Baqeas et al.

BMC Palliative Care (2021) 20:88

https://doi.org/10.1186/s12904-021-00784-5

RESEARCH ARTICLE Open Access

Compassion fatigue and compassion

satisfaction among palliative care health
providers: a scoping review
Manal Hassan Baqeas* , Jenny Davis and Beverley Copnell

Abstract
Background: Palliative care can be demanding and stressful for providers. There is increasing recognition in the
literature of the impact of caregiving in palliative care settings, including compassion fatigue and compassion
satisfaction. However, to date this literature has not been systematically reviewed. The purpose of this scoping
review was to map the literature on compassion fatigue and compassion satisfaction among palliative care health
providers caring for adult patients.
Methods: Scoping review method guided by Joanna Briggs Institute guidelines was conducted using four
electronic databases to identify the relevant studies published with no time limit. Following the title and abstract
review, two reviewers independently screened full-text articles, and extracted study data. A narrative approach to
synthesizing the literature was used.
Results: Twenty studies were included in the review. Five themes emerged from synthesis: conceptualisation of
compassion fatigue and compassion satisfaction; measurement of compassion fatigue and compassion satisfaction;
consequences of compassion fatigue or compassion satisfaction and providing care for patients with life-threatening
conditions; predictors or associated factors of compassion fatigue and compassion satisfaction among palliative care health
providers; and strategies or interventions to support palliative care health providers and reduce compassion fatigue.
Conclusions: Limited studies examined the effectiveness of specific interventions to improve compassion satisfaction and
reduce compassion fatigue among palliative care health providers. Further investigation of the impacts of compassion
fatigue and compassion satisfaction on palliative care health providers and their work is also needed.
Keywords: Compassion fatigue, Compassion satisfaction, Palliative care, Palliative care health providers, Scoping review

Background care in various settings such as dedicated hospital wards,

Palliative care aims to support people with life-threatening hospices, and community, and through consultancy to pa-
conditions and improve their quality of life [1]. Palliative tients in other areas [2].
care health providers (PCHP) comprise medical, nursing, Prolonged contact with these patients predisposes
and allied health care professionals who work in palliative PCHP to emotional and psychological distress such as
care settings and who have specific knowledge, skills, and compassion fatigue. There are various definitions of
expertise in providing care for people living with a life lim- compassion fatigue documented in the literature. In gen-
iting illness and their families. PCHP can provide direct eral, compassion fatigue is a term used to describe the
exhaustion that results from prolonged exposure to
* Correspondence: [email protected]
compassion stress among those who work in a caring
School of Nursing and Midwifery, La Trobe University, Bundoora, VIC 3086, profession [3]. Compassion fatigue is also described as
Australia

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Baqeas et al. BMC Palliative Care (2021) 20:88 Page 2 of 13

the diminished ability to feel compassion or empathize Charting the data 5. Collating, summarizing and report-
when providing care. In contrast, compassion satisfac- ing the results [12]. There is a sixth (optional) step that
tion is related to the pleasure derived from alleviation of includes consultation with key stakeholders. This step
patient suffering and positive work experience [4]. There was omitted, however, and only evidence published in
is no consensus in the literature on the dimensions or peer-reviewed literature was included.
components of compassion fatigue. However, there is a
general agreement that compassion fatigue is related to Stage 1. Identifying the research question
both burnout (BO) and secondary traumatic stress This review aims to identify what is known about com-
(STS). While STS is very closely related to compassion passion fatigue and compassion satisfaction among
fatigue, the nature of the relationship is defined differ- PCHP. To address the study aim, the review was con-
ently and both terms used interchangeably by some au- ducted to answer the following question: “what research
thors [4]. The concept of compassion satisfaction is has been undertaken on compassion fatigue and com-
related to positive work experience, whereas compassion passion satisfaction among palliative care health
fatigue is associated with physical and emotional exhaus- providers?”
tion, caused by constant, progressive, and cumulative
negative experiences associated with various clinical set- Stage 2. Identifying relevant publications
tings [3, 5, 6]. Compassion fatigue has negative impacts The review was conducted by a team of researchers in-
on job satisfaction and patient outcomes [7–9]. This em- cluding the primary researcher, content experts, and
phasizes the significance of investigating compassion fa- methodological experts. A search of four electronic data-
tigue in PCHP. bases: MEDLINE (OVID), CINAHL, PsycInfo, and
To date, compassion fatigue has been widely studied EMBASE was conducted in August 2019. To ensure a
in health care providers in a range of settings, as synthe- comprehensive search, the search terms “compassion fa-
sized in a recent meta-narrative review [10]. However, to tigue”, “compassion satisfaction”, and “palliative care
our knowledge, no such synthesis has been undertaken health providers” were initially kept broad and then ex-
of literature pertaining specifically to PCHP. This gap in ploded to cover MeSH terms. In addition, keywords in-
the literature makes it difficult to identify and implement cluded in the title and abstract of retrieved papers, and
interventions to support these workers. Therefore, the the keywords used to describe the articles were identi-
aim of this scoping review is to synthesize findings from fied. These keywords were searched across the databases.
extant research about compassion fatigue and compas- Finally, the reference lists of the selected articles were
sion satisfaction among PCHP. hand searched to identify additional studies. The terms
“compassion fatigue”, “compassion satisfaction”, and
Methods “palliative care health providers” were combined with
The scoping review, as a method, is suitable when the the following terms: “burnout, professional”, “stress dis-
study topic is abstract, broad, emerging, or multi- orders, post-traumatic”, “fatigue, compassion”, “second-
dimensional [11]. Scoping reviews are used to answer a ary trauma”, “secondary traumatic stress”, “secondary
broad question such as “what is known about the study traumatization”, “trauma, vicarious”, “traumas, second-
concepts?” [11]. It was, therefore, deemed suitable to ad- ary”, “traumatic stress, secondary”, “burnout, career’,
dress the aim of the current study. It answers the re- “burnout, occupational”, “burnout, professional”, “sec-
search question through a narrative synthesis of the ondary post-traumatic stress”, “hospice professionals”,
literature. In addition, it is used to summarize the “hospice, palliative care nursing”, “palliative care”, “pal-
current knowledge about a topic and identify knowledge liative medicine”, “terminal care”, “palliative supportive
gaps regardless of the quality of reviewed studies and care”, and “palliative treatment”. The Boolean operators
their design [11]. ‘AND’ and ‘OR’ were used to combine various terms and
The current scoping review was conducted based on concepts. All identified sources were stored in the End-
the guidelines published by the Joanna Briggs Institute Note reference program. Irrelevant records and dupli-
(JBI) [12]. These guidelines were developed based on the cates were excluded from the literature search. The final
previous work by Arksey and O’Malley [13] and Levac, screening of title/abstract and then full text was man-
Colquhoun, and O’Brien [14]. In addition, the literature aged in Covidence.
review followed the PRISMA-ScR checklist to provide Inclusion criteria were: 1. all research designs (e.g.,
clear details of the search protocol and enhance meth- quantitative, qualitative, mixed methods, and systematic
odological transparency [11]. As per the Joanna Briggs reviews); 2. addressing compassion fatigue and compas-
Institute guidelines, the following five stages were sion satisfaction from the perspectives of PCHP caring
followed: 1. Identifying the research question 2. Identify- for adult patients in any practice setting; 3. published in
ing relevant studies 3. Selection of relevant studies 4. English with no date limits applied. Exclusion criteria
Baqeas et al. BMC Palliative Care (2021) 20:88 Page 3 of 13

were: 1. grey literature (e.g., book chapters, theses, re- with one study from each of Australia, Canada, New
ports, and conference abstracts); 2. Non-research publi- Zealand, and India. The majority of the studies were
cations (eg editorials; discussion papers; opinion pieces); published within the last 5 years (n = 15). More than half
3. targeting volunteers working in palliative care settings; of the studies were correlational (n = 10), four studies
4. investigating BO without STS or Compassion Fatigue; were qualitative, one a quantitative descriptive study,
5. focusing on PCHP working with pediatric patients as one a pre-post study with control group, one pre-post
we consider pediatric palliative care has distinct differ- with no control group, two studies examined the psy-
ences from adult palliative care and can be considered a chometric properties of the Professional Quality of Life
speciality in its own right [15]. (ProQOL) scale, one paper was a systematic review.
Study populations included PCHP from several disci-
Stage 3. Publication selection plines (n = 14), only nurses (n = 3), or only physicians
After removal of duplicates, article titles and abstracts (n = 2).
were screened by two researchers independently. Dis- The samples in the included studies were recruited from
agreements were discussed and resolved by consensus various settings that provide palliative care (Table 1). One
among the research team. After full text screening, stud- study was conducted in inpatient hospices and hospitals
ies meeting all inclusion criteria were included in the [20]. One study was conducted in inpatient hospices [21],
final review. one in outpatient hospices [1], and one in hospice settings
without specifying whether inpatient or outpatient [22].
Stage 4. Charting the data One study was conducted in outpatient palliative care set-
A data extraction table was used to extract the data from ting [24]. Eight studies included participants from both in-
the included studies. Extracted data included country, patient and outpatient settings including hospices [16, 18,
year of publication, names of authors, study purpose, re- 19, 23, 28–30, 33]. However, the combination between
search design, study sample, and main study findings. inpatient and outpatient settings in these eight studies
The data extraction was conducted by one researcher was unclear and not described in detail. Six studies
and reviewed by the research team. Any disagreements included participants from settings that provide in-
in data extraction were resolved by consensus. Refer- patient and outpatient services without stating specif-
ences were managed utilising EndNote (version X9) and ically if all participants were recruited from inpatient,
included studies were imported to Covidence during the outpatient, or both [17, 25–27, 31, 32].
final screening. In line with the PRISMA-ScR standards
[11], no formal quality appraisal was undertaken as it Themes extracted from the included studies
was not intended to exclude any paper based on quality Five main themes were identified in the synthesis of the
assessment. included studies: 1. conceptualisation of compassion fa-
tigue and compassion satisfaction; 2. measurement of
Stage 5 data synthesis compassion fatigue and satisfaction; 3. consequences of
Narrative synthesis was employed due to the heterogen- compassion fatigue or satisfaction and of providing care
eity of the studies. The characteristics of the reviewed for patients with life-threatening conditions; 4. predic-
studies (i.e design, sample, settings, main variables, and tors or associated factors of compassion fatigue and sat-
publication year) were collated and summarized. Studies isfaction among PCHP; 5. strategies or interventions to
were summarized in a Table and a content analysis was support PCHP and reduce compassion fatigue. These
performed based on the tabulated data. Then, contents themes are described further in the following sections.
were translated into main themes. Lastly, the findings The summary of the included studies is shown in
were interpreted and compared with studies from other Table 1.
settings.
Theme 1- conceptualisation of compassion fatigue
Results Overall, the reviewed studies did not discuss the concep-
Overall, the initial search yielded 1822 records. After re- tualisation of compassion fatigue in depth. Their defin-
moving duplicates, 1085 records were screened for po- ition was mainly embedded in that used by the
tential relevance by title and abstract. Of these, 921 measurement tool and thus reflects changes in the con-
records were found to be irrelevant and 164 full-text ar- cept over time. Compassion satisfaction was defined by
ticles were screened. Finally, 144 articles were excluded some studies as a positive consequence of providing care
and 20 articles were included in the final review (Fig. 1). for acutely ill or traumatised patients (e.g., a sense of ac-
Studies were conducted in different countries worldwide, complishment and reward) [1, 18, 19, 22, 25, 30, 31].
the majority in a Western setting. Countries represented Some studies treated compassion fatigue as a single
were: United States (n = 9), Spain (n = 3), Israel (n = 3), discrete entity with no constitutive components [1, 21].
Baqeas et al. BMC Palliative Care (2021) 20:88 Page 4 of 13

Fig. 1 Flow diagram of search strategy

On the other hand, some studies treated compassion fa- in conceptualisation described in the previous section.
tigue as being synonymous with STS, and these terms The ProQOL-V includes two domains of compassion
were used interchangeably [20, 31, 32]. The remaining fatigue (composed of BO and STS) and compassion
studies conceptualized compassion fatigue as having two satisfaction. The ProQOL-IV measures three domains:
discrete components (STS and BO), each of which was compassion satisfaction, BO, and compassion fatigue/
measured separately [16, 18, 19, 22, 23, 25, 27–30]. The secondary trauma. The ProQOL-III measures three
qualitative studies did not specify a clear definition of domains: compassion satisfaction, BO, and compas-
compassion fatigue [17, 24, 26, 33]. sion fatigue. The 20-item compassion fatigue scale
(CFS) is a subscale of the 66-item Compassion Satis-
Theme 2: measurement of compassion fatigue and faction/Fatigue Self-Test for Helpers which measures
satisfaction compassion satisfaction, compassion fatigue, and BO.
The measurement tools used to assess compassion fa- The 13-item Compassion Fatigue Short-Scale mea-
tigue and compassion satisfaction among PCHP in- sures compassion fatigue in two dimensions (second-
cluded the 30-item professional quality of life scale ary trauma and job BO).
(ProQOL) scale, the 20-item compassion fatigue scale The most commonly used measure of compassion fa-
(CFS), and the 13-item Compassion Fatigue Short-Scale. tigue and compassion satisfaction among PCHP was the
The various versions of the ProQOL reflect the changes ProQOL scale (III, IV, and V versions), which was used
Table 1 Summary Table of Included Studies
Authors, Year, and Settings Design Sample Research Aims Outcomes
Country
Alkema et al. [1], USA Outpatient palliative Quantitative (Cross n = 37 Examine the relationships Self-care strategies were
care settings: home sectional survey) Hospice Professionals among self-care, compassion associated with decreased
hospice settings. including fatigue, compassion satisfac- levels of compassion fatigue
17 Registered Nurse tion, and BO among hospice and BO and higher levels of
5 Home Health Aide care workers. compassion satisfaction.
4 Social Worker
2 Volunteer Coordinator
3 Bereavement Professional
Baqeas et al. BMC Palliative Care

2 Chaplain
1 Administrative Assistant
2 Medical Director
2 Other.
Barnett, Ruiz [16], USA Both inpatient and Quantitative (Cross 90 hospice nurses. To study the role of self- Psychological distress can
outpatient palliative sectional survey) esteem in mediating the rela- decrease self-esteem, and
(2021) 20:88

care settings tionship between compassion thereby increase the risk of

Inpatient – hospices, fatigue and psychological dis- compassion fatigue.
hospitals, nursing tress among hospice nurses.
homes, other long-
term care facilities,
Outpatient – home
healthcare.
Bessen et al. [17], USA Medical centre – Qualitative (semi- 13 physicians. To describe compassionate There were variable ways for
unable to determine structured interviews) care provision by physicians delivering compassionate care.
if includes both during end-of-life care. Physicians need training in
inpatient and end-of-life care to overcome
outpatient settings. some barriers of providing
care on organizational and in-
dividual level.
Frey et al. [18], New Inpatient – hospital, Quantitative (Cross 256 registered nurses. To investigate BO and BO negatively associated with
Zealand hospice, residential sectional survey) compassion fatigue and their psychological empowerment
aged care, associated factors among & commitment & challenge
Outpatient – hospital, nurses in New Zealand. components of psychological
community hospice, hardiness. STS negatively
district nursing, associated with palliative care
general practice, education.
other community Compassion satisfaction
services. positively associated with
palliative care education,
psychological empowerment,
& both commitment &
challenge components of
psychological hardiness.
Galiana et al. [19], Brazil and Inpatient and Psychometrics Brazil/ (n = 161) To assess the reliability and Both Spanish and Portuguese
Spain. outpatient palliative Spain/ (n = 385) validity of the Spanish and the versions of the ProQOL show
care settings PCHP including doctors, Portuguese versions of the good psychometric properties.
including hospice nurses, psychologists, nursing ProQOL scale.
(Home-based assistants, social workers and
Page 5 of 13
Table 1 Summary Table of Included Studies (Continued)
Authors, Year, and Settings Design Sample Research Aims Outcomes
Country
palliative care other. (Individual providers
Social-health center number not specified)
unit palliative care
Hospital support
team
Hospice
Oncology unit
Intensive treatment
Baqeas et al. BMC Palliative Care

unit
Pediatrics unit of
palliative care
Others)
Heeter et al. [20], USA Inpatient hospice and (Pre-Post) one group 36 Hospice and PCHP Examine the effects of 6-week The 6-week technology-
hospital palliative including nurses, managers technology-assisted meditation assisted meditation technology
(2021) 20:88

care settings from the respective home program on emotional aware- successfully reduced compas-
hospice and palliative care ness, compassion fatigue, and sion fatigue/BO and increased
units, physicians, clerical, aides, BO emotional awareness among
social workers, and others. the study participants.
(Individual providers number
not specified)
Hill et al. [10] Various settings Systematic Review 547 PCHP across 9 studies To explore the effectiveness of Few interventions were helpful
interventions used to enhance to support palliative care staff
psychological wellbeing of and improve their well-being.
palliative care staff.
Hilliard [21], USA Inpatient palliative Two groups pre-post- n = 17 nurses, social workers, To examine the effectiveness Music therapy was effective to
care settings: hospice test group and chaplains (Individual of music therapy to reduce improve team building but
providers number not compassion fatigue and not reduce compassion
specified) improve team building of fatigue.
hospice workers.
Hotchkiss [22], USA Hospice settings Quantitative (Cross 324 Hospice care professionals Examine the relationship Participants had high levels of
from VITAS® sectional survey) including between compassion self-care and compassion satis-
Healthcare 68 Registered nurse satisfaction, BO, STS, and faction and low levels of STS
60 Chaplain mindful self-care and BO. Self-care strategies
48 Social worker can improve compassion
40 Home health aid satisfaction.
28 Licensed vocational nurse
20 Administrative
16 Management
14 Nurse practitioners
8 Physician
4 Music therapists
18Other
Kaur et al. [23], India Inpatient and Quantitative (Cross 65 PCHP including doctor, To explore the professional The authors concluded that
Outpatient palliative sectional survey) nurse, counselor, psychologist, quality of life among PCHP. implementing specific
care settings social worker, pharmacist, or interventions could be helpful
including hospice physiotherapist. (Individual to reduce STS and BO and
Page 6 of 13

(hospital and hospice number not specified). enhance compassion

Table 1 Summary Table of Included Studies (Continued)
Authors, Year, and Settings Design Sample Research Aims Outcomes
Country
at cancer palliative satisfaction among PCHP.
care centers)
Melvin [24], USA Outpatient palliative Qualitative (semi- 6 palliative care nurses Assess prevalence of Compassion fatigue had
care settings: home structured interviews) compassion fatigue, its negative physical and
health agency consequences, and methods emotional health impacts on
of coping with it among palliative care nurses.
palliative care nurses.
Baqeas et al. BMC Palliative Care

Montross-Thomas et al. [25], Can not determine Quantitative (Cross 390 hospice staff and To investigate the role of Hospice care providers who
USA the participants were sectional survey) volunteers (Individual practicing rituals to improve practice rituals were found to
recruited online providers not specified) professional quality of life have better professional
through a among hospice care providers quality of life.
membership list
serve of the National
(2021) 20:88

Hospice and Palliative

Care Organization
(NHPCO). All
participants were
hospice staff or
volunteers who were
emailed a description
of the study and a
Survey Monkey link
Mota Vargas et al. [26], Can not determine Qualitative (semi- 10 PCHP include nurses, To describe experiences of PCHP were found to go
Spain (purposeful sample) structured individual doctors and psychologists. palliative care workers over through various phases during
interviews) Individual providers number time their professional life.
not specified).
O’Mahony et al. [27], USA Can not determine Quantitative (Cross 66 PCHP including physicians, Examine the relationship Neuroticism was associated
Participants were sectional survey) nurses, chaplains, social between personality traits and with STS and BO.
recruited from a workers, and other. (Individual compassion fatigue in PCHP. Agreeableness was associated
group of 70 providers number not with compassion satisfaction.
professionals specified) Experience in palliative care
participating in a was associated with lower
continuing education levels of BO and increased
program on palliative levels of compassion
medicine in Midwest satisfaction.
Academic Medical
Center
Samson, Shvartzman [28], Both inpatient and Quantitative (Cross 144 PCHP including To identify the association STS was found to be
Israel outpatient palliative sectional survey) 47 Physicians between STS and significantly correlated with
care settings 97 Nurses peritraumatic dissociation clinical levels of peritraumatic
(hospital-based and/ among palliative workers. dissociation among palliative
or home-based pallia- workers.
tive care units)
Samson, Shvartzman [29], Both inpatient and Quantitative (Cross 241 participants providing To assess the relationship There was a significant
Israel outpatient palliative sectional survey) palliative care and primary between exposure to death relationship between exposure
care settings (end-of- care including and dying and professional to death and dying and
Page 7 of 13
Table 1 Summary Table of Included Studies (Continued)
Authors, Year, and Settings Design Sample Research Aims Outcomes
Country
life community- and 84 Physician quality of life in PCHP professional quality of life
hospital-based pallia- 157 Nurse among the study participants.
tive care units)
Samson et al. [30], Israel Both inpatient and Quantitative 1100 health care providers To assess the reliability and The Hebrew version of the
outpatient palliative (psychometric validity of the Hebrew version compassion satisfaction
care settings properties) of the 30-item ProQol scale subscale was found to show
including hospice good psychometric properties
Baqeas et al. BMC Palliative Care

(home- and hospital-

based hospice units
and of primary health
care providers, work-
ing in Clalit Health
Care Services and
Maccabi Health Care
(2021) 20:88

Services (the two lar-

gest health care or-
ganizations in Israel)
Sansó et al. [31], Spain Can not determine Quantitative (Cross 387 PCHP include doctors, To assess the relationships There was a significant
settings: member e- sectional survey) nurses, psychologists, nursing among Self-Care, Awareness, relationship among the study
mail list of the Span- assistants, social workers. professional quality of life, and variables consistent with the
ish Society of Pallia- (Individual providers number Coping with Death among awareness-based model of
tive Care not specified) PCHP. self-care.
Slocum-Gori et al. [32], Can not determine: Quantitative (Cross 630 PCHP including clinical, Examine the relationships Compassion satisfaction was
Canada The Canadian sectional survey) administrative, allied health among compassion fatigue, negatively associated with BO
Hospice Palliative workers and volunteers. compassion satisfaction, and and compassion fatigue. BO
Care Association (Individual providers number BO among palliative care and compassion fatigue were
(CHPCA) provided not specified) workers positively associated.
their membership Compassion satisfaction, BO,
mail-out for contact- and compassion fatigue
ing managers and differed significantly according
administrators of HPC to some characteristics of the
organizations. sample.
Zambrano et al. [33], Inpatient and Qualitative (one-on- 7 palliative medicine physician To assess experiences of The study participants were at
Australia. outpatient palliative one interview) specialists palliative medicine specialists high risk for compassion
care settings who provide care for dying fatigue. However, they used
including hospice patients, as well as the impact some coping strategies that
(inpatient unit/ of providing care for these reduced their stress.
hospice, a patients
consultation liaison
into tertiary and
other hospitals in the
region and a
community outreach
program)
Page 8 of 13
Baqeas et al. BMC Palliative Care (2021) 20:88 Page 9 of 13

in 11 studies [1, 18, 20, 22, 23, 25, 27–29, 31, 32]. This Theme 4: predictors or associated factors of compassion
scale measures compassion satisfaction, STS, and BO. fatigue and satisfaction
The items of each subscale are rated on a five-point Eleven articles provided data about the correlates of high
Likert-type scale. The scale has demonstrated excellent levels of compassion fatigue and poor compassion satis-
psychometric properties with Cronbach’s alpha of 0.80 faction among PCHP. In general, studies included PCHP
or more for its subscales [4]. from several disciplines. However, two studies had only
The Compassion Fatigue Scale (CFS) was used in only nurse samples and one study had both physician and
one study [21] which was a pre-post study. This tool is nurse samples. The synthesis of these studies is included
distinguished from the other tools by focusing more on below.
the helper and working environment. In addition, the In general, demographic, personal, and organisational
Compassion Fatigue Short-Scale was used in one study factors were associated with compassion fatigue and
[16]. This tool measures only compassion fatigue. Both compassion satisfaction among PCHP. Demographic fac-
the 20-item CFS and the 13-item CFS were reported to tors were found to be associated with compassion fa-
have adequate reliability and validity [16, 21]. Therefore, tigue in some studies. Slocum-Gori et al. [32] found that
all of the three tools have been utilised internationally employment status was associated with compassion fa-
with various populations. Apart from the psychometric tigue as part-time workers had lower scores than those
properties of these three measurement tools, authors did who worked full time. Additionally, they found that
not report any other evidence about their efficacy. In greater experience in palliative care was associated with
addition, they did not provide a rationale for their choice lower levels of BO. O’Mahony et al. [27] supported these
of these tools in their studies. results and found that duration of experience in pallia-
Four studies reported the levels of compassion fatigue tive care was associated with higher levels of compassion
and compassion satisfaction among PCHP. All four used satisfaction.
the professional quality of life scale (ProQOL) scale. In Personal factors were found to be associated with
the study of Frey et al., [18] about half (48.4%) of pallia- compassion fatigue in several studies. For example, hav-
tive care nurses had moderate to high levels of compas- ing a neuroticism personality trait was associated with
sion satisfaction. However, about a quarter of the increased levels of STS and BO among PCHP, while hav-
participants had high BO scores (26.8%) and more than ing an agreeableness personality trait was associated with
half (51.6%) had moderate STS [18]. O’Mahony et al. increased levels of compassion satisfaction [27]. In
[27] found that palliative medicine physicians had overall addition, psychological hardiness (e.g., commitment and
high levels of compassion satisfaction and low levels of challenge) were associated with lower BO and greater
BO and STS. Alkema, Linton, and Davies [1] found that compassion satisfaction [18]. Furthermore, practicing
the mean scores of compassion satisfaction, BO, and some personal rituals on specific occasions was associ-
compassion fatigue among hospice professionals were in ated with lower BO and more compassion satisfaction
the average range. Finally, Kaur, Sharma, and Chaturvedi among hospice staff [25]. Also, the ability to cope with
reported that, among palliative care providers, 49.2% had death was associated with lower levels of compassion fa-
an average level of compassion satisfaction, 53.8% had tigue and BO and higher compassion satisfaction among
an average level of BO, while 95.4% scored above 75th PCHP [31]. Greater exposure to death was also signifi-
percentile on STS [23]. cantly correlated with STS among physicians and nurses
employed in a palliative care unit [29]. In addition, high
Theme 3: consequences of compassion fatigue levels of dissociation (detachment) were associated with
Two studies, both qualitative, reported consequences of higher levels of STS [28]. Psychological distress was also
compassion fatigue among their findings. A study con- associated with increased compassion fatigue [16]. Fur-
ducted by Melvin reported that providing palliative care ther, using self-care strategies was associated with lower
and working with dying patients could contribute to levels of compassion fatigue and BO and higher levels of
compassion fatigue among PCHP [24]. The author also compassion satisfaction [1]. Further, mindful self-care
suggests that providing palliative care and working with was associated with more compassion satisfaction and
dying patients could contribute to physical and emo- less risk of BO among health care workers in the pallia-
tional consequences. PCHP reported feeling responsible tive care setting [22].
for patient care even after going home and leaving the Frey et al. found that organizational factors such as
workplace [24]. In addition to compassion fatigue, work- work-related empowerment could decrease BO levels
ing with dying patients likely affects many dimensions [18]. Furthermore, the authors found that STS was nega-
concerning mental health including feelings of guilt, sad- tively associated with previous palliative care education
ness, crying, thinking of death, remembering personal [18]. Kaur et al. concluded that receiving training in pal-
experiences with death, isolation, and grief [33]. liative care was associated with lower levels of BO and
Baqeas et al. BMC Palliative Care (2021) 20:88 Page 10 of 13

STS [23]. Kaur et al. found that professional orientation Crawford reported that PCHP highlighted supportive
was associated with compassion satisfaction, with nurses measures such as finding spiritual meaning, receiving
scoring lower levels than other health professionals [23]. support, and using both problem-focused and emotion-
Slocum-Gori et al. [32] found that compassion fatigue focused coping strategies [33]. Bessen, Jain, Brooks et al.
was negatively correlated with compassion satisfaction reported that physicians described sharing experiences
and positively correlated with BO. with their colleagues or using individual-based strategies
(e.g., improving self-awareness) to prevent compassion
Theme 5: strategies or interventions to support PCHP or fatigue [17].
reduce compassion fatigue
In one systematic review, Hill et al. identified multiple Discussion
interventions reported to improve wellbeing of PCHP; This scoping review mapped available evidence on com-
however, most were found to be ineffective in reducing passion fatigue and compassion satisfaction among
compassion fatigue [34]. Examples of these interventions PCHP in various palliative care settings. The current
include cognitive training, education, relaxation, and scoping review included all relevant studies regardless of
support [34]. Two of the included studies evaluated in- the publication year but the majority that met inclusion
terventions to reduce compassion fatigue among PCHP. criteria were published within the last 5 years (n = 16).
The first study by Heeter, Lehto, Allbritton, Day and This suggests that interest in compassion fatigue and
Wiseman examined the effectiveness of a 6-week medi- compassion satisfaction in the field of palliative care is
tation program delivered via smartphone apps to reduce increasing.
compassion fatigue among 36 PCHP [20]. The single Themes that emerged in this review were also reported
group pre and post-test study design reported a signifi- by previous reviews focusing on other health profes-
cant reduction in compassion fatigue after the interven- sionals in non-palliative care settings. In a meta-
tion [20]. Another study conducted by Hilliard [21] narrative review related to compassion fatigue in health
investigated the effectiveness of a music therapy inter- literature, the main themes that emerged were related to
vention to reduce compassion fatigue in a sample of 17 predictors/risk factors of compassion fatigue, its conse-
hospice workers. Participants were randomly assigned to quences, conceptualization, and measurement [10]. An-
an ecological music therapy group and a didactic music other review related to compassion fatigue in cancer
therapy group. A pre-and post-test was performed to care providers included themes related to compassion
measure compassion fatigue levels. The results indicated fatigue prevalence, measurement, and management [35].
no significant differences in compassion fatigue between These reviews reported various predictors/risk factors
pre-and post-test scores of compassion fatigue in either and consequences of compassion fatigue that are, to
group [21]. some extent, similar to these reported in the current
Four qualitative studies reported strategies to support study.
PCHP from the perspectives of the study participants Findings in our review suggest a general agreement
[17, 24, 26, 33]. These studies did not actually measure that compassion satisfaction reflects a sense of accom-
the effectiveness of these strategies. However, the re- plishment and reward of providing care for patients [1,
searchers interviewed PCHP and asked them to list 18, 19, 22, 25, 30, 31]. However, there was no consensus
strategies they believed helped to protect them from on the definition of compassion fatigue in palliative care
compassion fatigue. Palliative care nurses in the study by settings. While some studies treated compassion fatigue
Melvin described adopting various strategies including as a single discrete entity, or synonymous with STS [20,
setting professional boundaries, seeking support from 31, 32], it was considered a multi-dimensional concept
colleagues and supervisors, reflection, physical exercise, by others [16, 18, 19, 22, 23, 25, 27–30]. The multi-
and social activities out of work [24]. In the study of dimensionality of compassion fatigue is further compli-
Mota Vargas et al. researchers interviewed PCHP and cated because it is informed by different theories that in-
asked them to identify the self-care strategies they used form the definition of compassion fatigue [10, 36]. This
[26]. Participants reported that reflecting on their experi- renders the development of a unified meaning of com-
ence of providing palliative care, understanding the passion fatigue difficult. This also resulted in the vari-
methods used to enhance self-control, and acknowledg- ability of the domains or subscales of the measures used
ing one’s limits and accepting the fact that many things to assess compassion fatigue. Most of the included stud-
cannot be changed and learning to live with them were ies used the ProQOL scale which assessed BO and STS
the most commonly used strategies. Other self-care as components of compassion fatigue rather than report-
strategies included attending training in palliative care, ing an overall score for compassion fatigue.
improving their communication skills, and developing Compassion is a central concept for PCHP who pro-
personal hobbies [26]. Zambrano, Chur-Hansen, and vide care for people with life limiting conditions. The
Baqeas et al. BMC Palliative Care (2021) 20:88 Page 11 of 13

more empathic a palliative care provider becomes, the explicating this content. We recommend that PCHP
more likely compassion fatigue will occur. Therefore, it undergo specific education/training in this area, whether
is important to educate PCHP to modify empathetic through formal programs or continuing professional
ability in response to prolonged work with patients development.
needing palliative care. The human nervous system plays A number of interventions have been shown to reduce
an important role in regulating the empathetic response compassion fatigue and improve compassion satisfaction
of the individual. Recent literature has shown that em- across a wide range of populations [39, 40]. However,
pathy is influenced by nervous system stimulation and it few intervention studies were conducted specific to the
may lead to empathic distress [37]. field of palliative care. Only two of the included studies
The literature review revealed various organizational in this review involved interventions and measured their
factors (e.g., work-related empowerment, receiving train- effectiveness to mitigate compassion fatigue and improve
ing in palliative care, and being recognized as a palliative compassion satisfaction among PCHP. Only one of the
care nurse) and demographic factors (e.g., employment tested interventions (The 6-week technology-assisted
status as part-time workers or full time and experience meditation) was found to be effective in reducing com-
in palliative care) associated with compassion fatigue passion fatigue. Despite this, many descriptive or correl-
and compassion satisfaction across PCHP. Further, it ational studies pointed to such interventions. Other
was noted that some personal factors associated with studies investigated strategies to support PCHP using
compassion fatigue and compassion satisfaction were self-report data with correlational or qualitative ap-
nonmodifiable (e.g., neuroticism personality trait and proaches rather than actually implementing these strat-
psychological hardiness). Additional factors included egies or measuring their effectiveness [17, 24, 26, 33].
personal variables such as practicing some personal rit- Therefore, most of the knowledge regarding the inter-
uals, the ability to cope with death and self-care, levels ventions used to mitigate compassion fatigue and im-
of dissociation, using self-care strategies and mindful prove compassion satisfaction among PCHP is informed
self-care. Therefore, it can be concluded that compas- by low level evidence. Furthermore, while there is some
sion fatigue and compassion satisfaction are predicted by overlap between palliative care and other health care
many factors, some of which may not be modifiable. specialties, there are also aspects that are unique to pal-
The majority of studies included participants from liative care. Therefore, it cannot be assumed that re-
multiple work settings (hospital, hospice and community) search undertaken in other specialty areas can be
and none compared findings across settings or attempted applied to PCHP, and we recommend interventions be
to differentiate between them. Given that work in the vari- tested in this population.
ous settings can vary considerably, the incidence and ex-
perience of compassion fatigue may also vary. Future Strengths and limitations
research should explore the impact of work setting on The strengths of this review include conducting a com-
compassion fatigue and compassion satisfaction. prehensive search with no limits on publication dates. In
Receiving palliative care training or education was addition, studies that used concepts related to compas-
found to help reduce the likelihood of developing symp- sion fatigue but did not examine the concept directly
toms of compassion fatigue [18, 23, 38]. None of these (e.g., empathy, moral distress) were excluded from the
studies explored the content of education programs to literature search to make the search methodology more
identify which aspects induced this effect. Studies in non- rigorous. Nevertheless, the review has some limitations.
palliative care settings have investigated training programs First, some relevant studies may have been missed des-
specifically focused on reducing or preventing compassion pite using a rigorous search strategy. This could occur
fatigue. For example, in a Pre- Post- test study conducted due to the complexity of compassion fatigue terms and
to examine the effect of Mindful Self-Compassion (MSC) inconsistencies in its conceptualisation across different
training on compassion fatigue and resilience among studies. Second, only publications written in English
nurses working in various settings, there was a significant were included which limits generalisability and may
reduction in the scores of secondary trauma and BO after introduce language bias. The limited number of studies
the intervention [39]. Another study reported a significant examining compassion fatigue in palliative care settings
reduction in participants’ compassion fatigue and BO and may warrant conducting a broad search in all languages.
improvement in compassion satisfaction after Compassion Grey literature was excluded, which may introduce pub-
Fatigue Specialist Training for mental health professionals lication bias.
[40]. It would seem likely given the nature of palliative The results of this review highlight a gap in the litera-
care work that specialist education programs would in- ture examining impacts of compassion fatigue and com-
clude a focus on similar self-care activities; an examination passion satisfaction on PCHP. This gap in the literature
of the curricula of these programs would be useful in demonstrates the need for further research on the
Baqeas et al. BMC Palliative Care (2021) 20:88 Page 12 of 13

impacts of compassion fatigue and compassion satisfac- conduct of the study, nor in the writing of the manuscript. No other funding
tion on PCHP. Therefore, as nurses make up a signifi- was received.

cant proportion of the palliative care health provider

Availability of data and materials
workforce, we recommend exploring the impact of Data used in this manuscript consist of published articles which cannot be
compassion fatigue and compassion satisfaction on shared by the authors for copyright reasons but are available through
productivity among palliative care nurses. Targeting a subscription to the relevant journals/databases.

homogeneous sample of nurses is also recommended

Declarations
since the included studies predominantly involved
heterogenous samples of PCHP rather than specifically Ethics approval and consent to participate
nurses. Research is also required to understand whether Not applicable; no original data.
and how the experience of compassion fatigue and com-
Consent for publication
passion satisfaction may vary across different work envi- Not applicable; no details, images, or videos relating to individual persons
ronments. In addition, there is a need to conduct included.
interventional studies to identify the most effective strat-
egies, including education or training, to reduce compas- Competing interests
The author(s) declare no potential conflicts of interest with respect to the
sion fatigue among PCHP. manuscript, authorship, and/or publication of this article.

Received: 8 August 2020 Accepted: 1 June 2021

Conclusion
This review sought to identify current evidence about
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