The Cost of Caring: Compassion Fatigue among Peer Overdose Response Workers in British Columbia

Abstract

Background: The drug toxicity crisis has had dramatic impacts on people who use drugs. Peer overdose response workers (peer responders), i.e., individuals with lived/living experience of drug use who work in overdose response settings, are particularly susceptible to negative physical and mental health impacts of the crisis. Despite that, the mental health impacts on peer responders have yet to be studied and measured. Methods: The Professional Quality of Life survey (Version 5) was completed by 47 peer responders at two organizations in British Columbia between September 2020 and March 2021 to assess compassion satisfaction and compassion fatigue. The Likert scale responses were converted into numerical values and scores were calculated for each sub-scale. The mean score was calculated for each sub-scale and categorized as low, medium, or high, based on the instructions for Version 5 of the instrument. Results: Our study uncovered a high mean score for compassion satisfaction, low mean score for burnout, and medium mean score for secondary traumatic stress among peer responders. These results may be due to the participants’ strong feelings of pride and recognition from their work, as well as the low number of participants that felt they had too much to do at work. Conclusion: Although peer responders derive pleasure and fulfillment from their jobs, i.e., compassion satisfaction, they also sometimes face burnout and stress due to continuous exposure to the trauma of the people they support. These results shed light on the areas that need to be targeted when creating supports for peer responders.

Keywords:

• Compassion fatigue
• compassion satisfaction
• secondary traumatic stress
• burnout
• peer responders
• overdose response
• overdose prevention sites
• people who use drugs
• frontline workers
• overdose related deaths

Background

For several years now, deaths due to drug toxicity (overdoses) have been on the rise in Canada. According to data from the Government of Canada, 29,052 opioid toxicity deaths have been recorded between January 2016 and December 2021 (Public Health Agency of Canada, 2022). In British Columbia (BC), the drug toxicity crisis was declared a public health emergency in April 2016 (BC Gov News, 2016), and was driven by an increase in the unpredictability and toxicity of the composition of opioids and other drugs sold in the illicit market (BC Coroners Service, 2021). Evidence from the BC Coroners Service shows that illicit drug toxicity deaths have risen further since the onset of the coronavirus disease of 2019 (COVID-19) and the implementation of public health measures including physical distancing, reduced capacity and hours of operation of overdose prevention services, and interruption of the existing drug supply in March 2020 (BC Coroners Service, 2021). In 2021, 2,224 suspected drug overdose deaths were reported—the highest yearly death toll on record (BC Coroners Service, 2021). drug

People with lived/living experience of drug use, commonly referred to as peers¹ are at the forefront of overdose response initiatives (Bardwell et al., 2018; Greer et al., 2016; Kennedy et al., 2019; Law, 2018; Mamdani et al., 2021; Smart, 2018). Peer overdose response workers (peer responders) are individuals with lived/living experience of drug use who work in overdose response settings (Greer et al., 2016). Peer responders are employed in a variety of settings in BC, including shelter and housing agencies, supervised consumption sites, and overdose prevention services (Greer et al., 2016). Peer responders have been and are central to the development of harm reduction initiatives across Canada. They lead and inform the harm reduction movement in various ways through their involvement in research, program and policy development, outreach, as well as advocacy (Bardwell et al., 2018; Canadian Association of People who Use Drugs, 2021; Gillespie et al., 2018; Greer, 2019; Jozaghi et al., 2018; Kennedy et al., 2019; Marshall et al., 2015; Wagner et al., 2014).

Studies have indicated that working in overdose response settings is meaningful for peer responders and gives them a sense of purpose (Pauly et al., 2021). This meaning that peer responders derive from their work may be classified as “compassion satisfaction”, which is defined as the pleasure one derives from doing their work, including from helping others, contributing to the work setting, and to the greater good of the society (Bride et al., 2007; Stamm, 2010).

Despite the positive impact of working in overdose response settings, studies have shown that this work can be stressful and emotionally taxing for peer responders due to the repeated exposure to death and trauma of others (Bardwell et al., 2018; Declaire, 2018; Kennedy et al., 2019; Mamdani et al., 2021; Shepard, 2013; Teti et al., 2009; Wagner et al., 2014). The upward surge in overdose deaths is especially devastating for peer responders who are not only facing deaths of clients, but of friends and family members, and are at risk of overdosing themselves (Mamdani et al., 2021). Many peer responders have reported feeling burnout and “running [themselves] ragged” due to the constant worrying and inability to unwind (Mamdani et al., 2021). Peer responders’ personal and professional lives are heavily intertwined because they are part of the community they serve, and they are constantly working to support community members in need, even outside the work environment (Mamdani et al., 2021). As such, they are unable to escape the crisis and unwind (Mamdani et al., 2021). In addition, peer work is often precarious and peer responders are often under-recognized and under-paid for their life saving work, which can add stress into their lives (Clarke et al., 2007; Greer et al., 2020; Mamdani et al., 2021; Olding et al., 2021a). Peer responders’ shared experience with their clients, coupled with the socio-economic marginalization associated with drug use, renders them particularly vulnerable to physical and mental health harms (Olding et al., 2021b).

The terms “compassion fatigue” and “burnout” identify and categorize the increasingly prominent mental health deterioration of those working in helping professions such as nurses, doctors, therapists, and social workers (Adams et al., 2006; Cocker & Joss, 2016; Conrad & Kellar-Guenther, 2006; Figley, 1995, 2002; Hunsaker et al., 2015; Pearlman & Saakvitne, 1995; Ray et al., 2013). Compassion fatigue is described as an individual’s “diminished capacity to care as a consequence of repeated exposure to the suffering of [others]” (Nicola et al., 2020). Compassion fatigue is often the umbrella term used for burnout and secondary traumatic stress (STS) (Nicola et al., 2020). Burnout is “a state of physical and mental exhaustion caused by a depleted ability to cope with one’s everyday environment, resultant from one’s responses to the ongoing demands and stressors of one’s daily life” (Maslach, 1982; The Florida Center for Public Health Preparedness, 2004) while STS is defined as the stress of repeated exposure to trauma of others rather than from exposure to the trauma itself (Nicola et al., 2020; The Florida Center for Public Health Preparedness, 2004). While many definitions of burnout tend to place the onus on the individual for lacking coping skills, it is important to note that this inability to cope is, more often than not, a result of one’s perceived demands outweighing the resources available to them (The Florida Center for Public Health Preparedness, 2004). Studies have indicated that burnout and STS are closely linked in that when burnout increases, STS also increases (Ruiz-Fernández et al., 2020). On the other hand, compassion satisfaction is inversely associated with burnout and STS such that when compassion satisfaction is high, burnout and STS are low (Ruiz-Fernández et al., 2020).

Factors associated with compassion fatigue include workload intensity, inadequate rest periods between shifts, task repetitiveness, low job satisfaction, lack of meaningful recognition, and lack of managerial support (Ray et al., 2013). Many of these factors have previously been described as stressors faced by peer responders (Mamdani et al., 2021). Yet, despite the obvious connection between compassion fatigue and overdose contexts, there is limited literature in this area. A study by Winstanley highlights the concept of “Overdose Compassion Fatigue” (OCF), i.e., “distress or a reduction in empathy resulting from knowledge of or exposure(s) to overdose-related harms” (Winstanley, 2020). OCF is different from occupational compassion fatigue because OCF can result from a single traumatic exposure and is independent of potential confounding factors (e.g., personal history of trauma, low social support, and work stress) (Winstanley, 2020), whereas compassion fatigue is believed to occur over a period of time and resulting from an accumulation of factors (Adams et al., 2006; Conrad & Kellar-Guenther, 2006). Since peer responders often witness overdoses among those with whom they have an emotional connection, and may also be at risk of experiencing overdoses themselves, the distress they feel would be expected to be much greater than those of individuals experiencing OCF from a single exposure. Yet, thus far, neither OCF nor occupational compassion fatigue has been applied to the context of peer responders.

This study aims to quantitatively assess compassion satisfaction, burnout and STS among peer responders in BC. We hope that the results will fill an important gap in literature and will have implications for policy and programming for peer responders who provide crucial services to people who use drugs during the ongoing dual public health emergencies in BC.

Methods

Study participants, settings and recruitment

This particular study was a component of a larger evaluation of the Peer2Peer project (Ackermann et al., 2021), a community-based research project aimed at identifying, designing, implementing, and evaluating supports for peer responders. The ROSE Model, an intervention consisting of multiple strategies to improve Recognition of peer work, Organizational support, and Skill development for Everyone, was implemented at two organizations (Mamdani et al., 2021). These include: (1) SOLID Outreach Society—a peer worker-led organization in Victoria, BC, that educates, advocates, and provides services for individuals that use drugs (Solid Outreach, 2020), and (2) RainCity Housing—a not-for-profit, housing-first organization in Vancouver and Maple Ridge, that provides housing and support services for people living with mental health, drug use, and other challenges (RainCity Housing, 2020).

The inclusion criteria for participants were those who: (1) work, formally or informally, in overdose response settings, (2) identify as a peer responder (3) are over the age of 18, and (4) are able to complete a questionnaire in English. All eligible peer responders at the pilot sites were invited by their organizational managers in person to participate in the study and participation was voluntary.

Instrument

The Professional Quality of Life (ProQOL) survey (version 5) was used to assess compassion satisfaction and compassion fatigue (Stamm, 2009). Compassion fatigue is measured in terms of burnout and secondary traumatic stress (STS) (Conrad & Kellar-Guenther, 2006; Stamm, 2009). This survey was selected as it is a validated tool that is used to measure both the positive as well as negative aspects of an occupation (Bride et al., 2007). The timeframe in the ProQOL survey is also appropriate in that it allows us to assess recent experiences of peer responders; Given the unpredictability of peer work, we felt that a 7-day period, which several other tools assess, would be too short to get a complete picture on the work-related stressors and benefits of peer work (Bride et al., 2007). ProQOL is also commonly used by several studies aimed at quantifying these measures among front line workers including nurses, doctors, etc., which allows for comparison of scores across professions (Hooper et al., 2010; Keidel, 2002; Nicola et al., 2020; Sheppard, 2015).

The ProQOL survey version 5 is divided into three subscales based on what it is intended to measure: compassion satisfaction, burnout, and STS. For each subscale, there are 10 statements which participants are asked to rate from 1 to 5 (1 = Never, 2 = Rarely, 3 = Sometimes, 4 = Often, 5 = Very Often) based on their degree of agreement with that statement. A total score for each subscale is then calculated, and scores can be categorized as low, medium, or high (≤22, low; 23–41, medium; and ≥42, high) (Stamm, 2009).

The ProQOL survey (Version 5) was administered as part of a larger survey to evaluate the Peer2Peer project. Thus, in addition to the full ProQOL tool, the survey included a demographic questionnaire, and questions adapted from other tools such as the SF-12 health survey, the Job Satisfaction Survey and the Canadian Community Health Survey. Relevant questions from our larger survey that provided insight into the ProQOL subscales were included in our analysis.

Data collection

The survey was administered between September 2020 and March 2021 in three cities where the intervention strategies were implemented.

The survey was administered to participants by Peer Research Assistants (PRAs), i.e., peer responders who were trained in research methods and ethics and were a part of the project working group. The PRAs read out each question on the survey and recorded the participants’ responses on the paper survey. Prior to survey administration, informed written consent was obtained from the participants.

The survey took approximately one hour to complete. Participants were given a $25 honorarium to complete the survey, as per the BC peer worker payment standards (BC Centre for Disease Control, 2018).

Data analysis

The analysis of quantitative survey data was conducted by two academic researchers (ZM and EA). The results were summarized in a report which was presented to the PRAs for data validation. The PRAs helped to interpret the results and situate them within the context of their lives. While the aim of this article is to quantify compassion satisfaction and compassion fatigue among peer workers using the ProQOL survey, descriptive analyses were conducted for relevant questions from the larger survey that provided insight into compassion satisfaction and compassion fatigue scores.

Likert scale responses from the ProQOL survey were converted into numerical values and scores were calculated for each sub-scale. The mean score was calculated for each sub-scale and categorized as low, medium, or high, based on the scoring instructions for version 5. Non-parametric tests (Mann–Whitney U test and Kruskal–Wallis H) were conducted to compare means in each sub-scale by participants’ socio-demographic characteristics, i.e., gender, age, location, and ethnicity. Spearman’s rank correlation test was conducted to measure the correlation between sub-scales of the ProQOL survey. All analyses were conducted using R statistical software, version 4.0.2 (The R Foundation, 2020) and a p value less than 0.05 was considered statistically significant.

Ethics

The study received Research Ethics approval from the University of British Columbia Research Ethics Board (REB #: H18-00867) and harmonized approval from University of Victoria and Island Health.

Results

The survey was completed by 47 peer responders: 18 from Vancouver, 21 from Victoria and 8 from Maple Ridge. The demographic profile of survey participants is presented in Table 1. There was a diversity in participants in terms of gender, age and self-reported indigeneity. Just over half of the participants were men (55%), and over 40 years old (57%). The majority of the participants self-reported as non-Indigenous (77%).

Table 1. Demographic characteristics of participants.

	Total sample
	n, (%)
	n = 47, (100%)
Location
Vancouver	18 (38%)
Victoria	21 (45%)
Maple ridge	8 (17%)
Gender
Men	26 (55%)
Women	21 (44%)
Age
18–40	20 (43%)
41–50	14 (29%)
Over 51	13 (28%)
Self-identified indigeneity
Non-indigenous	36 (77%)
Reported indigenous	11 (23%)

Compassion satisfaction

The mean compassion satisfaction score among the participants was 42 (SD = 5.16) which can be classified as “high” according to the ProQOL Version 5 scoring instructions (Stamm, 2009; Table 2). Most individuals scored high for compassion satisfaction (59.6%, n = 28), over a third of the participants (40%, n = 19) scored in the medium range, but none scored low.

Table 2. Professional quality of life survey sub-scale scores.

Sub-scale	Score (Stamm, 2009)	n (%)	Mean (μ)	Standard deviation (σ)
Compassion Satisfaction	LOW (≤22)	0 (0%)	42	5.47
	MEDIUM (23 to 41)	19 (40.4%)
	HIGH (≥42)	28 (59.6%)
Burnout	LOW (< =22)	30 (63.8%)	20	5.50
	MEDIUM (23 to 41)	17 (36.2%)
	HIGH (> =42)	0 (0%)
Secondary Traumatic Stress	LOW (< =22)	25 (53.2%)	23	7.34
	MEDIUM (23 to 41)	21 (44.7%)
	HIGH (≥42)	1 (2.1%)

The high compassion satisfaction score may be explained by results of some of the questions in the larger evaluation survey adapted from different tools. For example, for the question “I like the people I work with,” a vast majority (91%) of the participants agreed (the remaining 9% were neutral, no one disagreed). This indicates that peer responders have good relationships with their colleagues which may explain their high compassion satisfaction.

A sense of pride and feeling that they have something important to contribute to society may also be a predictor for high compassion satisfaction among peer responders. All (100%) of the participants indicated that they felt a sense of pride in their job which would explain the overall high compassion satisfaction score.

Table 3 indicates the mean scores for each sub-scale by socio-demographic characteristics. Women had a significantly higher compassion satisfaction score than men (44 vs. 41). Furthermore, individuals in Maple Ridge and Vancouver had a significantly higher compassion satisfaction score than those in Victoria (45 and 44 compared to 39). There were no significant differences in the compassion satisfaction scores between the different ages and ethnicities.

Table 3. Professional quality of life survey subscale scores by socio-demographic characteristics.

	Total sample	Compassion satisfaction		Burnout		Secondary traumatic stress
	n, (%)		U/H (p)		U/H (p)		U/H (p)
Aggregate	n = 47, (100%)	Mean score, Rank	42	Mean score, Rank	20	Mean score, Rank	23
Location			H = 10.39 (p = 0.006)		H = 14.18 (p = 0.0008)		H = 13.08 (p = 0.0014)
Vancouver	18 (38%)	44		16		19
Victoria	21 (45%)	39		23		25
Maple ridge	8 (17%)	45		22		29
Gender			U = 176 (p = 0.04)		U = 220.5 (p = 0.26)		U = 244 (p = 0.54)
Men	26 (55%)	40		21		24
Women	21 (44%)	44		19		23
Age			H = 0.84 (p = 0.66)		H = 0.66 (p = 0.72)		H = 4.36 (p = 0.11)
40 and under	20 (43%)	42		20		21
41–50	14 (29%)	41		20		26
Over 51	13 (28%)	43		21		24
Ethnicity			U = 166.5 (p = 0.44)		U = 175.5 (p = 0.58)		U = 174 (p = 0.55)
Reported Indigenous	11 (23%)	42		20		22
Non-Indigenous	36 (77%)	42		20		24
Note: U = Mann–Whitney U Test, H = Kruskal–Wallis Test, p = significance level

Burnout

The mean burnout score was 20 (SD = 5.50) which falls in the “low” range (Table 2). At an individual level, almost two thirds of the participants (63.8%) scored low and the remaining scored medium on the burnout scale.

There are many factors associated with burnout and the results of some questions in the larger evaluation survey provided insights into this. One such factor is receiving recognition for the work done by peer responders. Participants that agreed that they were recognized for the work they do had 2.72 times higher odds of scoring low for burnout (vs. scoring medium). Over three-fourths of the participants agreed that they felt recognized for the work they do, accounting for the overall low burnout score.

Perception of pay being unfair appears to be another potential reason for burnout. Two thirds of the participants agreed that they were paid a fair amount for the work they do, and those that agreed had 2.1 times higher odds of scoring low on the burnout scale compared to those that disagreed.

Another potential predictor for burnout seems to be workload. Participants that felt they had too much to do at work had 3.8 times higher odds of scoring medium on the burnout scale (no one scored high), compared to those who did not feel they had too much work. However, the majority of the participants (77%) did not feel they had too much to do at work, which would explain the overall low burnout score.

Verbal conflict at work also seems to be a predictor for burnout. Participants that agree that there is too much bickering and fighting at work are 6.4 times more likely to score medium for burnout (no one scored high) compared to those that disagreed.

Overall, our results indicate that burnout seems to be associated with lack of recognition and appreciation in the workplace, perception of inequitable pay, high workload, as well as a non-supportive work environment, characterized by bickering and fighting in the workplace.

Table 3 indicates the mean scores for each sub-scale by socio-demographic characteristics. There were statistically significant differences in the burnout score by location, with individuals in Victoria and Maple Ridge having significantly higher burnout scores (23 and 22 respectively) than Vancouver (16). There were no significant differences in the burnout scores between the different genders, age groups or by self-reported indigeneity.

Secondary traumatic stress

The mean STS score was 23 (SD = 7.34) which is “medium” (Table 2). Specifically, 53% of the participants scored low on the STS scale, 45% scored medium and 2% scored high. While no other questions on the survey provided insight into the reasons for STS among peer responders, discussions with PRAs during data validation as well as published literature provided some explanation, and this has been described in the discussion.

Table 3 indicates the mean scores for each sub-scale by socio-demographic characteristics. There were statistically significant differences in the STS score by location, with individuals in Maple Ridge and Victoria having significantly higher STS scores (29 and 25), compared to Vancouver (19). There were no significant differences in the STS scores between genders, age groups, or by self-reported indigeneity.

Correlations between ProQOL subscales

In Table 4, we show that the sub-scales were correlated. Compassion satisfaction was negatively correlated with burnout (p < 0.05) and STS (p > 0.05), although the correlation with the latter was not statistically significant. This means that as compassion satisfaction increases, burnout and STS decrease. On the other hand, burnout and STS were positively correlated with each other (p < 0.05), which means that increase in one is often linked with increase on the other subscale. This would explain why both burnout and STS are considered indicators for compassion fatigue.

Table 4. Bivariate correlations between ProQOL subscales.

	Compassion satisfaction	Burnout	Secondary traumatic stress
	ρ (p value)	ρ (p value)	ρ (p value)
Compassion satisfaction		−0.40 (p = 0.005)	−0.27 (p = 0.07)
Burnout	−0.40 (p = 0.005)		0.70 (p = 0.03 × 10^-6)
Secondary traumatic stress	−0.27 (p = 0.07)	0.70 (p = 0.03 × 10^-6)

Note: ρ = Spearman’s rank correlation estimate. p = significance level.

Discussion

The aim of this study was to explore and measure compassion satisfaction and compassion fatigue (characterized by burnout and secondary traumatic stress) among peer responders in BC. Our study shows that peer responders in overdose response settings during the dual public health emergencies, related to the drug toxicity crisis and COVID-19, experience high compassion satisfaction, low burnout, and medium STS. As there is no prior literature relating compassion fatigue and compassion satisfaction to peer responders, this study provides novel findings and lays the groundwork for further research.

The high compassion satisfaction score among peer responders underscores the rewarding nature of peer work. The high compassion satisfaction score can potentially be explained with findings from our previous paper outlining the meaning and motivation peers derive from their work including a sense of purpose from helping others, pride from finding and being an inspiration to others, and a sense of belonging within a community (Pauly et al., 2021). Pauly and colleagues (2021) highlighted how work had provided new meaning to the lives of peer responders and how the pleasure they derived from their work had a direct impact upon reducing their levels of stress. It was, therefore, unsurprising that in our survey, 100% of survey participants felt a sense of pride in their job. The high compassion satisfaction score for peer responders is an important contrast to the experiences of other emergency service providers in the forefront of the drug toxicity crisis (Knaak et al., 2019). According to a study by Knaak et al. (2019), stigma against people who use drugs amongst frontline workers (fire services, police, etc.) manifest in the form of low compassion satisfaction (Knaak et al., 2019). The interesting contrast between peer responders and emergency service providers may explain why peer responders are often the preferred responders in overdose response contexts (Bardwell et al., 2018; Pauly et al., 2021). This finding has important implications for the role of peer responders in overdose contexts in BC; peer responders ought to be more recognized and legitimized as first responders in overdose response contexts.

Our study found a higher compassion satisfaction score for women than men. Our results do not provide any insight into the reasons for this difference. However, the results may be explained by the innate personality differences between the genders, shown by previous research, which indicates that women are believed to be more empathetic than men (Baez et al., 2017; Sharma et al., 2016). As such, women may derive more meaning from their work and feel more satisfied from helping others than do men.

Our sample had a mean burnout score of 20, which is classified as low. This result was surprising given the relationship between burnout and high staff turnover rate. A study examining rates of burnout among Child Protection Workers in Colorado demonstrated very low rates of burnout, and this was attributed to the high turnover rate, indicating that burnt out employees may just quit their jobs (Conrad & Kellar-Guenther, 2006). However, unlike other professionals, peer responders don’t often have the liberty to quit their jobs as and when they feel stressed or burnt out due to the scarcity of alternate means of employment for people who use drugs (Greer et al., 2020). Even those who do leave formal peer roles never fully leave work as they are members of the same community and whether they are paid for their work or not, they constantly strive to keep their loved ones and communities safe (Mamdani et al., 2021). In other words, working in overdose response settings and saving lives is not just a job for peer responders, it is their reality as individuals with lived/living experience. Hence, peer responders are at increased risk of burnout. Yet, we found that within our sample, burnout was low. A potential explanation for low burnout in our sample may be the fact that burnout is “believed to occur over a period of time and resulting from an accumulation of factors” (Winstanley, 2020); discussions with organizational managers in Vancouver and Victoria reveal that many staff were new and hired during the COVID-19 pandemic. As such, it is possible that the newer staff have not yet accumulated the stress and trauma of working as peer responders and are, thus, feeling less burnt out. Furthermore, given that our sample includes peer responders who already had access to the ROSE model strategies, the low average burnout score may indicate that the strategies are working well in reducing burnout.

For STS, the mean score fell in the medium range, and almost 47% of the participants scored medium to high on the STS scale. This is especially alarming given that the participants in this study already had access to support interventions through the ROSE model. Discussions with PRAs during data validation indicate that over the many years since the declaration of the drug toxicity crisis as a public health emergency, peer responders have been exposed to significant trauma and death which has increased with the onset of COVID-19 (Mamdani et al., 2021). Research shows that that even a single exposure to a fatal or non-fatal overdose can lead to considerable stress, burnout and overdose-related compassion fatigue (Winstanley, 2020). Over time, this constant exposure to death can lead to feelings of numbness and hopelessness (Winstanley, 2020), explaining the medium mean STS score among peer responders.

Many studies have shown STS among doctors, nurses and other frontline workers (Alharbi et al., 2020; Gustafsson & Hemberg, 2021; Hooper et al., 2010; Keidel, 2002; Ruiz-Fernández et al., 2020; Xie et al., 2021). A study by Ruiz-Fernández et al. (2020) revealed that the mean STS score of their sample of healthcare workers was 19.9 whereas the mean of our sample was 23 (Ruiz-Fernández et al., 2020). It must be noted that the former study used Version 4 of ProQOL, which has slightly different scoring and interpretation. The higher STS score for peer responders compared to healthcare professionals may be due to several factors: 1) Unlike healthcare professionals, peer responders often do not have opportunities to unwind after a stressful day at work; their work is often 24 hours a day as their personal and professional lives are inter-twined and they live and work within a community traumatically impacted by the drug toxicity crisis (Mamdani et al., 2021). This repeated exposure to others’ suffering coupled with similar personal issues can generate STS. 2) Healthcare professionals like doctors and nurses may have systems of support such as paid time off and access to counseling (Johnson, 2017; Joint Task Force on Overdose Prevention & Response, 2017). Peer responders, however, lack such institutional supports. Furthermore, healthcare professionals’ work arrangements are generally stable and long-term unlike the work arrangements of peer responders, which are often precarious (Greer et al., 2020). 3) Doctors and nurses often do not have an emotional attachment with their patients and may not have the same lived/living experience as their patients, which may potentially make it easier for them to deal with secondary trauma. On the other hand, peer responders are often not responding to mere clients, rather to friends and family members (Mamdani et al., 2021). Overall, the higher levels of STS identified in peer communities are indicative of an overarching institutional system that devalues the expertise of people who use drugs.

Consistent with other studies (Ruiz-Fernández et al., 2020), we found that compassion satisfaction was inversely associated with burnout and STS, although the association between compassion satisfaction and STS was statistically insignificant. This indicates that a high compassion satisfaction can be a protective factor against burnout and STS and has implications for intervention-planning for peer responders. For example, to reduce burnout among peer responders, more opportunities of work should be created for peer responders, where they feel valued and appreciated.

Our study uncovered location-based differences in compassion satisfaction, burnout, and STS. Participants in Vancouver had significantly lower burnout and STS compared to Victoria and Maple Ridge. Consultation with PRAs revealed that these differences may be due to the high number of new staff in Vancouver and the better availability of community resources for people who use drugs in that area, such as free food, overdose prevention services, etc.

Previous research has indicated that compassion fatigue can have significant mental and physical health impacts, including sleep disturbance, emotional distress, and increased risk of depression, anxiety and post-traumatic stress disorder (Cocker & Joss, 2016; Gustafsson & Hemberg, 2021; Pearlman & Saakvitne, 1995; Ray et al., 2013). As such, compassion fatigue among peer responders must not be ignored since it is critical for their health and wellbeing. Organizations must strive to implement supports for peer responders to reduce burnout and STS. Studies have shown that organizational interventions which increase awareness and knowledge of compassion fatigue (Nolte et al., 2017), or equip individuals with tools to reduce stress during work (Hevezi, 2016) can reduce compassion fatigue. Informal and formal peer support can also prevent compassion fatigue (Steinheiser, 2018). Given the link between compassion satisfaction and feeling recognized at work, organizations must also strive to improve appreciation and recognition for peer responders and pay equitably, based on the peer payment standards (Greer & Buxton, 2018). Furthermore, organizations should provide peer responders with options to take paid time off to recuperate, as needed. Since self-care has shown to be effective in reducing compassion fatigue (Alkema et al., 2008), facilitating peer responders to partake in self-care activities may also be useful. The ROSE model holds much promise in improving working conditions for peer responders (Ackermann et al., 2021; Mamdani et al., 2021), in turn improving compassion satisfaction and reducing compassion fatigue among peer responders, and this potentially explains the low burnout, medium STS and high compassion satisfaction among our sample of participants.

The illicit drug toxicity crisis has been ongoing for several years, and given the accumulative effects of burnout and STS, compassion fatigue among peer responders and its consequent health impact would only be expected to worsen. Thus, in addition to implementing organizational supports for peer responders, there is a critical need to take systemic measures, such as decriminalization of drug use as well as regulation and scale up of safe supply initiatives. If these systemic measures are not implemented soon, compassion fatigue among peer responders may become the next public health crisis.

Although our study is novel, it does have limitations. First, our data are from three urban centers in BC where our pilot sites are located. Close knit social networks as well as stigma in rural areas may increase the impact of overdose fatalities on their communities (Winstanley, 2020). Additionally, although almost all peer responders at the study sites were sampled, the sample size is still small. A more expansive study is needed to fully grasp regional differences in compassion satisfaction, burnout and STS, and better represent all peer responders in BC. Future research should also be done on a national scale using quantitative and qualitative methods to get a complete picture on what is going on in the front lines during these dual public health emergencies. Also, the survey included some questions that required participants to recall their experiences over a 30-day period, which introduces a potential recall and reflection bias. Another limitation is that our sample consisted of peer responders who already had access to the ROSE model strategies and it is difficult to generalize the findings to all peer responders in BC; peer responders at other sites without access to such interventions may have a higher score for compassion fatigue. That said, despite having access to the ROSE model strategies, there is a considerable number of participants that scored medium for burnout and high for STS. This indicates the seriousness of the issue and underscores the need for upstream measures to address compassion fatigue among peer responders in BC.

Conclusion

The results of our study highlight an important juxtaposition; the deep fulfillment that peer responders derive from their jobs, amid some measures of burnout and secondary traumatic stress. Despite having access to the ROSE model strategies, there were a considerable number of participants that scored medium for burnout and high for secondary traumatic stress. These seemingly-opposite observations are not antagonistic—rather, they are intimately linked. Because peers are so deeply connected to the suffering of their clients through their shared lived/living experience, their stress is amplified. Peer workers who lack organizational support may have higher compassion fatigue scores. There is, therefore, a need for more systemic measures, such as decriminalization of drugs and scale up of safe supply initiatives. Further research should focus on assessing compassion satisfaction and fatigue among peer workers in rural areas or in areas where organizational supports are limited. A nation-wide study using quantitative and qualitative methods to assess compassion satisfaction and fatigue among peer responders is also warranted to fully grasp what is going on in the front lines during these dual public health emergencies.

Abbreviations
BC	=	British Columbia
COVID-19	=	Coronavirus Disease of 2019
PRA	=	peer research assistant
ProQOL	=	Professional Quality of Life survey
ROSE	=	Recognition of peer work, Organizational support, and Skill development for Everyone
STS	=	Secondary Traumatic Stress.

Disclosure statement

No conflict of interest has been reported by the authors.

Additional information

Funding

This work was supported by the Health Canada.

Notes

1 During our study, several individuals with lived/ living experience indicated that they find the term “peer” derogatory and suggested the use of the term “experiential worker” or “people with lived/ living experience (PWLLE)” instead. However, given that the term “peer” is still widely recognized internationally and used in literature, we have used this term in our manuscript.