International Journal of Nursing Studies 69 (2017) 9–24

Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Review

Compassion fatigue: A meta-narrative review of the healthcare

literature
Shane Sinclair* , Shelley Raffin-Bouchal, Lorraine Venturato, Jane Mijovic-Kondejewski,
Lorraine Smith-MacDonald
Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada

A R T I C L E I N F O A B S T R A C T

Article history: Background: Compassion fatigue describes a work-related stress response in healthcare providers that is
Received 10 June 2016 considered a ‘cost of caring’ and a key contributor to the loss of compassion in healthcare.
Received in revised form 8 January 2017 Objective: The purpose of this review was to critically examine the construct of compassion fatigue and to
Accepted 9 January 2017
determine if it is an accurate descriptor of work-related stress in healthcare providers and a valid target
variable for intervention.
Keywords: Design: Meta-narrative review.
Audiology practitioners
Data Sources: PubMed, Medline, CINAHL, PsycINFO, and Web of Science databases, Google Scholar, the
Compassion fatigue
Consultants
grey literature, and manual searches of bibliographies.
Genetic counselors Review methods: Seminal articles and theoretical and empirical studies on compassion fatigue in the
Midwives healthcare literature were identified and appraised for their validity and relevance to our review. Sources
Nurses were mapped according to the following criteria: 1) definitions; 2) conceptual analyses; 3) signs and
Pediatrics symptoms; 4) measures; 5) prevalence and associated risk factors; and 6) interventions. A narrative
Physicians account of included studies that critically examines the concept of compassion fatigue in healthcare was
Psychologists employed, and recommendations for practice, policy and further research were made.
Residents
Results: 90 studies from the nursing literature and healthcare in general were included in the review.
Findings emphasized that the physical, emotional, social and spiritual health of healthcare providers is
impaired by cumulative stress related to their work, which can impact the delivery of healthcare services;
however, the precise nature of compassion fatigue and that it is predicated on the provision of
compassionate care is associated with significant limitations. The conceptualization of compassion
fatigue was expropriated from crisis counseling and psychotherapy and focuses on limited facets of
compassion. Empirical studies primarily measure compassion fatigue using the Professional Quality of
Life Scale, which does not assess any of the elements of compassion. Reported risk factors for compassion
fatigue include job-related factors, fewer healthcare qualifications and less years experience; however,
there is no research demonstrating that exemplary compassionate carers are more susceptible to
‘compassion fatigue’.
Conclusion: In the last two decades, compassion fatigue has become a contemporary and iconic
euphemism that should be critically reexamined in favour of a new discourse on healthcare provider
work-related stress.
© 2017 Elsevier Ltd. All rights reserved.

What is already known about the topic?  Compassion fatigue is considered a key contributor to the loss of
 Compassion fatigue is a term that is used to describe a stress compassion in healthcare.
response in healthcare providers.  Some researchers have suggested that the term ‘compassion
fatigue’ is problematic and ill-defined, and efforts directed at the
development of interventions are criticized.

* Corresponding author at: Faculty of Nursing, University of Calgary, 2500 What this paper adds
University Drive NW, Calgary, Alberta, T2N 1N2, Canada.  Compassion fatigue appears to lack conceptual foundation.
E-mail address: [email protected] (S. Sinclair).

http://dx.doi.org/10.1016/j.ijnurstu.2017.01.003
0020-7489/© 2017 Elsevier Ltd. All rights reserved.
10 S. Sinclair et al. / International Journal of Nursing Studies 69 (2017) 9–24

 Compassion fatigue cannot be empirically validated or mea- their work (Sikka et al., 2015). To facilitate such a transformation in
sured. healthcare systems, research describing interventions to minimize
 Compassion fatigue represents an emotive euphemism for a or prevent stress responses in healthcare providers must evolve
broad family of occupational stresses unique to healthcare (reviewed in Boyle, 2011). A critical first step in developing these
providers. interventions is conceptual clarity regarding the stress response of
interest and its measurement through valid and reliable instru-
ments. Historically, a corpus of terms has been used to describe the
1. Introduction effects of healthcare-related demands and expectations on health-
care providers, including burnout and compassion fatigue (Boyle,
The demands of the healthcare system, including high expect- 2011; Sabo, 2011a). Burnout refers to the lack of interest in work,
ations, time constraints, a lack of social support and a sense of exhaustion, and the physical and emotional collapse that evolves
inadequate skills to address patient suffering can lead to severe over time in response to a period of high workload; burnout is
stress in healthcare providers, which affects their health and associated with many occupations. Compassion fatigue refers to an
performance, and impacts job satisfaction, workforce stability, acute onset of physical and emotional responses that culminate in
retention, workplace wellness and patient outcomes (Van Bogaert a decrease in compassionate feelings towards others because of an
et al., 2013). Work-related stress is particularly pertinent to nurses, individual’s occupation. Over the last two decades, compassion
who make up the largest proportion of the healthcare workforce fatigue has received considerable attention as an important stress
and are on the front lines of patient care. In 2006–2008, data from response in nurses and the spectrum of healthcare providers
several national surveys showed that the overall burnout rate (Boyle, 2011). While this has raised awareness of the work-related
among nurses in the US ranged from 20% to 40% (Neff et al., 2011; stress that healthcare providers face, some researchers have
McHugh et al., 2011; McHugh and Ma, 2014). In 2011, 74% of 4614 suggested that the term ‘compassion fatigue’ is problematic and ill-
nurses surveyed by the American Nurses Association identified defined (Fernando and Consedine, 2014a; Ledoux, 2015). Others
acute and chronic effects of stress and overwork as a top safety and propose that tools purported to quantify compassion fatigue do not
health concern (American Nurses Association, 2011). measure the construct or lack construct validity (Bride et al., 2007;
Stress is defined as the body's physical, mental or emotional Ledoux, 2015). Juxtaposed with the conceptual ambiguity sur-
response to a change (Selye, 1983). The pathogenic role of stress rounding the construct of compassion fatigue is increasing interest
was identified by Walter B. Cannon (1871–1945), a Harvard and evidence that compassion is a cornerstone of quality health-
physiologist, and later expanded by Hans Seyle (1907–1982), a care (American Medical Association, 2001; Flocke et al., 2002;
Czech endocrinologist. Cannon speculated that chronic emotional Department of Health, 2008; Paterson, 2011; Francis, 2013). It is
arousal following crises, or the everyday pressures of modern life, unsurprising therefore, that the identification of a lack of
stimulates a fight or flight physiological response in humans. Seyle compassion as a key contributor to systemic healthcare failures
identified the General Adaptation Syndrome (GAS), in which in the United Kingdom was met with a collective and immediate
environmental influences, termed ‘stressors’, produce a combina- call to action (American Medical Association, 2001; Institute of
tion of physiological changes in the body, termed a ‘stress Medicine, 2004; Maclean, 2014). With compassion fatigue identi-
response’ (Harrington, 2008). The stress response results in an fied as a negative consequence of caring that could impact entire
increase in adrenaline and corticosterone levels, which raises heart organizations (Compassion Fatigue Awareness Project, 2015), and
rate, respiration and blood pressure, and has a major impact on recommendations that the delivery of compassionate care,
physical functioning. In the short term, the stress response allows particularly by nurses, should be enhanced, increased effort was
an individual to quickly meet challenges. Once exhaustion is directed toward identifying and addressing compassion fatigue in
reached, the stress response becomes detrimental to physical and healthcare. However, after two decades of scholarship and more
psychological health, leading to a variety of effects such as reduced than 350 peer-reviewed publications on the topic, there is still no
immune function, cardiovascular disease, obesity, anxiety, depres- broadly accepted definition of compassion fatigue, its relationship
sion and addiction (Cohen et al., 2007, 2012; Torres, 2007; Sinha, to compassion is uncertain (Canadian Nursing Association, 2010),
2008). and reputed compassion fatigue interventions are increasingly
Nursing is recognized as a particularly stressful profession criticized (Fernando and Consedine, 2014a; Ledoux, 2015).
(Jones and Johnston, 1997; McVicar, 2003; Rutledge et al., 2009; To more accurately inform the development of valid measures
Sharma et al., 2014; Johnston et al., 2016). Studies in nurses and interventions that target the occupational stressors that
indicate that their physical, emotional, social and spiritual health is nurses and providers across the spectrum of healthcare face, it is
impaired by cumulative stress related to interactions with large necessary to critically examine the concept of compassion fatigue
volumes of often highly complex patients on an ongoing basis, in the healthcare literature. Therefore, the objectives of this study
trauma and practice environments with limited resources and were 1) to perform a meta-narrative review encompassing the
increased demands (Boyle, 2011; Sharma et al., 2014). Nursing identification, conceptualization, measurement and management
patient-related stressors include frequent exposure to suffering, of compassion fatigue in healthcare providers, and 2) to determine
death and dying, vicarious trauma, and providing care to ‘difficult’ the validity of compassion fatigue as a construct of scientific
patients and families while meeting expectations for patient inquiry and as a descriptor of the work-related stress faced by
satisfaction (McCloskey and Taggart, 2010; Hamilton et al., 2016). healthcare providers.
Practice-related stressors include expanding workloads, long
hours, change in procedures, staffing levels, interpersonal relation- 2. Methods
ships, role ambiguity, responding to frequent workflow interrup-
tions, limited resources and a feeling of lack of control (McCloskey A meta-narrative approach according to the RAMESES (Realist
and Taggart, 2010; Cuneo et al., 2011; Hamilton et al., 2016). And MEta-narrative Evidence Syntheses: Evolving Standards)
In recognition of the work related stressors that nurses and all standards was used. The aim of a meta-narrative review is to
healthcare providers experience, the framework for the delivery of clarify and critique an important, but complex and/or controversial
high value health care has been expanded from the Triple Aim to topic. A meta-narrative synthesizes, by means of an over-arching
the Quadruple aim, in which the fourth goal includes creating narrative, heterogeneous topics that have been conceptualized and
conditions to ensure healthcare providers find joy and meaning in studied differently (Wong et al., 2013).
 S. Sinclair et al. / International Journal of Nursing Studies 69 (2017) 9–24 11

The phases of the meta-narrative review were conducted compassion fatigue was estimated. The PubMed, Medline, CINAHL
according to Greenhalgh et al. (2004a,b, 2005). These phases and PsycINFO databases (1980–2016) were searched using the
included 1) a planning phase, where a review team (SS, JK, SRB, LV, term ‘compassion fatigue,’ and ISI Web of Science Citation Index
LSM) comprising research and content experts was compiled; 2) a was used to identify all articles cited 5 times or more. Resulting
search phase, where the domains that encompass compassion documents were assessed according to the criteria defined by
fatigue were identified by initial informal cursory searches, Greenhalgh et al. (2004a,b, 2005) and Contandriopoulos et al.
seminal articles on compassion fatigue were identified by (2010).
electronic searches and citation tracking, and other theoretical These seminal articles were mapped to the domains of
and empirical documents on compassion fatigue were identified compassion fatigue identified during the initial search phase.
using snowballing, electronic databases, and additional searches; Searches for other relevant articles included prospective snow-
3) a mapping phase, where findings from the search phase were balling (identifying articles that cited the seminal articles),
used to establish key elements of compassion fatigue; 4) an retrospective snowballing (searching the bibliographies of articles
appraisal phase, where eligible documents were appraised for that cited the seminal articles) and a search of the PubMed,
their validity and relevance to our review; 5) a synthesis phase, Medline, CINAHL and PsycINFO databases using the following
where a narrative account of included documents that critically search-terms: compassion fatigue, nurses, physicians, counselors,
examines the concept of compassion fatigue in healthcare was emergency, definition, concept, symptoms, measure, intervention
prepared; and 6) a recommendations phase, where the findings (Appendix A in Supplementary material).
from the critical appraisal of the included documents were Other documents were identified from additional searches (e.g.,
summarized and recommendations for practice, policy, education Canadian Nurses Association; American Nurses Association;
and research were made. Compassion Fatigue Awareness Project; ProQOL.org, Google
Scholar).
2.1. Search and mapping phase
2.2. Appraisal phase
Guiding principles for the meta-narrative review were devel-
oped and an overview of the field of compassion fatigue research Documents were included based on their validity and relevance
was provided by an initial pragmatic and iterative search phase. to the perspectives of compassion fatigue identified in this review.
During this phase, the diverse domains that encompass the In accordance with Contandriopoulos et al. (2010), a strength-of
compassion fatigue literature were identified as 1) definitions of evidence grading tool was not used during the appraisal phase.
compassion fatigue; 2) conceptual analyses of compassion fatigue; Many of the documents that are central to the evolving field of
3) signs and symptoms of compassion fatigue; 4) measures of compassion fatigue research are theoretical and could not be
compassion fatigue; 5) the prevalence of compassion fatigue and meaningfully appraised by such grading tools. Therefore, inclusion
associated risk factors; and 6) interventions for compassion criteria were 1) empirical or theoretical studies and documents
fatigue. that focused on compassion fatigue as a concept and 2) studies/
A search for the seminal articles that made a core contribution documents within the healthcare setting. Exclusion criteria were:
to the literature on compassion fatigue was then performed. The 1) documents that focused on related concepts such as burnout,
strategy for identifying seminal articles was adapted from Green- secondary traumatic stress, and vicarious trauma; 2) documents
halgh et al. (2004a,b, 2005) and Contandriopoulos et al. (2010). that used the term ‘compassion fatigue’ interchangeably with
These researchers define seminal articles as those that are part of a other descriptors of work-related stress in healthcare providers; 3)
recognized research tradition, those that make an original and documents in social workers, first responders, educators, and
scholarly contribution to the research and those have been cited family caregivers; and 4) letters, commentaries, editorials, and
frequently. To identify seminal articles in compassion fatigue, the conference abstracts.
total population size of the peer-reviewed literature on

Fig. 1. Flow chart of search.

(Adapted from Greenhalgh et al., 2004a,b).
12 S. Sinclair et al. / International Journal of Nursing Studies 69 (2017) 9–24

Data from eligible documents were collated in a tabular form, crimes, war or natural disasters, compassion fatigue was defined as
including first author’s last name, year of publication, study ‘the formal caregiver’s reduced capacity or interest in being empathic
objective, study design, setting, participants, context, methods, or bearing the suffering of clients and (is) the behavioural and
results and notes. The search phase and the contribution of the emotional state that results from knowing about a traumatizing event
included documents to the various domains of compassion fatigue experienced by another person’ (Figley, 1995, 2002; Adams et al.,,
are shown in Fig. 1. 2006, p. 2; Boscarino et al., 2010, p. 2). Figley asserted that
compassion fatigue is identical to secondary traumatic stress
2.3. Synthesis and recommendations phase disorder (Figley, 1995, p. xv), which he identified as a disorder
embedded within the description of post traumatic stress disorder
Findings from the included documents were summarized as (PTSD) in Criterion A1 in the Diagnostic and Statistical Manual of
text and tables. Synopses of the included documents were Mental Disorders – IV (DSM-IV; American Psychiatric Association,
prepared and incorporated into an over-arching narrative detailing 1994):
and debating the historical, conceptual and practical aspects of ‘The essential feature of Posttraumatic Stress Disorder is
compassion fatigue. The concept of compassion fatigue was the development of characteristic symptoms following expo-
critiqued, applying the meta-narrative analysis principles of sure to an extreme traumatic stressor involving direct personal
pragmatism, pluralism, historicity, contestation, reflexivity and experience of an event that involves actual or threatened
peer review (Wong et al., 2013). The goal was to determine the death or serious injury, or other threat to one's physical
integrity of the research investigating compassion fatigue as a integrity; or witnessing an event that involves death, injury,
paradigm, provide critical insights into the existing evidence base, or a threat to the physical integrity of another person; or
and make recommendations for practice, policy and future learning about unexpected or violent death, serious harm, or
research based on the findings (Greenhalgh et al., 2004a,b, threat of death or injury experienced by a family member or
2005; Wong et al., 2013). other close associate’ (American Psychiatric Association, 1994,
p. 424).
3. Results
Figley proposed that compassion fatigue in psychotherapists is
the function of an empathetic reaction after witnessing another’s
A total of 90 documents on compassion fatigue were included in
suffering (Figley, 2002), with symptoms nearly identical to those of
this meta-narrative review. Of these, 31 were observational
PTSD, including intrusive thoughts, traumatic memories related to
studies, 11 were experimental studies, 3 were qualitative studies,
clients’ trauma, irritability or bouts of anger, difficulty sleeping and
4 were concept analyses, and the remainder were theoretical
concentrating, client avoidance, and hypervigilant or startle
documents. Empirical studies were conducted in the United States,
reactions when reminded of clients’ trauma (Newell and MacNeil,
Canada, Greece, Israel, Latvia, Spain, United Kingdom, Uganda,
2010). Importantly, Figley clearly stated that he intentionally used
South Africa, Korea, Australia, and New Zealand. Types of providers
the term ‘compassion fatigue’ to provide a less stigmatizing term to
investigated in these studies were nurses (n = 2444) (including but
describe secondary traumatic stress and its manifestations in
not limited to the following specialties: heart and vascular nurses
trauma workers and healthcare providers (Figley, 1995).
[n = 70], intensive care unit nurses [n = 130], emergency room
Since Figley identified compassion fatigue as a secondary
nurses [n = 357], hospital nurses [n = 42], oncology nurses [n = 299],
traumatic stress reaction, it has become a burgeoning field
liver and kidney transplant nurses [n = 14], and psychiatric nurses
of research. The literature has suggested there are similarities
[n = 174]), student midwives (n = 103), emergency medicine resi-
between compassion fatigue and countertransference, vicarious
dent physicians (n = 255), emergency medicine consultants
traumatization, and burnout, and the definition of compassion
(n = 681), pediatric health care providers (n = 971), family physi-
fatigue is frequently considered synonymous with secondary
cians (n = 128), audiology practitioners (n = 82), genetic councilors
traumatic stress and secondary traumatic stress disorder
(n = 402), and palliative care professionals (n = 387).
(reviewed in Najjar et al., 2009; Coetzee and Klopper, 2010).
While the conceptual ambiguity of compassion fatigue has been
3.1. Defining ‘Compassion fatigue’
discussed at length over the last two decades (Figley 1995, 2002;
Najjar et al., 2009; Coetzee and Klopper, 2010; Boyle, 2011; Sabo,
The term compassion fatigue was first used in the context of
2011a), the existence of compassion fatigue has largely escaped
healthcare in 1992 by Joinson, a nurse educator, to explain the ‘loss
criticism. In fact, compassion fatigue is globally and blindly
of the ability to nurture’ in emergency nurses. These nurses felt
accepted as a valid construct and a clinical reality based on
tired, depressed, angry, ineffective, apathetic and detached, and
published studies from North America (Perry, 2008; Austin et al.,
experienced somatic complaints such as headaches, insomnia and
2009; Meadors et al., 2009; Hooper et al., 2010; Potter et al., 2010;
gastrointestinal distress due to intense workloads and complex
Yoder, 2010; Sabo, 2011a,b; Kim, 2013; Neville and Cole, 2013;
patient needs; these responses escalated over time as a result of
Flarity et al., 2013; Berger et al., 2015; Hunsaker et al., 2015),
cumulative stress (Joinson, 1992). Theoretically, Joinson consid-
Europe (Lee and Laurenson, 2010; Circenis and Millere, 2011; El-
ered compassion fatigue synonymous with burnout, but neither
Bar et al., 2013; Markaki 2014; Mendes 2014; Mangoulia et al.,
provided the rationale for doing so nor conducted any subsequent
2015; Dasan et al., 2016), Australia (Ainsworth and Sgorbini, 2010;
studies to empirically define or establish a causal relation between
Vann and Coyer, 2014; Hegney et al., 2014), New Zealand (Huggard
compassion fatigue and burnout (Ledoux, 2015). Joinson expro-
and Dixon, 2011; Severn et al., 2012), Asia (Sung et al., 2012; Cho
priated the term ‘compassion fatigue’ from Doris Chase, a crisis
and Jung, 2014), Africa (Coetzee and Klopper, 2010; Elkonin and
counselor, whom Joinson quotes in her article as stating ‘
Van Der Vyver, 2011; Harrowing, 2011) and the Middle-East
. . . elements of burnout can occur in any setting, a unique form of
(Zeidner, 2013). In Canada, the national nursing association has
it, compassion fatigue, affects people in caregiving professions’
gone so far as to identify compassion fatigue as a substantial
(Joinson, 1992, p. 116).
challenge to nursing practice, which must be addressed using a
In 1995, compassion fatigue was adopted by Charles Figley to
collaborative approach that involves governments, healthcare
describe the ‘cost of caring’ in psychotherapists. Based on Figley’s
organizations and healthcare providers (Canadian Nursing Associ-
experiences with therapists and counselors who worked with
ation, 2010).
clients traumatized by physical or psychological abuse, violent
 S. Sinclair et al. / International Journal of Nursing Studies 69 (2017) 9–24 13

More recently however, researchers have taken a critical to project themselves into the perspective of a client and
approach, cautioning against the use of the term compassion experience the hurt, fear, anger or other emotions that the client
fatigue, as ‘it connotes a lessening of the expression of compassion’ is experiencing. The emotional energy resulting from this
(Ledoux, 2015, p. 2047Ledoux, 2015Ledoux, 2015, p. 2047; empathetic response vicariously causes compassion stress in the
Fernando and Consedine, 2014a). Based on literary analyses of therapist, having a negative psychological and physiological
the terms ‘compassion fatigue’ and ‘compassion’, it has been impact, which if not attended to could be compounded and lead
suggested that compassion fatigue ensues when compassion is to compassion fatigue. According to Figley’s model, compassion
interfered with (Fernando and Consedine, 2014a) or obstructed stress can be alleviated through a sense of achievement and/or
(Ledoux, 2015), and is therefore synonymous with moral distress disengagement by the therapist, with prolonged exposure to client
(Ledoux, 2015). As a result, these authors have advocated that an trauma, recollections of particularly traumatized clients and
empirical understanding of the construct of compassion is a unexpected life disruptions developing into and exacerbating
necessary prerequisite to determining the validity of the concept of compassion fatigue (Figley, 1995, 2002).
compassion fatigue (Fernando and Consedine, 2014a; Ledoux, Sabo (2011a) identified a number of limitations associated with
2015). A recent scoping review of compassion in the healthcare this model, including a lack of clarity on the concept of empathy,
literature confirmed that the construct of compassion has been the linear direction of the model, the binary dimension of
under studied in healthcare, with scholars employing precon- compassion fatigue, the lack of interactions between various
ceived understandings of compassion, resulting in it being broadly factors, and the premise that all healthcare providers that have
defined as a feeling, attitude, or trait associated with a response to empathy for their traumatized patients will eventually suffer from
suffering (Sinclair et al., 2016a). While studies in patient cohorts compassion fatigue. Sabo argued that Figley’s model was fatalistic,
have loosely defined compassion as a consortium of skills, allowing for no opportunity for healthcare providers to halt the
including listening, confronting, involvement, helping, presence, progression of compassion fatigue through coping, hope and
understanding and communicating (Bramley and Matiti, 2014; Van resilience or to counteract compassion fatigue by positive
der Cingel, 2011) an empirical, clinically relevant, patient validated outcomes within the therapeutic relationship.
understanding of compassion has largely escaped the purview of Figley’s model suggested a relationship between empathy and
scientific inquiry. In response to the necessity for a pragmatic compassion fatigue, which has been identified and/or perpetuated
understanding of compassion in healthcare, a recent empirical in concept analyses conducted by other authors (Wilson and Lindy,
study generated an evidence-based patient-informed definition of 1994; Sabo, 2006; Klimecki and Singer, 2011; Jenkins and Warren,
compassion as a virtuous response that seeks to address the suffering 2012; Vachon et al., 2015). Some have proposed that the causes and
and needs of a person through relational understanding and action attributes of compassion fatigue originate from a disruption in
(Sinclair et al., 2016b). empathy, or ‘empathetic strain’ between the healthcare provider
The suggestion that compassion fatigue is inextricably linked to and patient (Vachon et al., 2015). In this model, the antecedent of
the construct of compassion is problematic, as it implies there is compassion fatigue is intrusive empathetic strain, which can result
something inherently tiring about compassionate feelings and in overidentification and pathological bonding between healthcare
behaviours, and that healthcare providers’ capacity for compassion provider and patient, and the consequence is avoidance empa-
is limited or depletes over time (Fernando and Consedine, 2014a). thetic strain, which is characterized by the healthcare provider
Therefore, by virtue of their exposure to suffering and the distancing himself and avoiding the patient (Wilson and Lindy,
frequency of their compassionate responses, exemplary compas- 1994). In accordance with this, Klimecki and Singer (2011)
sionate care providers should be highly susceptible to compassion proposed that compassion fatigue be reconceptualized as ‘empa-
fatigue, and healthcare should be a sector of society that has the thetic distress fatigue’. Sabo (2006) described compassion fatigue
least compassionate individuals. However, compassion is consid- as a ‘natural consequence of caring for individuals who are
ered a practice competency and is central to codes of ethics across suffering’, and Jenkins and Warren (2012) suggested that caring for
healthcare professions (American Medical Association, 2001; traumatized patients can lead to compassion fatigue in critical care
Institute of Medicine, 2004; Maclean, 2014), with a lower nurses. Jenkins and Warren (2012) identified factors that contrib-
incidence of compassion fatigue occurring in older and more ute to compassion fatigue, including caregiver exposure to
experienced healthcare providers. In fact, age is reported to have suffering; continuous and intense contact with patients; high-
an inverse or non-relationship with compassion fatigue, while stress environments; and high therapeutic use of the self in
healthcare providers with fewer years experience have been providing care—interjecting caregiver’s personhood into clinical
reported as having higher levels of compassion fatigue (Berger encounters. The attributes of compassion fatigue were deperson-
et al., 2015; Dasan et al., 2016; Potter et al., 2010). alization, reduced output/endurance/diminished performance,
loss of empathy and poor judgment (Jenkins and Warren, 2012).
3.2. Conceptual analyses of compassion fatigue A number of studies have identified other key antecedents of
compassion fatigue. Valent (2002) proposed that compassion
In 1995, based on his clinical experience with psychotherapists, fatigue is the result of failed ‘Rescue-Caretaking’ strategies. In this
Figley proposed the first multifactor model of compassion fatigue model, compassion fatigue is the guilt and distress a caregiver feels
using the supposition that empathy is the essential ingredient in an at the inability to save an individual from harm. Coetzee and
effective therapeutic relationship, with caregiver suffering and the Klopper (2010) suggested that compassion fatigue is “the final
‘costs of caring’ being necessary and negative side effects of this result of a progressive and cumulative process that evolves from
empathetic stance (Figley, 1995, 2002). Assuming the centrality of compassion stress after a period of unrelieved compassion discomfort,
empathy and the ramifications of its depletion, Figley developed a which is caused by prolonged, continuous, and intense contact with
causal model based on eleven variables to predict the onset of patients, the use of self, and exposure to stress” (Coetzee and Klopper,
compassion fatigue in psychotherapists (Figley, 1995, 2002). The 2010, p. 239). They identified compassion fatigue as a state in
model identifies empathetic ability as an ability to notice pain in which compassionate energy expended surpasses the restorative
others and to be vulnerable to the cost of caring. It is proposed that process provided by compassion satisfaction, resulting in a loss of
direct exposure to the emotional energy of the suffering of a client the power to recover. In this model, the spiritual, emotional,
elicits empathetic understanding and an empathetic response in physical, social and intellectual indicators of compassion fatigue
the therapist. This empathetic response may require the therapist are poor judgment, disinterest in introspection, breakdown,
14 S. Sinclair et al. / International Journal of Nursing Studies 69 (2017) 9–24

apathy, desire to quit, lack of energy, burnout, being accident- disinterest in introspection, poor judgment, and a decrease in
prone, unresponsive, callous, indifferent and disorderly. In order to discernment (Coetzee and Klopper, 2010).
cope, nurses distance and isolate themselves from their patients,
and meaningful and purposeful interactions between nurses and 3.4. Measurement of compassion fatigue
patients are lost.
In contrast to more conventional theories, Fernando and Within the literature it is recognized that the measurement of
Consedine (2014a) critique the concept of compassion fatigue, compassion fatigue is challenging due to issues with taxonomy,
suggesting that the it has ‘serious limitations and fails to illuminate conceptual ambiguity and its relationship to occupational stress
interventions’ (Fernando and Consedine, 2014a, p. 295Fernando (Najjar et al., 2009). As a result, measures of compassion fatigue are
and Consedine, 2014aFernando and Consedine, 2014a, p. 295). not considered diagnostic tests; rather, they are presented as
They proposed a transactional model of compassion in physicians, screening tools to aid in the identification of compassion fatigue
in which the probability that a physician will behave compassion- and to guide organizational and individual decision-making in
ately in a given situation is determined by dynamic interactions mitigating workplace conditions that compound compassion
between physician, patient and family, clinical situation and fatigue (Stamm, 2010). Bride et al. (2007) noted that a caveat to
environmental factors. Physician factors that may impact a the use of compassion fatigue measures as screening tools is that
physician’s compassionate response include gender, personality, the scoring guidelines are conservative; they were developed to
baseline traits or disposition, past clinical experiences and minimize false negatives, which elevates the probability of false
communication skills. Patient and family factors include person- positives (Bride et al., 2007).
ality, gratitude, compliance and care expectations. Clinical factors Over the last two decades, several scales have been used to
include the degree to which a physician may consciously or measure compassion fatigue, including the Compassion Fatigue
unconsciously consider a patient “responsible,” for their condition, Self Test (CFST) (Figley, 1995; Figley and Stamm, 1996), the
the complexity of the situation and the physicians’ expertise. Compassion Fatigue Scale (CFS-R) (Gentry et al., 2002; Adams
Environmental and institutional factors are related to the demands et al.,, 2006, 2008), and the Professional Quality of Life Scale
of the job and feelings of control in the workplace. Fernando and (ProQOL) (Stamm, 2010) (Table 1). The CFST was the first
Consedine (2014a) proposed that it is the interplay of these factors instrument developed to measure compassion fatigue (Figley,
that promote compassion or produce barriers that impede it 1995; Figley and Stamm, 1996). It is a 40-item self-report measure
(Fernando and Consedine, 2014a). consisting of two subscales, Compassion Fatigue (23 items) and
Burnout (17 items). Subsequently, the CFST was adapted to the 30-
item CFS-R (two subscales, Compassion Fatigue [22 items] and
3.3. Symptoms of compassion fatigue
Burnout [8 items]) (Gentry et al., 2002) and the CFS-R short form
(13-items and two subscales, Secondary Trauma [5 items]and
Signs and symptoms of compassion fatigue in healthcare
Work Burnout [8 items]) (Adams et al., 2006, 2008). More recently,
providers have been proposed in the literature (reviewed in
positively oriented items that measure compassion satisfaction
Mathieu, 2008; Huggard, 2016). They can be classified as physical,
were included in the CFS-R, and it was renamed the ProQOL, with
behavioural, psychological and spiritual, and are suggested to have
the vast majority of current studies investigating compassion
a global impact on a healthcare provider’s identity, self-under-
fatigue using the ProQOL. The current version (ProQOL5) is a 30-
standing and existential well-being. Trans-generational and
item self report measure with three 10-item subscales, Compas-
societal transmission of symptoms of compassion fatigue have
sion Satisfaction, Burnout and Secondary Traumatic Stress.
also been implied (Gentry et al., 1997).
Compassion Fatigue was assessed in several iterations of the
Broadly, purported physical symptoms of compassion fatigue
ProQOL; however, in ProQOL5, Compassion Fatigue nominally
include: exhaustion, insomnia, compromised immunity, somati-
represents the ‘negative aspects of helping others’ and is assessed
zation, headaches, stomach aches, sleep disturbance, fatigue,
based on Burnout and Secondary Traumatic Stress. In the context of
emotional exhaustion, and hypochondria (reviewed in Mathieu,
the ProQOL, compassion satisfaction is defined as the pleasure an
2008; Huggard, 2016). Purported behavioural symptoms of
individual derives from being able to do their work well.
compassion fatigue include: increased alcohol intake (and other
Compassion fatigue is defined as feelings of unhappiness,
drugs), anger and irritability, strained personal relationships,
disconnectedness, and insensitivity to the work environment.
absenteeism, attrition, avoidance of patients, impaired clinical
Burnout is described as exhaustion, frustration, anger and
decision making, compromised patient care (reviewed in Mathieu,
depression associated with professional life, and Secondary
2008; Huggard, 2016), and ‘The Silencing Response’, whereby
Traumatic Stress is considered a negative feeling driven by fear
healthcare providers “silence” their patients by diverting con-
and primary or secondary work-related trauma (Stamm, 2010).
versations about traumatic memories, shutting down the patient,
Although it seems the ProQOL is more accurately measuring risks
and by referring the patient to a colleague (Baranowsky, 2002).
for secondary traumatic stress and burnout than compassion
Purported psychological symptoms of compassion fatigue include:
fatigue, it does facilitate comparisons of occupational facilitators
emotional exhaustion, relational distancing, negative self-image,
and inhibitors associated with caring across healthcare profes-
depression, reduced ability to feel sympathy and empathy,
sions, settings and geographical regions, and may therefore be a
cynicism, resentment, dread of working with certain patients,
valuable tool for monitoring healthcare provider welfare (Dasan
professional helplessness, diminished enjoyment/career satisfac-
et al., 2016).
tion, depersonalization, fear, fractured world view, heightened
anxiety, irrational fears, increased personal vulnerability, problems
3.5. Prevalence of compassion fatigue and associated risk factors
with intimacy, intrusive imagery, avoidance, insensitivity or
hypersensitivity to emotionally charged stimuli, loss of hope,
Compassion fatigue has been studied in many clinical groups,
difficulty separating personal and professional life, and failure to
including pediatric nurses (Berger et al., 2015) emergency
nurture and develop non-work related aspects of life (reviewed in
department nurses (Hooper et al., 2010; Flarity et al., 2013;
Mathieu, 2008; Huggard, 2016). Purported spiritual symptoms of
Hunsaker et al., 2015), intensive care unit nurses (Hooper et al.,
compassion fatigue, while overlapping considerably with psycho-
2010; Elkonin and Van Der Vyver, 2011; Mason et al., 2014),
logical symptoms, include lack of spiritual awareness and
oncology nurses (Hooper et al., 2010; Potter et al., 2010; Cho and
Table 1
Scales used to measure compassion fatigue.

First Author Instrument Items Subscales Scoring Risk Construct validity Reliability
Figley (1995) and Figley and Compassion 40 Compassion 5-point scale evaluating how often a respondent Based on the summative subscale Factor analysis: One stable factor, Cronbach’s a: 0.86–0.94
Stamm (1996) Fatigue Self Fatigue (23 experiences characteristics of compassion fatigue scores depression, fatigue,
Testa items) and burnout (1 = rarely/never, 2 = at times, 3 = not Extremely low risk: Compassion disillusionment and
Burnout (17 sure, 4 = often, 5 = very often) Fatigue, <26; Burnout, <36 worthlessness in association
items) Low risk: Compassion Fatigue, 27– with work
30; Burnout, 37–50
Moderate risk: Compassion
Fatigue, 31–35; Burnout, 51–75

S. Sinclair et al. / International Journal of Nursing Studies 69 (2017) 9–24

High risk: Compassion Fatigue, 36–
40; Burnout, <76–85

Gentry et al. (2002) Compassion 30 Compassion 10-point, visual, analog-type Likert-type scale NR NR NR
Fatigue Scale Fatigue (22 (1 = never or rarely, 10 = very often)
items)
Burnout (8
items)

Adams et al. (2006, 2008)b Compassion 13 Secondary 10-point, visual, analog-type Likert-type scale NR Factor, concurrent and predictive Cronbach’s a:.90 (whole
Fatigue Scale Trauma (5 (1 = never or rarely, 10 = very often) analysis: the instrument and instrument); 0.80
– Short form items) subscales correlated with (secondary trauma
Work physiological distress and subscale); 0.90 (burnout
Burnout (8 predicted physiological distress subscale)
items)

Stamm (2010) ProQOL 30 Compassion 5-point Likert-type scale evaluating how often a Compassion Satisfaction subscale: Three subscales measure Cronbach’s a:0.88
Satisfaction respondent experiences characteristics of >57, derive professional satisfaction separate constructs (compassion satisfaction
(10 items) compassion satisfaction, burnout and secondary from a job; <44, have a problem subscale); 0.75 (burnout
Burnout (10 traumatic stress (1 = rarely/never, 2 = at times, with a job or derive satisfaction subscale); 0.81 (secondary
items) 3 = not sure, 4 = often, 5 = very often) from other activities traumatic stress subscale)
Secondary Burnout subscale: >56, not effective
Traumatic in a position; <43, positive attitude
Stress (10 about the ability to be effective at
items) work.
Secondary Traumatic Stress
subscale: >57, problem at work or
with the work environment
a
Scoring categories derived from clinical experience, primarily in mental health workers, rather than published evidence (Bride et al., 2007; Figley, 1995).
b
Adams et al. (2006, 2008) were studies conducted in social workers. While these studies do not meet the inclusion criteria for this review, it was decided to cite them based on their contribution to the literature on the
measurement of compassion fatigue.

15
16 S. Sinclair et al. / International Journal of Nursing Studies 69 (2017) 9–24

Table 2
Reported prevalence of compassion fatigue and risk factors for developing compassion fatigue in healthcare providers.

Author Population Measure Prevalence of compassion fatigue Risk factors for compassion fatigue/
burnout-secondary traumatic stress
Reported as Burnout Secondary
compassion traumatic
fatigue stress
Nurses
Berger et al. 239 pediatric registered ProQOL 5 NR Low risk: Low risk:  <40 years of age
(2015) nurses in a five-hospital system in the US 23% 21.8%  Working in a medical–surgical unit
Moderate Moderate
risk: 47.7% risk: 51.0%
High risk: High risk:
29.3% 27.2%
Hunsaker 284 emergency department nurses ProQOL 5 Low risk: 65.9% Average NR  Low level of manager support
et al. throughout the US risk: 54.1%
(2015)
Mangoulia 174 registered and assistant ProQOL R-IV Low risk: 11.5% Low risk: NR  Female vs. male
et al. psychiatric nurses who worked in 12 public Moderate risk: 13.8%  Working fewer weekends
(2015) hospitals, in the greater metropolitan area 43.7% Moderate  Financial stress
of Athens Greece High risk: 44.8% risk: 36.8%  Assistant nurse vs. registered nurse
High risk:  Did not choose to work in the psychiatric
49.4% unit
 Wanting to leave the psychiatric unit

Mason et al. 26 experienced surgical intensive care unit ProQOL 5 NR Low risk: Low risk: NR
(2014) trauma nurses 42% 62%
Moderate Moderate
risk: 58% risk: 38%
Cho and Jung 171 oncology nurses caring for cancer ProQOL 5 Low risk: 27.5% NR NR  Empathy
(2014) patients in Korea Korean Moderate risk:
version 50.9%
High risk: 21.6%
Kim (2013) 14 liver and kidney transplant nurse ProQOL 5 NR Low risk: Low risk:  Level of education
coordinators from a large multiorgan 36% 50%
transplant center in the Southeast region of Moderate Moderate
the US risk: 64% risk: 50%
Neville and Nurses in direct patient care at Hunterdon ProQOL-R-V 73.6% were above NR NR NR
Cole Medical Center (HMC), Flemington, New the established
(2013) Jersey normative data
Hegney et al. 132 nurses working in a tertiary hospital in ProQOL 5 Potential risk: High: High: 0%  Anxiety
(2014) Australia 20% 10.6%  Stress
At-risk: 12.4%  Depression
Very distressed:
7.6%
Flarity et al. 73 nurses at Memorial Hospital, University ProQOL 5 At least one Moderate Moderate NR
(2013) of Colorado Health’s two Emergency symptom of high:59% high:60%
Departments compassion
fatigue in the last
30 days: 60%
Hooper et al. 49 emergency nurses ProQOL R-IV Low risk: 14.3% Low risk: NR  Oncology higher than emergency nurses
(2010) Moderate risk: 18.4% or intensive care nurses
57.1% Moderate
High risk: 28.6% risk: 59.2%
High risk:
22.4%
32 intensive care nurses Low risk: 15.6% Low risk:
Moderate risk: 21.9%
56.3% Moderate
High risk: 28.1% risk: 43.8%
High risk:
34.4%
16 nephrology nurses Low risk: 12.5% Low risk:
Moderate risk: 12.5%
62.5% Moderate
High risk: 25% risk: 62.5%
High risk:
25%
12 oncology nurses Low risk: 25% Low risk:
Moderate risk: 16.7%
41.7% Moderate
High risk: 33.3% risk: 58.3%
High risk:
25%
Young et al. 45 nurses in the heart and vascular intensive ProQOL 5 NR Low risk: Low risk: NR
(2011) care unit in a 484-bed academic medical 16% 24%
center in central Pennsylvania Moderate Moderate
risk: 29% risk: 19%
 S. Sinclair et al. / International Journal of Nursing Studies 69 (2017) 9–24 17

Table 2 (Continued)
Author Population Measure Prevalence of compassion fatigue Risk factors for compassion fatigue/
burnout-secondary traumatic stress
Reported as Burnout Secondary
compassion traumatic
fatigue stress
25 nurse in the heart and vascular Low risk: Low risk:
intermediate care unit in a 484-bed 21% 19%
academic medical center in central Moderate Moderate
Pennsylvania risk: 4% risk: 6%
Circenis and 129 nurses from several hospitals in Latvia ProQOL R-V NR At risk: At risk:  Inadequate salary,
Millere 54% 50%  Psychological pressure working with
(2011) patients
 Professional achievement of nurses

Elkonin and 30 professional nurses from three intensive ProQOL-R-IV Low risk: 40% Low risk: NR NR
Van Der care units, registered with the South African Average risk: 57% 3%
Vyver Nursing Council, with a minimum of 6 High risk: 40% Moderate
(2011) months’ intensive care nursing experience risk: 20%
High
risk:7%
Yoder (2010) 106 nuses in a Midwest MagnetTM ProQOL R-IV 15.8% 7.6% NR  Working 8 h shifts vs. 12 h shifts
designated
123-bed community hospital.
Abendroth 216 registered hospice nurses in Florida ProQOL-CSF- Low risk: 21.3% Low risk: NR  Experiencing a patient's traumatic death
and R-III Moderate-high 38.9%  Stress
Flannery risk: 78.7% Moderate-  Anxiety
(2006) High risk: 26.4% high risk:  Life demands
61.1%  Excessive empathy (blurred professional
High risk: boundaries)
10.2%

Physicians
El-Bar et al. 128 family physicians at Clalit Health Compassion Extremely low Extremely NR  Former immigration to Israel
(2013) Services clinics in the Negev (Israel’s Satisfaction risk: 32% low risk:
southern region) and Fatigue Low risk: 10.2% 56.3%
Test Moderate risk: Moderate
questionnaires 11.7% risk: 34.4%
High risk: 10.9% High risk:
Extremely high 9.4%
risk: 35.2%
Huggard and 253 doctors, ProQOL High risk: 17.1% High risk: NR NR
Dixon working in four locations in New Zealand 19.5%
(2011) and training
in a variety of specialty disciplines
Pfifferling Office-based physicians Survey 54% NR NR NR
and Gilley
(2000)

Consultants
Dasan et al. 681 NHS emergency medicine ProQOL NR Low risk: Low risk:  Age (scores improve at 60+ years of age)
(2016) Consultants throughout the UK 21% 55.4%  Married/single vs. widowed/divorced/
Moderate Moderate separated
risk: 78.7% risk: 44.5%  Number of years worked as a consultant
High risk: High risk: (scores worsen over the first 10 years and
0.3 0.2% then improve from 20 years onwards)

Severn et al. 82 audiology practitioners members of the ProQOL Low risk: 29% Low risk: NR  Age
(2012) New Zealand Audiological Society version 3 High risk: 22% 26%  Time demands
High risk:  Patient contact
20%  Accountability and administration
 Equipment

Midwives
Beaumont 103 student midwives studying at ProQOL Low risk: 60.45% Low risk: NR NR
et al. university Moderate risk: 49.5%
(2015) 39.6% Moderate
risk: 50.5%
Residents
Bellolio et al. 188 residents in Emergency Care in the US ProQOL 5 NR Low risk: Low risk:  >80 h per week
(2014) 57% 77%  Night shift
Moderate Moderate  Child dependents
risk: 43% risk: 23%

Councellors
Lee et al. 402 genetic counselors in N America ProQOL 5 Moderate risk: Low NR  Trait anxiety
(2015) 39% risk:13%  Compassion satisfaction
High risk:61% Moderate  Burnout
18 S. Sinclair et al. / International Journal of Nursing Studies 69 (2017) 9–24

Table 2 (Continued)
Author Population Measure Prevalence of compassion fatigue Risk factors for compassion fatigue/
burnout-secondary traumatic stress
Reported as Burnout Secondary
compassion traumatic
fatigue stress
risk: 68%  Ethnicity other than Caucasian
High risk:
19%

General
Branch and 296 direct care providers at St. Louis ProQOL 5 NR High risk: High risk:  Pediatric intensive care unit
Klinkenberg Children’s
(2015) Hospital 30.9% 26.9%
Potter et al. 154 healthcare providers including ProQOL-R-IV Low risk: 64% Low risk: NR  11–20 years of general healthcare expe-
(2010) registered nurses, medical assistants, and High risk: 36% 61.5% rience
radiology technicians at a National Cancer High risk:  Bachelor’s and advanced degrees
Institute-designated comprehensive cancer 38.5%
center in the Midwestern US
Robins et al. 314 health care providers at The Children's Compassion Moderate-high Moderate- NR  More years in direct care
(2009) Hospital of Philadelphia (86 physicians, 136 Satisfaction risk: 39% high risk:  Greater blurring of caregiver boundaries
nurses, 43 mental health practitioners and Fatigue 21%
[psychologists and social workers],49 allied Test
health [speech and language, occupational
therapy, and physical therapy]
practitioners)
Meadors 176 employees of a pediatric intensive care ProQOL High risk: 7.3% High-risk: NR  Secondary traumatic stress as measured
et al. unit, neonatal intensive care unit, and/or Low risk: 43% 1.2% by the secondary traumatic stress scale
(2009) pediatric unit Low risk: (Bride et al., 2007)
76%

PROQOL IV: 3 subscales: compassion satisfaction, burnout, and compassion fatigue/secondary trauma.
PROQOLV: 2 subscales: compassion satisfaction and compassion fatigue, comprised of burnout and secondary trauma.

Jung, 2014), nephrology nurses (Hooper et al., 2010), cardiac nurses et al., 2009; Cho and Jung, 2014). One study identified secondary
(Young et al., 2011), liver and renal nurse coordinators (Kim, 2013), traumatic stress as a predictive factor for compassion fatigue
psychiatric nurses (Mangoulia et al., 2015), pediatric nurses (Meadors et al., 2009).
(Berger et al., 2015); primary care nurses (Abendroth and Flannery,
2006; Yoder, 2010; Circenis and Millere, 2011; Neville and Cole, 3.6. Intervention programs
2013; Hegney et al., 2014), midwives (Beaumont et al., 2015),
audiologists (Severn et al., 2012), physicians (Pfifferling and Gilley, A variety of interventions to prevent and manage healthcare
2000; Huggard and Dixon, 2011; El-Bar et al., 2013; Fernando and provider compassion fatigue have been proposed in the literature
Consedine, 2014a), consultants (Severn et al., 2012; Dasan et al., (Table 3). Strategies include self-care, employee wellness pro-
2016), counselors (Lee et al., 2015) and residents (Bellolio et al., grams, education interventions, and the cultivation of healthcare
2014). Table 2 provides an overview of the reported prevalence of providers personal qualities such as resiliency (reviewed in
‘risk for compassion fatigue’ in various healthcare providers, along Wentzel and Brysiewicz, 2014).
with associated risk factors; notably, all cited studies used the Self-care interventions are the primary modality for compas-
terminology ‘compassion fatigue,’ sion fatigue prevention and management, emphasizing the need
In terms of risk factors (Table 2), in some studies there were no for healthcare providers to achieve work-life balance (Houck,
statistically significant associations between demographic varia- 2014). The wealth of research in nursing identifies compassion
bles and risk for developing compassion fatigue (Meadors et al., fatigue self-care interventions as exercise, good nutrition, and
2009; Yoder, 2010; Hegney et al., 2014; Bellolio et al., 2014). One maintaining healthy social-networks, as well as participation in
study of registered psychiatric nurses in Athens found that women activities that promote relaxation and rejuvenation, such as art,
had a significantly higher risk (1.2–8 times) for developing spirituality and mind–body techniques (yoga, meditation) (Boyle,
compassion fatigue than men (Mangoulia et al., 2015). Organiza- 2011; Hevezi 2015). Recent studies showed a negative correlation
tional and job-related factors, including patient contact, equip- between exercise and compassion fatigue in staff nurses, clinical
ment, time, accountability and administration were also identified nurse leaders and advanced nurse practitioners in outpatient and
as significant risk factors for developing compassion fatigue inpatient settings (Neville and Cole, 2013) and structured
(Severn et al., 2012), with resources, department size and quality of meditations and compassion fatigue in oncology nurses (Hevezi,
relationships at work as contributing elements (Yoder, 2010; 2015). In other healthcare providers, there are also negative
Circenis and Millere, 2011; Bellolio et al., 2014; Berger et al., 2015; correlations between indicators of self care (physical, inner and
Mangoulia et al., 2015; Dasan et al., 2016). Other studies found social self-care) and compassion fatigue (Sanso et al., 2015).
significant associations between fewer healthcare qualifications Employee wellness programs aimed at mitigating compassion
and less years experience with higher risk for developing fatigue include employee health screenings, role modeling,
compassion fatigue (Potter et al., 2010; Circenis and Millere, preceptor or mentor programs and staff retreats. Opportunities
2011; Hegney et al., 2014; Mangoulia et al., 2015; Dasan et al., to interact with other healthcare providers through formal
2016). Three studies identified empathy and blurring of caregiver programs that offer emotional support, such as structured support
boundaries as risk factors (Abendroth and Flannery, 2006; Robins groups and debriefings around deaths and difficult clinical
 S. Sinclair et al. / International Journal of Nursing Studies 69 (2017) 9–24 19

Table 3
Empirical studies investigating interventions for the prevention and management of healthcare provider compassion fatigue.

Author Population Intervention Measure Outcomes

Compassion Burnout Secondary

satisfaction trauma
Hevezi (2015) Convenience sample of 17 self- Breathing and meditation ProQOL 5 Increase: P = 0.027 Decrease: Decrease:
identified registered oncology techniques 5 days per week for a 4-week P = 0.003 P = 0.047
nurses in an academic medical period
center

Markwell et al. Convenience sample of 158 “Snack and Relax” a program of healthy ProQOL No significant difference between nurses
(2015) registered nurses in a hospital snacks and holistic participating in ‘Snack and Relax” and those that
relaxation methods did not

Weidlich and 93 military and civilian nurses, Care Provider ProQOL No significant Decrease No
Ugarriza licensed practical nurses, and Support Program of self-awareness difference P < 0.001 significant
(2015) medics at an Army Medical Center activities and energy management difference

Meadors and 185 health care providers and Seminar entitled “Addressing the Compassion Increased knowledge NR NR
Lamson staff biopsychosocial fatigue of the warning signs
(2008) and who were currently employed or needs of professional questionnaire of compassion
Meadors et al. affiliated with a children’s caregivers,” and Index of fatigue: P = 0.001
(2010) hospital Clinical Stress Increased ability to
at a regional southeastern manage stressors:
hospital in the US P  0.002
Increased ability to
manage grief:
P = 0.001
Increase in relaxed
feelings, calm and
peaceful: P  0.003

Houck (2014) 34 oncology nurses at a 572-bed, Educational program titled “Running on NR NR NR NR

Magnet1-designated Empty? How to Rejuvenate, Recharge and
community hospital in the Refill”
northeastern US

Flarity et al. 73 nurses at Memorial Hospital, Seminar titles “Compassion PROQOL5 Increase: P = 0.0004 Decrease: Decrease:
(2013) University Fatigue Resiliency,” and multimedia P < 0.001 P = 0.001
of Colorado Health’s two resources including a “Tools of Hope” DVD,
Emergency Departments Guided imagery/music CD and access to a
resources on a website

Potter et al. 13 oncology nurses at a National 5-week program involving five 90-min PROQOL IV No significant No Decrease at 6
(2013) Cancer Institute-designated sessions on compassion fatigue resiliency difference significant months post
comprehensive cancer center in difference program:
the midwestern US P < 0.05

situations led by trained professionals are also considered and continuing medical education programs to increase awareness
mitigators of compassion fatigue (Pickett et al., 1994; Houck, and provide tools to address the physical, behavioural and
2014; Aycock and Boyle, 2009). For nurses, on-site resources psychological demands associated with caregiving (Meadors and
include professional counseling and the availability of a psychiatric Lamson, 2008; Meadors et al., 2010; Flarity et al., 2013; Houck,
clinical nurse specialist to offer support (Aycock and Boyle, 2009; 2014). Meadors and Lamson (2008) and Meadors et al. (2010)
Boyle, 2011). Some hospitals provide rounds based on the Schwartz developed an education module on healthcare provider self-care
Center Rounds model, whereby nurses meet and discuss needs and that is based on Figley’s multifactor model of compassion stress
their feelings about difficult clinical situations in a supportive and compassion fatigue. The module raised awareness of
environment (Lally, 2005). On-site spiritual care interventions compassion fatigue and its application reduced clinical stress in
include “blessing of hands” ceremony, in which nurses have their healthcare providers working on pediatric intensive care units
hands blessed and prayer is offered for sustainment in caregiving; (Meadors and Lamson, 2008). Other educational intervention
“Tea for the Soul” support groups whereby a chaplain offers programs that have been applied to compassion fatigue include the
supportive conversations with nurses in the company of tea, Accelerated Recovery Programme (ARP), Mindfulness-Based Stress
cookies, and quiet music (Aycock and Boyle, 2009); and “Snack and Reduction (MBSR); The Academy of Traumatology/Green Cross
Relax”—a nurse holistic relaxation intervention that also provides standards of self-care; and the Creative Compassion Mode (Gentry
staff with healthy snacks (Markwell et al., 2015). et al., 2002; Cohen-Katz et al., 2004; Figley, 2005; Radey and Figley,
A variety of education programs have been designed to promote 2007). The Accelerated Recovery Programme (ARP) was developed
knowledge and skill development in coping, adaptation and to treat compassion fatigue originating from secondary trauma
emotional self-care (Meadors and Lamson, 2008, 2010; Flarity (Gentry et al., 2002). The ARP is a five-step structured therapy
et al., 2013; Aycock and Boyle, 2009; Boyle, 2011; Houck, 2014). A program that addresses identification of compassion fatigue
number of authors recommend the integration of compassion symptoms and triggers, utilization of resources for countering
fatigue educational interventions within nursing school curricula compassion fatigue, grounding and containment skills to help
20 S. Sinclair et al. / International Journal of Nursing Studies 69 (2017) 9–24

control situations and symptoms, self-soothing, boundary setting, trauma and is then expected to provide ongoing support and
internal conflict resolution and self-care after completion of the interventions to patients and families (Boyle, 2011), a nurse
ARP. Pre-/posttest PROQoL scores and Satisfaction With Life Scale working in a hospice frequently exposed to death and dying
scores suggest that compassion fatigue symptoms are responsive (Sinclair, 2011; Melvin, 2012), a family practitioner with prolonged
to ARP treatment (Flarity et al., 2013). MBSR teaches participants to involvement in patient care that includes managing chronic
deal with stress, pain and demands of everyday life through illnesses, and a physician who states s/he has difficulty remaining
meditation focused on self-awareness related to ones feelings. compassionate even though s/he is not exposed to trauma
Nurses in clinical practice reported increased patience, calmness or (Fernando and Consedine, 2014a). Second, the antecedents and
relaxation as a primary benefit of an 8-week MBSR program pathways of compassion fatigue should be based on a conceptual
(Cohen-Katz et al., 2004). As a result, MBSR has been proposed as a model that stipulates the various elements of compassion, in order
program to facilitate recognition and management of compassion that the determinants and their relationship to one another can be
fatigue in oncology nurses (Potter et al., 2010). The Academy of clearly delineated. Currently, conceptual analyses of compassion
Traumatology/Green Cross standards of self-care provide guidance fatigue tend to focus on limited facets of compassion (e.g.
on ethics, self-care, self-awareness, self-assessment and develop- behaviours, motivators) and not the entire construct (Sinclair
ment of a prevention plan (Figley, 2005). In contrast, the Creative et al., 2016a). Compassion is multi-faceted, involving virtues, a
Compassion Model emphasizes compassion satisfaction and the proactive response, seeking to understand, relational communi-
positive elements of healthcare work (Radey and Figley, 2007) cating, confronting and action (Sinclair et al., 2016a,b). Until risk
rather than focusing on addressing compassion fatigue issues factors, antecedents, pathways and manifestations of compassion
directly (Wentzel and Brysiewicz, 2014). fatigue are identified, based on a valid multifaceted model of
The cultivation of healthcare providers’ personal qualities, such compassion that is consistent and relevant across multiple
as resiliency has also been proposed as an effective strategy for healthcare professions, the construct validity of compassion
combating compassion fatigue. Resilience is the process of coping fatigue is further, questioned. Third, it has been suggested that
with or overcoming exposure to adversity (Egeland et al., 1993). the presence of any one of the more than forty physical,
The Care Provider Support Program (CPSP) was developed as a behavioural, psychological and spiritual symptoms (reviewed in
strategy to improve resiliency and decrease compassion fatigue in Mathieu, 2008; Huggard, 2016) can validate the diagnosis of
military and civilian registered nurses, licensed practical nurses, compassion fatigue, although generally more than one symptom
and medics who treat wounded soldiers. One intervention study should be demonstrated before a healthcare provider is identified
reported that a significant reduction in burnout, as measured by as having compassion fatigue (Lombardo and Eyre, 2011). Yet,
the ProQOL, led to decreased compassion fatigue. The program evidence supporting the classification of these symptoms as
focuses on self-awareness activities and energy conservation and is concurrent and related to compassion fatigue is lacking. Fourth,
based on the premise that highly resilient people are flexible, able currently the ProQOL is the most frequently used measure of
to respond to change and to recover after adversity (Weidlich and compassion fatigue in research and was utilized in the majority of
Ugarriza, 2015). A compassion fatigue resiliency program designed published articles on compassion fatigue. Despite its broad
to enable nurses to recognize threatening events and use acceptance, the ProQOL provides no direct measure of compassion
intentionality, self-validation, connection and self-care to self- fatigue and does not indirectly assess all purported aspects of the
regulate the associated stress was reported to show a significant concept of compassion fatigue (trauma symptoms, cognitive
reduction in secondary traumatic stress at six months post distortions, general psychological distress, burnout) (Bride et al.,
intervention in oncology nurses (Potter et al., 2013). 2007). Further, the ProQOL emphasizes the rewarding aspects of
clinical practice by considering compassion satisfaction, but the
4. Discussion relationship between compassion fatigue and compassion satis-
faction has not been established (Bride et al., 2007). Most
This meta-narrative review examines the concept of compas- importantly, the ProQOL is a self-report instrument that does
sion fatigue in the healthcare literature and demonstrates that not measure any elements of compassion itself (Ledoux, 2015;
there are multiple and conflicting theories on its nature. Bride et al., 2007), which is an inherently relational care construct,
Compassion fatigue is a phenomenon adopted by nursing from anchored in action aimed at relieving suffering (Bramley and
psychotherapy that has been mostly studied in nurses. It has Matiti, 2014; Van der Cingel, 2011; Sinclair et al., 2016a,b; Fernando
expropriated origins in crisis counseling, and has evolved into a and Consedine, 2014a,b). A comprehensive measure of compassion
contemporary and unquestioned euphemism for healthcare fatigue should include all the components of compassion,
provider stress. While this has raised awareness of the nature, incorporating the perspectives of researchers and clinicians, as
degree, and complexity of stress responses in nurses and across the well as the recipients of compassion— patients and their families.
spectrum of healthcare providers, the concept of compassion A recent report suggests that ‘compassion fatigue rests on a most
fatigue has been largely unchallenged and remains poorly fragile foundation’ (Ledoux, 2015), which the findings of this meta-
understood. Despite this conceptual ambiguity, all study authors narrative review confirm. Additionally, the current review identi-
in this review agree that nurses and all healthcare providers fied the concept of compassion fatigue as a euphemism for a broad
purported to be suffering from compassion fatigue are unlikely to family of occupational stresses uniquely attributed to healthcare
be able to deliver quality patient care (Alkema et al., 2008; providers that lacks construct validly and therefore cannot be
Canadian Nursing Association, 2010). empirically validated or measured. As a result, researchers
There are a multitude of theoretical and empirical studies on frequently conflate compassion, sympathy and empathy in
compassion fatigue and while many are plausible, the findings conceptualizing compassion fatigue (Sinclair et al., 2016a),
from this meta-narrative review suggest that they are associated ignoring their distinguishing characteristics, motivators, outcomes
with significant limitations. First, conceptual analyses of compas- and responses in the process (Sinclair et al., 2016c). Conceptually,
sion fatigue are not generalizable across healthcare settings or sympathy is understood as “a pity-based response to a distressing
professions. It is hard to envisage how a single conceptual model of situation that is characterized by a lack of relational understanding
compassion fatigue can be equally relevant and applicable to a and the self-preservation of the responder” (Sinclair et al., 2016c, p.
psychotherapist who may be chronically burdened with her 6). Empathy, the most frequently commandeered construct in the
clients’ distressing memories, a nurse who experiences acute compassion fatigue literature, has been identified has having at
 S. Sinclair et al. / International Journal of Nursing Studies 69 (2017) 9–24 21

least two components (Post et al., 2014; Hein and Singer, 2008). factors. In the Transactional Model of Physician Compassion,
The first aspect is cognitive empathy taking defined as the, “the physician, patient and family, clinical situation, and environmental
ability to understand intentions, desires, beliefs of another person factors interact to influence physician compassion (Fernando
resulting from (cognitively) reasoning about the other’s state” (Hein and Consedine, 2014a). We suggest that the product of this
and Singer, 2008, p. 154). Affective empathy, on the other hand model may not only be ‘physician compassion’ but ‘optimal
involves emotional resonance or feeling with the person in need compassionate care’, whereby the interaction of factors that affect
(Sinclair et al., 2016c). Compassion while sharing many of the a provider’s ability to be compassionate (burnout/overload;
features of empathy is motivated by not only the affective state of external distractions; difficult patient/family; complex clinical
the responder but also by their virtues and is predicated on action situations) are inextricably linked to patient outcomes—the
(Sinclair et al., 2016b). While the concept of compassion fatigue is ultimate indicator of healthcare provider compassion (Fernando
used synonymously with other occupational stress monikers, an and Consedine, 2014a,b).
equally significant issue is the conflation of the etymological roots In our review and critique of definitions and concepts, we do
upon which this foundation rests. not intend to diminish the severity of stress responses that
As a result, we propose that compassion fatigue in clinical healthcare providers face on a daily, moment-by-moment basis in
research and practice should be re-conceptualized. We do not caring for others. At the same time, terminology must not distract
contest that contemporary healthcare providers are susceptible us from comprehending, studying and developing evidence-
to emotional and physical vicarious suffering associated with based interventions to address the physical and emotional fatigue
their work, but suggesting that compassion is somehow the experienced by healthcare providers. Equally, there is increased
primary contributor to this phenomena is unfounded and detracts international concern about the state of compassion in health
from the significant work-related issues and burnout faced by systems, and interventions must be developed to prevent its
healthcare providers. If compassion was the underlying issue, one erosion across healthcare, whether its depletion is due to innate
would expect that healthcare providers, particularly exemplary factors within healthcare providers, environmental factors, a
compassionate carers, would be particularly vulnerable to the multitude of system factors or a combination of these. In addition,
effects of compassion fatigue. As a result of their so-called academic, institutional and government resources must be
‘chronic compassion’, a collorary pandemic of ‘compassion strategically allocated to research and fund targeted interventions
fatigue’ would ensue, making them among societies least that reduce occupational stress for healthcare providers. These
compassionate individuals. Recent research, history and spiritual interventions may include self-awareness, communication pro-
traditions suggest the opposite—increased opportunities to grams and mindfulness meditation for healthcare providers, and
express compassion seem to sustain baseline compassion, institutional interventions such as mitigating time constraints on
mitigate work-related stress, and are beneficial for responders patient-clinician interactions and implementing strategies that
and recipients, within and outside of healthcare (Armstrong and promote compassionate teamwork and support in the work
Knopf, 2010; Doris 2010; Seppala, 2013). It is more likely that environment.
healthcare providers are experiencing the negative consequences There is a large literature on compassion fatigue, and
associated with a broad range of occupational stressors that we believe our methodology was rigorous and captured a
inhibit their ability to be compassionate, and as a result, patient representative set of studies that has enabled a balanced critique
care becomes compromised. We and others (Ledoux, 2015) of the concept of compassion fatigue in healthcare. Our study is
suggest that a valid understanding of compassion fatigue must be limited as we did not apply a strength-of evidence criteria to
based in an empirical understanding of compassion, allowing included articles, which is more characteristic of s systematic
compassion fatigue to not only be disentangled from other review than a meta narrative review. This methodological
occupational stress monikers such as vicarious trauma and decision was based on the observation that many articles
burnout, but from the constructs of empathy and sympathy considered relevant to this review were theoretical and could
(Sinclair et al., 2016c). Importantly, functional neural plasticity not be appropriately assessed with a strength-of evidence
studies indicate that empathy training is more associated with grading. We hope that this review will serve as a foundation
negative affective states of emotional contagion, distress and for more systematic studies.
aversion, whereas compassion training activated neuro regions In conclusion, we suggest that a new discourse on healthcare
associated with positive affective states of reward, love, affiliation provider occupational stress and burnout is needed, which
and concern for another (Klimecki et al., 2014). This suggests that expunges the problematic concept of compassion fatigue. In
the generation of compassion in response to distressing situations the last two decades, compassion fatigue has become a
fosters emotional well-being (Fredrickson et al., 2008), positive contemporary and iconic euphemism that has raised awareness
emotions (Klimecki et al., 2013) and prosocial behavior, and of the physical, behavioural, psychological and spiritual impacts
ironically may represent a potent strategy for preventing burnout. of working as healthcare provider; however, it is significantly
Interestingly, Figley’s (1995, 2002) original multifactor model of problematic for multiple reasons. By focusing exclusively on
compassion fatigue was based on empathy, while other studies compassion fatigue, other equally important negative ‘endpoints'
suggest that a key factor related to compassionate care occurs associated with healthcare professions, such as burnout, second-
when there is discord between healthcare providers’ intentions ary traumatic stress, countertransference and vicarious trauma-
and their ability to provide such care in the midst of a resource tization, may not be adequately addressed. As a result, the state of
constrained, labour intensive healthcare setting (Valent, 2002; the science of compassion research and the implementation of
Coetzee and Klopper, 2010; Ledoux, 2015). Ledoux (2015) evidence-based multifaceted intervention programs is impeded—
correlates this phenomenon to moral distress, which we suggest ultimately impacting the advancement of compassionate care to
may be more accurately termed ‘compassion distress’—the patients and the development of compassionate healthcare
inability to relieve suffering as a result of compassion being systems.
obstructed, mistargeted or not having its intended effect. Fernando
and Consedine (2014a) proposed a transactional model of
Conflict of interest
physician compassion that seems to honour healthcare providers’
lived clinical experiences while acknowledging the highly
None.
relational nature of compassion and a multitude of associated
22 S. Sinclair et al. / International Journal of Nursing Studies 69 (2017) 9–24

Funding Compassion Fatigue Awareness Project (CFAP), 2015. www.compassionfatigue.org.

(Accessed 25 March 2016).
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