healthcare

Systematic Review
Interventions for Compassion Fatigue in Healthcare
Providers—A Systematic Review of Randomised
Controlled Trials
Sanjay Patole 1,2, * , Dinesh Pawale 1 and Chandra Rath 1,2

1 Neonatal Directorate, KEM Hospital for Women, Perth, WA 6008, Australia;

[email protected] (D.P.); [email protected] (C.R.)
2 School of Medicine, University of Western Australia, Perth, WA 6009, Australia
* Correspondence: [email protected]

Abstract: Background: Compassion fatigue is a significant issue considering its consequences includ-
ing negative feelings, impaired cognition, and increased risk of long-term morbidities. We aimed to
assess current evidence on the effects of interventions for compassion fatigue in healthcare providers
(HCP). Methods: We used the Cochrane methodology for Systematic Reviews and Meta-Analyses
(PRISMA) for conducting and reporting this review. Results: Fifteen RCTs (n = 1740) were included.
The sample size of individual studies was small ranging from 23 to 605. There was significant het-
erogeneity in participant, intervention, control, and outcome characteristics. The tools for assessing
intervention effects on compassion fatigue included ProQOL, compassion fatigue scale, and nurses
compassion fatigue inventory. Thirteen out of the fifteen included RCTs had overall high risk of
bias (ROB). Meta-analysis could not be performed given the significant heterogeneity. Conclusions:
Current evidence on interventions for reducing compassion fatigue in HCPs is inadequate. Given the
benefits reported in some of the included studies, well-designed and adequately powered RCTs are
urgently needed.

Keywords: compassion fatigue; burnout; secondary traumatic stress; professional quality of life

Citation: Patole, S.; Pawale, D.; Rath,

C. Interventions for Compassion
1. Introduction
Fatigue in Healthcare Providers—A
Systematic Review of Randomised Empathy and compassion are at the core of the medical field, the business of providing
Controlled Trials. Healthcare 2024, 12, care and comfort and, if possible, cure for patients. Empathy, the driver of prosocial be-
171. https://doi.org/10.3390/ haviour, is the ability to understand and truly share the feelings of others [1–3]. Empathy is
healthcare12020171 considered as the first step to more humane care [4] and critical for effective communication
and healthcare [5–10].
Academic Editor: John H. Foster
Driven by empathy, compassion is the deep feeling that arises after becoming dis-
Received: 29 November 2023 tressed by another person’s suffering, accompanied by a strong desire to help and improve
Revised: 4 January 2024 his/her wellbeing [11–14]. Compassion leads to acts of kindness, taking empathy a step
Accepted: 9 January 2024 ahead [15–18].
Published: 11 January 2024 Carrying the emotional burden of the suffering of other people over a long period can
hurt the care provider due to the acute or cumulative effects of secondary stress [19,20].
Researchers hence consider empathy as a double-edged sword or the ‘cost of caring’ and
emphasise the importance of awareness of this risk in healthcare providers [21–26]. The
Copyright: © 2024 by the authors.
broad definition of compassion fatigue [27] is focused on secondary traumatic stress (STS),
Licensee MDPI, Basel, Switzerland.
the emotional duress experienced by people in close contact with a trauma survivor [28,29].
This article is an open access article
Aspects of burnout were later added to this definition to include energy depletion as a well-
distributed under the terms and
conditions of the Creative Commons
known feature of compassion fatigue [29–33]. The secondary stress in compassion fatigue
Attribution (CC BY) license (https://
is similar to that in STS. However, compassion fatigue is characterised by reduced empathic
creativecommons.org/licenses/by/ capacity after repeated exposure to traumatic situations experienced by others [34,35].
4.0/).

Healthcare 2024, 12, 171. https://doi.org/10.3390/healthcare12020171 https://www.mdpi.com/journal/healthcare

Healthcare 2024, 12, 171 2 of 14

Researchers suggest that STS occurs first and gives rise to compassion fatigue [36]. Com-
passion fatigue is a form of vicarious trauma with symptoms like that of post-traumatic
stress disorder (PTSD) but without the inner change in worldview [37,38].
The significance of compassion fatigue cannot be overemphasised given its high
prevalence [39–42]. Moreover, it has serious consequences including negative feelings,
impaired cognition, and increased risk of long-term morbidities such as cardiovascular
disease, and psychiatric illness [43–45].
Current evidence includes only a few systematic reviews in the field of compas-
sion fatigue [46–52]. These reviews have significant heterogeneity in the participant (e.g.,
physicians, nurses, radiographers), faculty (e.g., oncology, emergency department), and
location (e.g., rural, low-middle income nations) characteristics, and the evaluated aspects
of compassion fatigue (e.g., prevalence, risk factors, interventions). Furthermore, some of
these reviews focus on isolated components of compassion fatigue [48,52]. Interpreting
and applying evidence from such heterogenous studies is hence difficult [53]. The recent
systematic review by Chen et al. [54] has focused mainly on the effects of psychological
interventions on empathy (not compassion) fatigue only in nurses. Similarly, the system-
atic review by Xie et al. [55] has assessed the effects of psychological interventions on
compassion fatigue only in nurses.
Given the significance of underlining issues, we aimed to review the current evidence
on the effect of various strategies for reducing compassion fatigue in healthcare providers.
Our specific objective was to conduct a comprehensive and robust systematic review
focused exclusively on randomised controlled trials (RCTs) of interventions for compassion
fatigue in healthcare providers. Our findings will help in guiding research and clinical
practice in the field.

2. Material and Methods

We followed the Cochrane methodology [56] and the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) [57] statement for this systematic review.
The protocol was approved by the university supervisor for this project [58].

2.1. Literature Search

PubMed, EMBASE, CINAHL, Emcare, and Cochrane library were searched from
inception until December 2022. Grey literature was searched through Mednar (https:
//mednar.com (accessed on 10 January 2023)). Reviewers DP and SP independently
searched the literature. The reference lists of the relevant studies were hand-searched to
identify additional articles. No language restrictions were applied. The literature search
focussed separately on systematic reviews and clinical/randomised trials assessing any
intervention for compassion fatigue as follows:
(1) The above-mentioned databases were searched for systematic reviews on interven-
tions for compassion fatigue. PubMed were searched using the search terms (“compas-
sion fatigue”[MeSH Terms] OR (“compassion”[All Fields] AND “fatigue”[All Fields])
OR “compassion fatigue”[All Fields]) AND (meta-analysis [Filter] OR systematic
review [Filter]). Similar terms were used for other databases.
(2) All databases were searched again for individual RCTs on interventions for compas-
sion fatigue. PubMed was searched using the following broad key words: ((compas-
sion fatigue) OR (compassion satisfaction)) OR (empathy fatigue) Filters: Clinical Trial,
Randomized Controlled Trial. That automatic mapping system of PubMed expanded
it to cover all the following terms: (“compassion fatigue”[MeSH Terms] OR (“compas-
sion”[All Fields] AND “fatigue”[All Fields]) OR “compassion fatigue”[All Fields] OR
((“empathy”[MeSH Terms] OR “empathy”[All Fields] OR “compassion”[All Fields])
AND (“personal satisfaction”[MeSH Terms] OR (“personal”[All Fields] AND “sat-
isfaction”[All Fields]) OR “personal satisfaction”[All Fields] OR “satisfaction”[All
Fields] OR “satisfactions”[All Fields] OR “satisfaction s”[All Fields])) OR ((“empa-
thy”[MeSH Terms] OR “empathy”[All Fields]) AND (“fatiguability”[All Fields] OR
Healthcare 2024, 12, 171 3 of 14

“fatiguable”[All Fields] OR “fatigue”[MeSH Terms] OR “fatigue”[All Fields] OR “fa-

tigued”[All Fields] OR “fatigues”[All Fields] OR “fatiguing”[All Fields] OR “fatigue-
ability”[All Fields]))) AND (clinicaltrial[Filter] OR randomizedcontrolledtrial[Filter]).
Similar terms were used for other databases.

2.2. Inclusion Criteria

RCTs and quasi-RCTs assessing interventions for compassion fatigue were eligible
for inclusion. Studies not assessing interventions for compassion fatigue or dealing with
STS, burnout, and vicarious trauma were excluded. We excluded reviews, editorials, case
reports, letters and commentaries but read them to identify potential studies.
The primary outcome was the effect of the intervention on compassion fatigue (Mean
pre-post difference in scores) measured by a validated tool such as the Professional Quality
of Life (ProQOL) scale [59–62]. Secondary outcomes included effects of the intervention
on individual components of compassion fatigue, including burnout and STS, and other
outcomes reported in the individual studies.

2.3. Assessing the Risk of Bias (ROB)

The Cochrane ROB tool (RoB 2.0) was used to assess the ROB based on the following
criteria [61]: 1. Was the allocation sequence adequately generated? 2. Was allocation
adequately concealed? 3. Was blinding of participants, personnel, and outcome assessors
adequate? 4. Were incomplete outcome data adequately addressed? 5. Are reports of
the study free of selective outcome reporting? 6. Was the study apparently free of other
problems? Overall, this tool assesses the randomisation process, deviations from intended
interventions, missing outcomes, the method for measuring the outcomes and selective
reporting [63].

2.4. Data Extraction

Two reviewers (SP and DP) independently extracted the data using a prespecified data
collection form. All reviewers verified the information about study design and outcomes
independently. Disagreements were resolved through joint discussions if required. If
required, we planned to contact the authors of included studies for incomplete data or
clarifications. Studies were excluded after two failed attempts to contact the authors.

2.5. Data Synthesis

We planned to conduct the meta-analysis using the Review manager V.5.4 (Cochrane
collaboration, Nordic Cochrane Centre, Copenhagen, Denmark). We selected the random-
effects model for meta-analysis given the significant heterogeneity [64]. We chose relative
risk (RR) size and the mean difference (MD) to express the effects for dichotomous and
continuous outcomes, respectively.

2.6. Assessment of Heterogeneity, Publication Bias and Certainty of the Evidence (CoE)
We planned to assess statistical heterogeneity with the χ2 test, I2 statistic and by visual
inspection of the forest plot (overlap of CIs) [65]. As recommended, an I2 value of >50%
indicates substantial heterogeneity [65]. When pooling was not possible, we planned to
present the non-pooled data in tabular form. We planned to check publication bias by
a funnel plot if more than 10 RCTs were available for meta-analysis. We also planned
to assess publication bias objectively by Egger’s test [66,67]. We planned to report the
certainty of evidence using the GRADE framework [68].

2.7. Exploring Heterogeneity

Heterogeneity was explored by considering the variations in participant, interventions,
comparator, and outcomes in included studies. We planned to explore differences in the
design (e.g., randomised vs. quasi-randomised) and settings (ICU vs. non-ICU, urban vs.
rural-remote) of the included studies.
 2.7. Exploring Heterogeneity
Heterogeneity was explored by considering the variations in participant, interven-
tions, comparator, and outcomes in included studies. We planned to explore differences
in the design (e.g., randomised vs. quasi-randomised) and settings (ICU vs. non-ICU, ur-
Healthcare 2024, 12, 171 ban vs. rural-remote) of the included studies. 4 of 14

3. Results
The literature search retrieved 865 potentially relevant citations. After carefully re-
3. Results
viewingThethe abstracts,
literature 260 duplicate
search studies
retrieved 865 were excluded.
potentially relevant A total of 570
citations. studies
After were
carefully re-
excluded
viewing after reading titles
the abstracts, and abstracts.
260 duplicate Twenty
studies werearticles wereAexcluded
excluded. afterstudies
total of 570 reading 35
were
full texts. Finally,
excluded 15 RCTs
after reading were
titles andincluded in the
abstracts. review
Twenty [69–83].
articles wereThe flow diagram
excluded of the
after reading
study selection process is shown in Figure 1.
35 full texts. Finally, 15 RCTs were included in the review [69–83]. The flow diagram of the
study selection process is shown in Figure 1.

Figure 1. PRISMA flow chart for study selection.

The characteristics of the 15 included studies are described in Table 1. There was
significant heterogeneity in the participants, interventions, control, and outcome charac-
teristics, and the settings, and timing of assessing the effect of the intervention in these
studies. The sample size of individual studies was small, ranging from 23 to 605 par-
ticipants [69–83]. The total sample size was 1740 (mean: 116). Nine out of fifteen in-
cluded studies showed reduction in either compassion fatigue or its components after
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Healthcare 2024, 12, 171 7 of 14

Majority of the included studies (11/15) recruited nurses working in different settings
ranging from intensive care unit, and emergency department to elderly care centres, and
trauma centres. Two studies recruited mental health workers, behavioural health clinicians,
and another recruited a proportion (39.5% of 253) of participants as psychologists, psy-
chotherapists, coaches, and counsellors. The studies were conducted in various nations
including Iran (n = 3), Turkey (n = 3), Slovakia, Israel, Spain, Korea (n = 1 each), and USA
(n = 5).
The interventions ranged from motivational messages, acupressure, and guided im-
agery to inhalation of patchouli oil, chromotherapy, and Emotion-Focused Training for
Health Professionals (EFT-HP). The various tools for assessing intervention effects included
the ProQOL, compassion fatigue scale, nurses compassion fatigue inventory, Disaster-
Helper Self-Efficacy Scale (DHSES), Rosenberg self-esteem scale (RSE), Self-rated Hope
Scale, Mastery scale, and the Pittsburgh Sleep Quality Index (PSQI).
Four studies had ‘wait list’ controls [71,72,79,81]. Other studies did not offer the
intervention to participants in the control group.
Trial registration was reported in 9/15 included RCTs [71,73–76,80–83]. An approach to
sample size and power estimation was reported in 6/15 included studies [69,70,72,77,78,80]. Some
of these trials did not report the rationale for sample size estimation adequately [72,78].
The distinction between primary and secondary outcomes was unclear in majority of the
included RCTs. Five studies were reported as a pilot [73,74,80–82]. The tools used in the
included studies for assessing the effect of interventions specifically on compassion fatigue
included ProQOL [84–89], compassion fatigue scale [70], and nurses compassion fatigue
inventory [69,90].
Our literature search revealed two recently published systematic reviews [54,55].
Chen et al. included 7 RCTs (Total 513 nurses) and assessed the effects of psychological
intervention on empathy fatigue in nurses. Four of the seven RCTs included in Chen
review were identified in our literature search and remaining three were judged ineligible
being non-RCTs [91–93]. Xie Wanging et al. that assessed the effects of psychological
interventions on compassion fatigue among nursing staff was excluded as the full paper
was not available despite contacting the authors [55]. The translated abstract in English
was unreliable (e.g., “Thirteen RCTs involving 13 nursing staff were included”).

3.1. Approach to Synthesis

Given the significant heterogeneity in participants, interventions (type and dura-
tion), controls, and outcomes as well as the settings, tools for assessments, and timing
of assessments post-intervention in the included RCTs pooling of data was considered
inappropriate. Hence, a narrative approach to synthesis was undertaken. A funnel plot to
assess the probability of publication bias was not considered.

3.2. Risk of Bias Assessment (Figure 2)

Thirteen out of the fifteen (87%) included studies had overall high ROB. The two
domains with high ROB involved the randomization process (12/15 (80%) included studies)
and in the measurement of outcomes (13/15 (87%) of the 15 included studies). The high
ROB in the measurement of outcomes domain is because of the nature of intervention and
reporting of outcomes by the participants themselves. Figure 2 provides the results of the
ROB assessment.
 Thirteen out of the fifteen (87%) included studies had overall high ROB. The two
domains with high ROB involved the randomization process (12/15 (80%) included stud-
ies) and in the measurement of outcomes (13/15 (87%) of the 15 included studies). The
high ROB in the measurement of outcomes domain is because of the nature of intervention
Healthcare 2024, 12, 171 and reporting of outcomes by the participants themselves. Figure 2 provides the8results
of 14
of the ROB assessment.

Riskofofbias
Figure2.2.Risk
Figure biasassessment
assessment of
of the
the included
includedstudies
studies[69–83].
[69–83].

4.4.Discussion
Discussion
Oursystematic
Our systematic review
review revealed
revealed1515RCTs
RCTs(n =
(n1740) assessing
= 1740) various
assessing interventions
various for
interventions
reducing compassion fatigue in healthcare providers from different sectors. Most
for reducing compassion fatigue in healthcare providers from different sectors. Most stud- studies
used the ProQOL scale for the purpose. Significant heterogeneity in characteristics of
ies used the ProQOL scale for the purpose. Significant heterogeneity in characteristics of
the settings, participants, interventions, comparator groups, outcomes, and timing (and
the settings, participants, interventions, comparator groups, outcomes, and timing (and
in few studies, the tool) for assessing the effects of the intervention meant conducting
inmeta-analysis
few studies, wasthe tool) for assessing the effects of the intervention meant conducting
inappropriate. All included studies had small sample size and high
meta-analysis was inappropriate. All included
risk of bias. Deriving a robust conclusion studies
from such had small
inadequate andsample size and
low-quality high
data wasrisk
ofhence
bias. difficult.
DerivingOura robust
findingsconclusion from
indicate the suchneed
urgent inadequate and low-quality
for well-designed data was
and adequately
hence difficult. Our findings indicate the urgent need for well-designed
powered definitive RCTs of interventions to reduce the risk of compassion fatigue in and adequately
powered
healthcaredefinitive
providers.RCTs of interventions to reduce the risk of compassion fatigue in
healthcare providers. of the methodology and results of two systematic reviews [46,54]
The significance
need to be discussed in the context of our systematic review. Cocker et al. [46] reported a
systematic review of studies assessing psychological interventions for reducing compassion
fatigue in healthcare providers in various settings. The studies used validated measures
such as Pro-QoL, Maslach Burnout Scale [94], or the Resilience Scale [95]. Of the total
229 studies identified, only 13 studies were included in the review (n = 671, range: 7 to
153). There was significant heterogeneity in participant, setting, and intervention character-
istics, the period of follow up, and the study design including the type of control group.
Participants were not truly representative of the target population as their selection was
based on convenience rather than random sampling. Given the small total sample size,
and the fact that 11 of the 13 included studies were non-RCTs it is difficult to derive clear
and valid conclusions from this systematic review. The results of the included two small
RCTs are also not helpful in this context [46]. The ideal intervention for compassion fatigue
would be one that reduces burnout and STS (the negative aspect) and increases compassion
satisfaction, the positive aspect of professional quality of life. One of the thirteen included
studies that showed such results involved a two-step intervention amongst emergency
nurses [96].
Healthcare 2024, 12, 171 9 of 14

Chen et al. reported a systematic review assessing the effects of psychological inter-
ventions on empathy (not compassion) fatigue in nurses [54]. Meta-analysis of data from
7 included RCTs (n = 513 nurses) showed that empathy fatigue (SMD = −0.22, 95% CI:
−0.42~−0.02, p = 0.03) and burnout (SMD = −0.37, 95% CI: −0.56~−0.19, p < 0.001) scores
were significantly lower in the intervention vs. control group. The empathy satisfaction
score was significantly higher in intervention vs. control group (SMD = 0.45, 95% CI:
0.27–0.63, p < 0.001). The effects of the intervention were significantly different in different
settings including ICU, paediatric, and other departments (p = 0.0007). Both mindfulness
(SMD = 0.50, 95% CI: 0.24–0.77, p = 0.0002) and other interventions (SMD = 0.41, 95% CI:
0.16–0.65, p = 0.001) had a significant effect on empathy satisfaction between the interven-
tion vs. control group [54]. We believe that pooling data from heterogeneous interventions
under a common label as ‘psychological’ interventions is debatable.
Overall, the data on the range of interventions from studies included in our systematic
review and those by Cocker et al. [46], Chen et al. [54], and the findings of some of the
studies discussed here [97–99] should be useful in selecting intervention for assessing in
future studies.
Selecting the design of future studies in this field is a critical issue. RCTs are considered
as the gold standard for clinical research to assess the effects (benefits and risks) of an
intervention [100]. The strength of the RCT design lies in its ability to control for not only
the known, but also the unknown confounders. No other study design can achieve this
goal [101,102]. However, well-designed large adequately powered RCTs are not easy to
conduct considering the difficulties related to their feasibility, acceptability, and need for
resources, and expertise. A systematic review and meta-analysis of RCTs with comparable
characteristics of participants, interventions, comparator, and outcomes provides a robust
way to synthesise the evidence with more power and precision when the available RCTs
are small and have conflicting results [103,104].
Randomisation at individual participant level will be difficult in RCTs of interventions
to reduce compassion fatigue and/or improve compassion satisfaction, especially in small
organisations. Contamination of the control group participants is inevitable if they work
in the same section of an organisation as those assigned to the intervention group. This
is particularly a possibility given the nature of psychological interventions and the fact
that humans influence others consciously or subconsciously. Cluster RCT design is hence
more appropriate for such studies [105–107]. The limitations of cluster RCTs include
the need for biostatisticians with expertise (e.g., power, precision, number and size of
the clusters, imbalance between clusters, intra-cluster correlation coefficient) [108–115].
Furthermore, the power and precision of results generated by a cluster-RCT are lower
compared to those from a conventional RCT. The stepped wedge design is an alternative for
rigorous evaluation of organisational interventions such as those for managing compassion
fatigue [116,117]. This unique design provides an option where all trial participants receive
the intervention but the order in which the intervention is received is randomised.
As for interventions, considering their simplicity, acceptability, ease of application,
and logistics of implementation, as well as resources and socioeconomic and cultural differ-
ences is important in designing trials in this field. The ProQOL scale is perhaps the most
appropriate tool for assessing effects of interventions for compassion fatigue considering
it is culturally adapted and validated in several countries and has high reliability and
validity [118,119]. Biological markers such as salivary amylase will optimise the validity
of the results RCTs [81]. Salivary amylase is a marker of stress-induced activation of the
autonomic nervous system. Its secretion is controlled by sympathetic activation through
β-adrenergic receptors. It has been used as a marker to measure effects of stress reduction
interventions [81]. The first responders and those in an intensive care set-up could be
the priority population for future trials given they are at high risk of compassion fatigue.
Equally important will be the considerations such as the settings (high- vs. low-income
counties), language, and culture. Considering the ethical implications for any intervention
to be assessed is an important issue in the design of future RCTs.
Healthcare 2024, 12, 171 10 of 14

5. Conclusions
Our comprehensive systematic review with robust methodology including assessment
of the risk of bias by a validated toll (ROB-2) indicates that current evidence on interventions
for reducing compassion fatigue in healthcare providers is inadequate. Given the benefits
reported in some of the included studies, there is an urgent need for well-designed and
adequately powered definitive RCTs in this field. Our systematic review is helpful in the
designing such trials.

Author Contributions: Conceptualization, S.P.; Methodology, S.P., D.P. and C.R.; Formal analysis,
S.P. and D.P.; Data curation S.P., D.P. and C.R.; Writing—original draft preparation S.P. and D.P.;
Writing—review and editing, S.P. and C.R.; Supervision, S.P. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflicts of interest.

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