Review
Compassion fatigue: A meta-narrative review of the healthcare literature

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Abstract

Background

Compassion fatigue describes a work-related stress response in healthcare providers that is considered a ‘cost of caring’ and a key contributor to the loss of compassion in healthcare.

Objective

The purpose of this review was to critically examine the construct of compassion fatigue and to determine if it is an accurate descriptor of work-related stress in healthcare providers and a valid target variable for intervention.

Design

Meta-narrative review.

Data Sources

PubMed, Medline, CINAHL, PsycINFO, and Web of Science databases, Google Scholar, the grey literature, and manual searches of bibliographies.

Review methods

Seminal articles and theoretical and empirical studies on compassion fatigue in the healthcare literature were identified and appraised for their validity and relevance to our review. Sources were mapped according to the following criteria: 1) definitions; 2) conceptual analyses; 3) signs and symptoms; 4) measures; 5) prevalence and associated risk factors; and 6) interventions. A narrative account of included studies that critically examines the concept of compassion fatigue in healthcare was employed, and recommendations for practice, policy and further research were made.

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.

Introduction

The demands of the healthcare system, including high expectations, time constraints, a lack of social support and a sense of inadequate skills to address patient suffering can lead to severe stress in healthcare providers, which affects their health and performance, and impacts job satisfaction, workforce stability, retention, workplace wellness and patient outcomes (Van Bogaert et al., 2013). Work-related stress is particularly pertinent to nurses, who make up the largest proportion of the healthcare workforce and are on the front lines of patient care. In 2006–2008, data from several national surveys showed that the overall burnout rate among nurses in the US ranged from 20% to 40% (Neff et al., 2011, McHugh et al., 2011, McHugh and Ma, 2014). In 2011, 74% of 4614 nurses surveyed by the American Nurses Association identified acute and chronic effects of stress and overwork as a top safety and health concern (American Nurses Association, 2011).

Stress is defined as the body's physical, mental or emotional response to a change (Selye, 1983). The pathogenic role of stress was identified by Walter B. Cannon (1871–1945), a Harvard physiologist, and later expanded by Hans Seyle (1907–1982), a Czech endocrinologist. Cannon speculated that chronic emotional arousal following crises, or the everyday pressures of modern life, stimulates a fight or flight physiological response in humans. Seyle identified the General Adaptation Syndrome (GAS), in which environmental influences, termed ‘stressors’, produce a combination of physiological changes in the body, termed a ‘stress response’ (Harrington, 2008). The stress response results in an increase in adrenaline and corticosterone levels, which raises heart rate, respiration and blood pressure, and has a major impact on physical functioning. In the short term, the stress response allows an individual to quickly meet challenges. Once exhaustion is reached, the stress response becomes detrimental to physical and psychological health, leading to a variety of effects such as reduced immune function, cardiovascular disease, obesity, anxiety, depression and addiction (Cohen et al., 2007, Cohen et al., 2012, Torres, 2007, Sinha, 2008).

Nursing is recognized as a particularly stressful profession (Jones and Johnston, 1997, McVicar, 2003, Rutledge et al., 2009, Sharma et al., 2014, Johnston et al., 2016). Studies in nurses indicate that their physical, emotional, social and spiritual health is impaired by cumulative stress related to interactions with large volumes of often highly complex patients on an ongoing basis, trauma and practice environments with limited resources and increased demands (Boyle, 2011, Sharma et al., 2014). Nursing patient-related stressors include frequent exposure to suffering, death and dying, vicarious trauma, and providing care to ‘difficult’ patients and families while meeting expectations for patient satisfaction (McCloskey and Taggart, 2010, Hamilton et al., 2016). Practice-related stressors include expanding workloads, long hours, change in procedures, staffing levels, interpersonal relationships, role ambiguity, responding to frequent workflow interruptions, limited resources and a feeling of lack of control (McCloskey and Taggart, 2010, Cuneo et al., 2011, Hamilton et al., 2016).

In recognition of the work related stressors that nurses and all healthcare providers experience, the framework for the delivery of high value health care has been expanded from the Triple Aim to the Quadruple aim, in which the fourth goal includes creating conditions to ensure healthcare providers find joy and meaning in their work (Sikka et al., 2015). To facilitate such a transformation in healthcare systems, research describing interventions to minimize or prevent stress responses in healthcare providers must evolve (reviewed in Boyle, 2011). A critical first step in developing these interventions is conceptual clarity regarding the stress response of interest and its measurement through valid and reliable instruments. Historically, a corpus of terms has been used to describe the effects of healthcare-related demands and expectations on healthcare providers, including burnout and compassion fatigue (Boyle, 2011, Sabo, 2011a). Burnout refers to the lack of interest in work, exhaustion, and the physical and emotional collapse that evolves over time in response to a period of high workload; burnout is associated with many occupations. Compassion fatigue refers to an acute onset of physical and emotional responses that culminate in a decrease in compassionate feelings towards others because of an individual’s occupation. Over the last two decades, compassion fatigue has received considerable attention as an important stress response in nurses and the spectrum of healthcare providers (Boyle, 2011). While this has raised awareness of the work-related stress that healthcare providers face, some researchers have suggested that the term ‘compassion fatigue’ is problematic and ill-defined (Fernando and Consedine, 2014a, Ledoux, 2015). Others propose that tools purported to quantify compassion fatigue do not measure the construct or lack construct validity (Bride et al., 2007, Ledoux, 2015). Juxtaposed with the conceptual ambiguity surrounding the construct of compassion fatigue is increasing interest and evidence that compassion is a cornerstone of quality healthcare (American Medical Association, 2001, Flocke et al., 2002, Department of Health, 2008, Paterson, 2011, Francis, 2013). It is unsurprising therefore, that the identification of a lack of compassion as a key contributor to systemic healthcare failures in the United Kingdom was met with a collective and immediate call to action (American Medical Association, 2001, Institute of Medicine, 2004, Maclean, 2014). With compassion fatigue identified as a negative consequence of caring that could impact entire organizations (Compassion Fatigue Awareness Project, 2015), and recommendations that the delivery of compassionate care, particularly by nurses, should be enhanced, increased effort was directed toward identifying and addressing compassion fatigue in healthcare. However, after two decades of scholarship and more than 350 peer-reviewed publications on the topic, there is still no broadly accepted definition of compassion fatigue, its relationship to compassion is uncertain (Canadian Nursing Association, 2010), and reputed compassion fatigue interventions are increasingly criticized (Fernando and Consedine, 2014a, Ledoux, 2015).

To more accurately inform the development of valid measures and interventions that target the occupational stressors that nurses and providers across the spectrum of healthcare face, it is necessary to critically examine the concept of compassion fatigue in the healthcare literature. Therefore, the objectives of this study were 1) to perform a meta-narrative review encompassing the identification, conceptualization, measurement and management of compassion fatigue in healthcare providers, and 2) to determine the validity of compassion fatigue as a construct of scientific inquiry and as a descriptor of the work-related stress faced by healthcare providers.

Section snippets

Methods

A meta-narrative approach according to the RAMESES (Realist And MEta-narrative Evidence Syntheses: Evolving Standards) standards was used. The aim of a meta-narrative review is to clarify and critique an important, but complex and/or controversial topic. A meta-narrative synthesizes, by means of an over-arching narrative, heterogeneous topics that have been conceptualized and studied differently (Wong et al., 2013).

The phases of the meta-narrative review were conducted according to Greenhalgh

Results

A total of 90 documents on compassion fatigue were included in this meta-narrative review. Of these, 31 were observational studies, 11 were experimental studies, 3 were qualitative studies, 4 were concept analyses, and the remainder were theoretical documents. Empirical studies were conducted in the United States, Canada, Greece, Israel, Latvia, Spain, United Kingdom, Uganda, South Africa, Korea, Australia, and New Zealand. Types of providers investigated in these studies were nurses (n = 2444)

Discussion

This meta-narrative review examines the concept of compassion fatigue in the healthcare literature and demonstrates that there are multiple and conflicting theories on its nature. Compassion fatigue is a phenomenon adopted by nursing from psychotherapy that has been mostly studied in nurses. It has expropriated origins in crisis counseling, and has evolved into a contemporary and unquestioned euphemism for healthcare provider stress. While this has raised awareness of the nature, degree, and

Conflict of interest

None.

Funding

This study was supported through Dr. Sinclair’s Cancer Care Research Professorship (Faculty of Nursing, University of Calgary).

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