The results of this study showed that sharing experiences in the online support group did not lead to a significant change in compassion fatigue of the family caregivers of the disabled elderly (p = 0.81). However, it was shown that the caregivers experienced moderate level of compassion satisfaction. The results also showed that the caregivers experienced low levels of caregiving burnout and moderate level of secondary traumatic stress and also compassion fatigue.
The presence of compassion fatigue in family caregivers has been confirmed in other studies (6). This study showed that the family caregivers faced various problems related to the care of the disabled elderly including a sense of responsibility towards the family and the elderly, a sense of lack of understanding, respect, and support by those around them, relatives of the elderly and society, and a sense of inadequacy in performing personal, family and professional duties. Furthermore, it was shown that the average time of elderly care reported by the participants was about five years. This prolongation of care time, according to Figley's model of compassion fatigue, is one of the causes of compassion fatigue(5). According to the participants in this study, continuous care caused physical, mental, and emotional problems including chronic feelings of pressure and stress, not having enough rest and fun, chronic fatigue, and not having time to be alone.
Furthermore, there are some beliefs in the Iranian social and religious culture about the moral duties of children in caring for parents in old age and at the time of disability, such as belief in afterworld and sin of giving up elderly parents. These beliefs which may somehow induce a sense of duty in children to care for parents. These cultural factors, along with the long-term care and dependence of the disabled elderly person on the family caregiver, can cause compassion fatigue in the family caregiver.
Moreover, believing in special rewards in the hereafter for those who care for the elderly, especially disabled parents, as well as having deep emotional relationships with parents in the long run and feeling satisfied with meeting their needs by the child, increases satisfaction with compassion, thus reducing the perceived burden of family caregivers of the disabled elderly. Accordingly, the findings of this study showed that the caregivers reported moderate levels of compassion fatigue.
Lynch et al. (2018) conducted a study about positive and negative aspects of compassion satisfaction and compassion fatigue as caregiving outcomes, which findings showed that most caregivers (82%) reported a moderate level of compassion satisfaction and about half of them showed moderate compassion fatigue (21). Given the family caregivers of the disabled elderly in this study were all the main members of the elderly family and about 70% of them were the children of the elderly, they experienced a moderate level of compassion satisfaction because emotional attachment and kinship relations between the caregiver and the elderly create a positive feeling and inner satisfaction for the caregiver. Furthermore, considering the religious teachings and the family-oriented culture of the Iranian community, it seems that caring for parents caused a feeling of inner satisfaction and inner peace in the caregivers. Day et al.(2011) also acknowledged that emotional bonds can create a sense of satisfaction in caregivers, although this per se is a risk factor for compassion fatigue(6). In other words, the stronger and deeper emotional bond between the caregivers and the elderly, the harder it will be for the caregiver to see the suffering of the elderly and this exposes the caregiver to more stress, and this stress is one of the factors underlying compassion fatigue according to Figley's model of compassion fatigue(5).
The family caregivers in this study reported a low level of burnout. It seems that although the elderly’s disabilities and their constant need for caregivers, in addition to other responsibilities to be done by the caregivers such as duties about other family matters and caring for their children, as well as responsibilities related to their profession or education affairs related to the caregivers and their children, family caregivers showed that they were been able to manage these complex situations and could balance between their various responsibilities. On other hand the most of caregivers in this study doesn't live with elderly (69.2%) and the most elderly’s incoming level is acceptable(69.2%). It seems that low level of caregiver's burnout in this study is related to level of independence of elderly individuals they care for.
It seems that the close family relationship of caregivers with the elderly and also the elderly’s disability and his/her dependence on the caregiver, both physically and mentally, increase the time of care for the disabled elderly (more than 30 hours per week). As a result, long-term care causes a very close emotional connection between the caregiver and the elderly. This increases the responsibility for care beyond the limit of caregiver duties, and ultimately a deep connection between the two parties can lead to the transfer of traumatic experiences of the elderly to the caregivers, leading to secondary trauma stress. In a similar vein, Lynch et al. showed that caring for more than 25 hours per week can significantly increase secondary stress (21). Besides, in Iranian social culture, family relationships have a great depth and strength, which in turn increases the relationship between caregivers and the elderly and can increase the level of secondary trauma stress in caregivers, as it was at moderate level in family caregivers of this study.
Concerning the effect of sharing experiences in the support group on compassion fatigue of family caregivers of the disabled elderly, the results of this study showed that compassion fatigue reported by caregivers had a slight decrease after the intervention, however this decrease was not statistically significant. Nevertheless, a review of the literature found no intervention study on caregivers’ compassion fatigue. Although sharing experiences in an online group is an efficient and low-cost solution in supporting family caregivers (24), given that compassion fatigue is a concept that develops in family caregivers over time and due to long-term care of the elderly, these caregivers receive less social support and experiences shared by peer groups. Perhaps social support is needed to heal this objectivity that is rooted in perceived stress and difficult situations, mental and physical stress, and the grief of seeing a loved one suffering for a long time. Therefore, there is a need for longer and more stable interventions than the intervention performed in this study.
On the other hand, the findings showed that the mean score of burnout in both intervention and control groups increased significantly after intervention. Also, the mean score of secondary trauma stress was significantly reduced in both groups. Given that these changes are significant in both groups, it may be more influenced by other reasons than the intervention. For instance long duration of caregiving maybe is the one reason for the increase in burnout, so that over the time, all caregivers have felt more burnout. Another considering point in this regard is the concurrence of the study with the Covid 19 pandemic conditions. This condition is considerable from two viewpoint. The first is that due to the pandemic condition, many individuals affected psychologically by limitation in their relationship and need to adjust their life style for being far from the risk of transition the corona virus. These factors may have affected on the quality of life of individuals and can influence on findings of the study. Such condition may have been effective in increasing the burnout of both intervention and control groups. On the other hand, due to the high mortality rate of Covid 19 disease, the priority of individuals and especially caregivers has been changed to prevent infection and reduce the risk of death, especially in the elderly. Thus, caregivers may focus more on preventing further aging and suffering, rather than focusing on the negative effects and trauma of caring for the elderly, and this has been associated with reduced secondary trauma stress.. Of course, it should be noted that because of the effect of this condition on both intervention and control group, researcher think that the main findings of the study is reliable.
The another effect of pandemic condition is related to the method of the study. In this way, there was no face to face sessions and probably this could make caregivers unreliable to researcher team. Although it was a limitation of the study, researchers tried to establish an empathic and trust based relationship with caregivers to decrease the effects of this distance.
Given that the results of this study confirmed the existence of compassion fatigue in the family caregivers of the disabled elderly, these caregivers need more stable and focused social support. Due to the lack of support groups for family caregivers of the elderly, especially those with disabilities, it is suggested that such groups be formed for them, especially the family caregivers of the disabled, and specialists and nurses provide educational, psychological, and social support for these people. Furthermore, it is recommended that in these or similar groups that have long-term activities, peers can share their care experiences to reduce the negative effects of elderly care on their personal lives by perceiving more social support.