Behavior

	 •	 Absenteeism

	 •	 Exhaustion

	 •	 Faulty judgment

	 •	 Irritability

	 •	 Tardiness

	 •	 Irresponsibility

	 •	 Frequent job changes

	 •	 Overwork

Effects on Interpersonal Relationships

	 •	 Withdrawal from colleagues

	 •	 Impatience

	 •	 Decrease in quality of relationship

	 •	 Poor communication

	 •	 Subsuming own needs

	 •	 Staff conflicts

In addition to direct observation, compassion can be 

indirectly identified through self-administered survey 

instruments. 

US Medical Command Use of the Professional 

Quality of Life Scale

The ProQOL27 scale is the current version of the old 

Compassion Fatigue Self Test2 and has been widely 

used in assessing compassion fatigue. The ProQOL 

is a 30-item survey instrument that consists of three 

subscales: (1) compassion fatigue, also known as secondary trauma scale; (2) burnout; and (3) compassion 

satisfaction. In keeping with the tone of this chapter, 

the discussion will focus specifically on issues related 

to compassion fatigue. The compassion fatigue variable is measured with 10 questions, and each response 

option ranges from 0 (never) through 5 (very often). 

Stamm28 reported updated descriptive statistics for 

the ProQOL to include compassion fatigue. Based 

on a comprehensive reanalysis of existing published 

research, she found the compassion fatigue mean 

score to be 12, with a standard deviation of 6.9 and a 

Cronbach’s alpha reliability score of .80. Throughout 

the remainder of this discussion, Stamm’s new results 

and the research it was based on will be referred to 

as ProQOL data. Additionally, because the ProQOL 

attempts to identify persons who are “compassion 

fatigued,” the instrument uses quartile scores as cutoff 

scores. In the ProQOL data the top quartile score is 17, 

meaning that respondents scoring 17 or above on the 

compassion fatigue scale are considered compassion 

fatigued.

Compassion fatigue is described as “your workrelated, secondary exposure to extremely stressful 

events.”27 The list below contains the 10 items on the 

Trauma/Compassion Fatigue Scale taken directly from 

the ProQOL:

	 •	 I am preoccupied with more than one person

I help.

	 •	 I jump or am startled by unexpected sounds.

	 •	 I find it difficult to separate my personal life

from my life as a helper.

	 •	 I think that I might have been “infected” by

the traumatic stress of those I help.

	 •	 Because of my helping, I have felt “on edge”

about various things.
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Provider Fatigue and Provider Resiliency Training

	 •	 I feel depressed as a result of my work as a

helper.

	 •	 I feel as though I am experiencing the trauma

of someone I have helped.

	 •	 I avoid certain activities or situations because

they remind me of frightening experiences of 

the people I help.

	 •	 As a result of my helping, I have intrusive,

frightening thoughts.

	 •	 I can’trecall important parts of my work with

trauma victims.27

In 2008 the Surgeon General of the US Army, 

Lieutenant General Schoomaker, required all Army 

MEDCOM personnel to complete the ProQOL. This 

requirement met the intent to assess MEDCOM personnel on compassion fatigue, burnout, and compassion satisfaction. MEDCOM personnel accessed the 

ProQOL scale through a secure Army Web site. Respondents were assured that “[t]he information on the 

ProQOL is protected. Scores on the assessment are for 

use in helping individuals to develop a self-care plan. 

Employees are not required to share the information 

with their supervisors.”29 

The de-identified database was analyzed by personnel assigned to the Soldier Family Support Branch of 

the AMEDD Center and School, using SPSS (Version 

16, SPSS Inc, Chicago, Illinois) statistical software. To 

meet the Surgeon General’s intent of assessing the 

levels of compassion fatigue in MEDCOM personnel, the analysis started with descriptive statistics for 

MEDCOM population demographics and population 

scores. As the name implies, MEDCOM is a medical 

organization that has about 27,000 soldiers and 28,000 

civilian employees30 assigned across 35 medical treatment facilities. For parity’s sake, demographic description is limited to respondent medical specialty. Figure 

23-2 illustrates the percentage of MEDCOM personnel 

by medical specialty. 

Using inferential statistics, the data were then 

analyzed to see whether MEDCOM scores differed 

from ProQOL data scores in a statistically significant 

way. A P value of < .001 was considered statistically 

significant. Analysis then focused on establishing descriptive statistics specific to MEDCOM compassion 

fatigue scores. With valid N = 50,478, the MEDCOM 

mean score for compassion fatigue was 9.8823 (minimum = 0.00, maximum = 50.00, ST = 6.71681, variance 

= 45.116).

A one-sample t test is an appropriate statistical test 

to compare a sample score to a known population 

score.31 In this case, MEDCOM is considered a sample 

of the greater population represented by the ProQOL 

data scores. A one-sample t test was conducted to compare the MEDCOM compassion fatigue mean score 

of 9.88 to the ProQOL data compassion fatigue mean 

score of 12. The MEDCOM compassion fatigue mean 

score was lower than the ProQOL data score and the 

difference was statistically significant with a 2-tailed 

test (t12 = -70.835, P < .001, df = 50,477). The mean difference was -2.11768 (95% CI, -2.1763 to -2.0591). 

Physician

9%

Nurse

21%

Other

Credentialed

Professional

17% Enlisted

Direct Care

13%

Admin Staff

19%

Support

Staff

21%

Figure 23-2. Percentage of US Army Medical Command 

personnel, by specialty, who completed the ProQOL survey 

in 2008. N=50,478.

table 23-1

percentage of medical command

personnel who meet compassion

fatigue cut score

Frequency Percent Valid 

Percent

Cumulative 

Percent

Not 

Compassion 

Fatigued

43,595 86.4 86.4 86.4

Compassion 

Fatigued

6,883 13.6 13.6 100.0

Total 50,478 100.0 100.0
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Combat and Operational Behavioral Health

Another question of interest is how the percentage 

of MEDCOM personnel with compassion fatigue differs from the percentage of personnel with compassion 

fatigue in the ProQOL data. Stamm’s establishment of a 

compassion fatigue cut score of 17, representing 25% of 

the ProQOL data population, allows this comparison. 

The percentage of MEDCOM personnel that scored at 

or above 17 on the compassion fatigue score was 13.6% 

(Table 23-1). This is further graphically represented in 

Figure 23-3.

To determine whether this difference is statistically 

significant, a goodness-of-fit test was conducted. A 

goodness-of-fit test is appropriate when the data score 

is nonparametric,31 which is true in this case using 

quartile-based cut scores. The goodness-of-fit test compares the observed number of personnel (MEDCOM) 

that meet or exceed the cutoff score to the expected 

percentage (ProQOL data) of personnel that meet or 

exceed the cutoff score (Table 23-2). The difference was 

found to be statistically significant with a chi-square 

of 3,477.4 (df = 1, P value < .001).

This study focused on assessing the level of compassion fatigue among MEDCOM personnel and then 

comparing it to levels of compassion fatigue in the 

ProQOL data that represent the greater population. 

The findings establish that MEDCOM personnel report 

less compassion fatigue overall and MEDCOM has a 

lower percentage of personnel who meet criteria for 

compassion fatigue when compared to the cumulative 

samples in published research. Though important, 

speculations about the reasons for this difference are 

beyond the scope of this discussion; further research 

is warranted.

Fatigued

14%

Fatigued

25%

Not fatigued

86%

Not fatigued

75%

ProQOL Compassion Fatigue

Cut-off

MEDCOM Compassion Fatigue

(N = 50,478)

Figure 23-3. Percentage of ProQOL respondents with compassion fatigue compared to US Army Medical Command 

personnel with compassion fatigue.

MEDCOM: US Army Medical Command ProQOL: Professional Quality of Life scale

table 23-2

MEDical COMmand Observed

Compassion Fatigue cut Score

Frequencies Compared to Expected

Frequencies Based on ProQOL Data* 

Observed N Expected N Residual

Not 

Compassion 

Fatigued

43,595 37,858.0 5,737.0

Compassion 

Fatigued

6,883 12,620.0 -5,737.0

Total 50,478

*No cells (.0%) have expected frequencies less than 5. The minimum 

expected cell frequency is 12,620.0.

ProQOL: Professional Quality of Life scale
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Provider Fatigue and Provider Resiliency Training

WAYS TO COMBAT PROVIDER FATIGUE

The EAT Model 

The EAT model was created by Pechacek as a teaching tool for the AMEDD Center and School. The model 

offers a simple, easy-to-remember way for leaders, providers, wounded individuals, and anyone in the helping profession to articulate a way to manage provider 

fatigue and/or burnout. One way to combat provider 

fatigue is using the “EAT” action plan (Figure 23-4): 

Educate yourself; Assess your level of provider fatigue; 

and Take action to build resiliency, create a self-care 

plan, and seek professional help if needed. Figure 

23-5 is a visual reminder that focus on the provider 

is essential to combating provider fatigue. Providers 

are involved with many relationships, including those 

with a patient, soldier, and client, as well as those with 

a colleague who shares stories of trauma. The work 

environment may include many cases of trauma, and 

its resources may be stressed in the attempt to provide 

services to providers and others. Providers are also 

affected by war, disaster, or other traumatic event. 

Figure 23-4. “EAT” to combat provider fatigue.

Educate yourself:

 Who is affected? 

 What is provider fatigue?

 What is resiliency? 

Assess your level of provider fatigue:

 What is the provider fatigue severity level?

 What is the resiliency level?

 How might resiliency be increased?

Take action:

 Build up your resiliency

 Create a self-care plan

 Seek professional help if needed

The level of provider fatigue may be assessed with 

the markers and effects listed above through self and 

buddy observation and discussion, as well as through 

self-tests such as Figley’s Secondary Trauma Scale2 and 

the Professional Quality of Life: Compassion Satisfaction and Fatigue Subscales–III.32

Building Resiliency

Resiliency training focuses on strength rather than 

on pathology. For providers, it is important to have a 

resiliency model and to know where resilient strength 

comes from. Providers should identify a resilient role 

model: Who has the qualities that you as a provider 

would like to have? Have any of the people you work 

with inspired you? Resiliency, like the “Battlemind” 

concept (see Chapter 4, Combat and Operational Stress 

Control, in this volume), is a person’s inner ability to 

face fear and adversity with courage, and the will to 

persevere and overcome adversity. 

To build resiliency, providers must accomplish two 

difficult tasks simultaneously in a stressful situation: 

“self-soothing” and “self-confronting.”33 Self-soothing 

PATIENT

PROVIDER

TRAUMA

WORK

SYSTEM

FELLOW

WORKERS

Figure 23-5. Focus on the provider is essential to combating provider fatigue. Providers are affected by their many 

relationships with patients and clients as well as colleagues, 

in a work environment with exposure to various types of 

trauma.
386

Combat and Operational Behavioral Health

is the ability to deliberately relax while facing a stressful situation. Examples of self-soothing activities 

include working out, running, taking a bubble bath, 

hiking, diving, dancing, or just breathing deeply. The 

purpose of self-soothing is to enable the second step, 

self-confronting. Self-confronting is the process of assessing one’s own anxiety and examining what might 

be learned from the situation. Providers should ask 

themselves questions such as:

	 •	 Why am I anxious?

	 •	 What am I trying to prove?

	 •	 Who am I trying to impress?

	 •	 What am I trying to fix?

	 •	 Am I depending on someone else to validate

my sense of self-worth? 

	 •	 What is the growth potential in this situation? 

Self-soothing without self-confronting leads to 

avoidance, such as withdrawing, being demanding or 

driven by emotions, overeating, or substance abuse. 

Self-confronting without self-soothing leads to the risk 

of negativity without the willingness to step back and 

look for growth opportunities.

A Holistic Approach to Renewal 

A provider can work to combat provider fatigue and 

build resiliency in five ways: (1) physically, (2) mentally, (3) emotionally, (4) spiritually, and (5) socially.

Physical Renewal

Nutrition is the first consideration in physical 

renewal. Under stress, some providers use food for 

comfort, and some refrain from eating. Maintaining 

good nutrition while avoiding fast food provides the 

best results. Furthermore, drinking the appropriate 

amount of water is important to fighting stress. Secondly, rest and relaxation are important for physical 

renewal, including sleep at night, breaks at work, and 

vacation time away from trauma. 

Other means of physical renewal are exercise and 

laughter. Exertion through exercise releases pent-up 

frustrations and renews energy. Studies have shown 

that consistent exercise is associated with improved 

depression scores in patients with depression, cancer, 

and cardiac disease, and even in healthy subjects.33

Other studies34 have shown that laughter can reduce 

or prevent hypertension. Laughter may initially cause 

blood pressure to increase, but it then decreases and 

breathing becomes deeper, sending oxygen-enriched 

blood and nutrients throughout the body. This increase 

in blood flow and oxygenation of blood can actually 

assist in healing. Not conducive to physical renewal are 

forms of avoidance such as substance abuse, gambling, 

or other addictions.

Mental Renewal

Fear is normal for providers, who may worry about 

how well they are taking care of patients or accomplishing other duties. Fear can also lead to feelings 

of shame and guilt. Like physical renewal, mental 

renewal results from relaxation, through activities 

like reading books, listening to music, or learning 

relaxation techniques from tapes or seminars. When 

the sympathetic nervous system is calmed and quieted 

by relaxation, muscle tension decreases, the heart rate 

slows, and a feeling of well-being occurs. 

Emotional Renewal

Emotional renewal means accepting and normalizing experience. Internalized anger, fear, depression, 

anxiety or other negative emotions can produce biochemical changes that have been shown to adversely 

affect the mind and body. The experiences of providing 

military medical care may cause troubling dreams or 

recurring thoughts. This is normal. Before providers 

can act to change their emotions, they must accept 

their situation. Emotional resiliency grows by thinking through daily events, sorting through emotions, 

talking with trusted friends, keeping a journal, and 

even laughing. Laughter can activate and strengthen 

the immune system by reducing four neuroendocrine 

hormones associated with the stress responses: epinephrine, cortisol, dopamine, and growth hormones.

Spiritual Renewal

Spiritual renewal is important to numerous military providers. Many have claimed that the sense of 

belonging to God or a higher power has assisted them 

in coping with anxiety and trauma. For many people, 

praise and worship with groups of people is uplifting 

and rejuvenating, listening to inspirational music or 

reading devotional books may be therapeutic, and taking time out to refocus attention on a greater “problem 

solver” reduces pressure when working in traumatic 

circumstances. Meditation can also be a source of provider resiliency; the ability to sit back, observe the 

mind, and direct attention to the present moment allows people to face challenges with renewed strength 

and flexibility. And for many, spiritual resiliency and 

renewal comes from forgiveness. Forgiveness is a way 

to avoid bitterness and recover from burnout; failing 

to forgive oneself and others often turns anger inward, 

resulting in bitterness, depression, and burnout.
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Provider Fatigue and Provider Resiliency Training

For many military healthcare providers, spirituality is a deep sense of comfort, support, and daily 

inspiration. Studies have demonstrated that religion 

and spirituality are associated with reduced risk of 

medical morbidity and mortality and lower rates of 

divorce, criminal behavior, suicide, and drug abuse.33

For some individuals, spirituality without a formal 

religion is their source of resiliency; however, according to a Gallup poll,34 religion plays a huge role in the 

lives of others: 

	 •	 for 70% of Americans, religion is a “very important” part of life;

	 •	 over 60% of Americans believe in angels;

and

	 •	 82% ofAmericans express interest in spiritual

growth.

Social Renewal

Humans are social creatures. Military providers 

need to be with and relate to others for growth and development. Making time for others increases positive 

mental health and builds resilience. Having a social 

network increases coping strategies, a key ingredient 

for building resiliency both on the job and in all aspects 

of life. Providers have often asked, “How do I keep 

from getting depressed, listening to people’s problems 

day after day?” The answer lies in the basic philosophy 

of looking for and emphasizing strengths rather than 

pathology in other people. Maddi35 studied hardiness 

and wrote extensively about how people obtain hardiness and thrive under adverse conditions. He has 

found that people who thrive under stress maintain 

three key beliefs that help turn adversity into advantage: (1) commitment: striving to become involved in 

ongoing events rather than feeling isolated; (2) control: 

trying to influence outcomes rather than lapsing into 

passivity; and (3) challenge: viewing stressful situations as opportunities for new learning.35

Leadership

Like all complex systems, the military is greatly 

affected by its leadership. It is imperative that leaders 

at all levels be familiar with the concepts discussed in 

this chapter and encourage their soldiers to practice 

them. Colonel Joseph Pecko, former chief of the Soldier 

and Family Support Branch of the AMEDD Center and 

School, commented on the role of leadership and its 

place in striving for resiliency: “Leadership may have 

many meanings, but leadership practices in regard to 

provider fatigue are very important.” Following the 

suggestions of PRT ensures strong leadership skills 

and the best results for all. Colonel Pecko encourages 

leaders to promote provider resiliency in the following ways:

	 •	 Place the care of the military care providers

as the highest priority. 

	 •	 Give credit and reward a job well done.

	 •	 Foster an environment of dignity and respect.

	 •	 Be available to talk with subordinates; spend

time with them. Embrace an open door as 

well as anonymous “back door” policy. Allow providers to talk about their experiences 

and feelings. Let providers know that you are 

aware of their situation and offer help. Often, 

providers cannot take action on their own 

because they are too close to the situation, so 

the suggestions and attitude from leadership 

can be helpful.

	 •	 Keep your staff informed. Clearly express

your policies and views on all matters. Allow 

subordinates to seek clarification on your 

policies without becoming defensive or seeing subordinates as disloyal. Try not to take 

subordinates’ actions personally.

	 •	 Allow providers sufficient time to recover

from duties, physically and mentally. Give 

them private time to do different work or 

catch up on tasks. Assist with the provider’s 

everyday tasks when possible.

	 •	 Establish a climate where subordinate leaders

can acknowledge stress and the desire to seek 

assistance. Teach leaders that seeking help 

takes courage. Encourage leaders to seek out 

and identify their most vulnerable and at-risk 

people. 

	 •	 Take care of yourself as a leader and set a

good example of self-care. Maintain a positive attitude during periods of adversity and 

challenge. The resiliency and mental toughness of the leader will shine through to others. 

Leaders setting an example in self-care and 

speaking the language of resiliency can bring 

about dramatic positive results in the work 

environment.

SUMMARY

In the 21st century, military care providers must 

understand provider fatigue and how it affects their 

care for those suffering from the effects of trauma. 

This chapter has defined types of fatigue related to 

the military healthcare provider and unit ministry 

teams, discussed Figley’s model of compassion 
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Combat and Operational Behavioral Health

fatigue, identified the symptoms and markers of 

provider fatigue, and listed methods of preventing 

provider fatigue as well as ways to promote renewal 

and resiliency for the provider, including the role of 

leaders. Promoting resiliency for the provider, like 

the broader mission of providing healthcare for all 

service members, depends on teamwork. At every 

level, leaders and providers must begin with self-care 

before promoting resiliency in their colleagues and 

subordinates.

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