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Compassion fatigue in mental health nurses: A systematic review J Psychiatr Ment Health Nurs. 2022;29:529–543. wileyonlinelibrary.com/journal/jpm | 529© 2021 John Wiley & Sons Ltd. Received: 4 June 2021 | Revised: 24 November 2021 | Accepted: 30 November 2021 DOI: 10.1111/jpm.12812 R E V I E W A R T I C L E Compassion fatigue in mental health nurses: A systematic review Cameron Marshman1,2 | Alison Hansen1,2 | Ian Munro1,2 1School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia 2Australian College of Mental Health Nurses, Clayton, Australian Capital Territory, Australia Correspondence Cameron Marshman, School of Nursing and Midwifery, Monash University, Clayton, Vic., Australia. Email: cameron.marshman@monash.edu Funding information The authors declare nil funding sources to be disclosed Accessible Summary What is known on the subject? • Compassion fatigue is the result of the unique stressors inherent in caregiving work, leading to a loss of compassion in clinical practice that may result in nega- tive outcomes for mental healthcare consumers. • Compassion fatigue has clear emotional and physical costs and significant im- pacts on staff recruitment and retention. What the paper adds to existing knowledge? • This review is the first to evaluate the quantitative literature on compassion fatigue in mental health nurses. • Research on compassion fatigue in mental health nurses does not accurately ac- count for the unique care relationship between nurse and consumer. • Competency- based education, strong mental health nurse leadership, positive organizational cultures, clinical supervision and reflection alongside individual self- care strategies may mitigate compassion fatigue. What are the implications for future practice? • Resources are urgently needed for education and workforce development that addresses compassion fatigue in mental health nurses. • Interventions addressing the physical, cognitive and emotional demands of care work are needed to ensure mental health nurses have the capability to provide sustainable compassionate care to consumers. Abstract Introduction: Although compassionate care is an essential component of mental health nursing, understandings of the impact of compassion fatigue is poorly understood. Aims/Questions: To examine and synthesize available data on the prevalence of com- passion fatigue within mental health nurses and consider what variables impact com- passion fatigue. Method: A search of MEDLINE, EMBASE, PsychINFO, Emcare, Web of Science, Scopus, CINAHL and grey literature for articles published between 1992 and February 2021 was conducted. Data were extracted from articles meeting inclusion criteria and integrated using narrative synthesis. Results: Twelve articles were included. Prevalence of compassion fatigue ranged from low to high. Variables were identified that may mitigate the risk of compassion fatigue. Strong leadership and positive workplace cultures, clinical supervision, reflection, www.wileyonlinelibrary.com/journal/jpm mailto: https://orcid.org/0000-0003-2681-1015 mailto:cameron.marshman@monash.edu http://crossmark.crossref.org/dialog/?doi=10.1111%2Fjpm.12812&domain=pdf&date_stamp=2021-12-28 530 | MARSHMAN et Al. 1 | INTRODUC TION Compassion is often a core value of healthcare organizations and should underpin the delivery of high- quality mental healthcare (Cleary et al., 2015). The use of compassion by mental health (MH) nurses may help enhance consumers feelings of safety (Cutler et al., 2020) and has been associated with increased consumer participa- tion and engagement (Lloyd & Carson, 2011). However, compassion fatigue (CF) may reduce the capability of nurses to provide high- quality compassionate care (Salyers et al., 2015, 2017). The use of empathy and compassion by MH nurses makes them particularly susceptible to CF as they work closely with consumers on a daily basis and are constantly exposed to the emotional pain and trauma of others (Turgoose & Maddox, 2017). Despite potential negative impacts for MH nurses, consumers and families, and healthcare or- ganizations, our understanding of CF in MH is limited in comparison with the broader nursing profession and other healthcare disciplines. The immeasurable costs of CF are something healthcare organi- zation cannot afford to dismiss in a global environment experiencing critical MH nursing shortages. Nurse recruitment is a global concern (World Health Organization, 2018) and countries, such as Australia, are predicting an undersupply of 18, 500 MH nurses by the year 2030 (Health Workforce Australia, 2014). Moreover, retention data from a study in the United States found 17.5% of MH nursing graduates left the profession after 1 year and 33.5% of MH nurs- ing graduates departed the profession after 2 years (Pelletier et al., 2019). Current research has linked high CF to increased staff turn- over intention (Sung et al., 2012), and authors have argued CF has clear implications for sustainable workforce retention (Jakimowicz et al., 2018). In a global environment suffering with the stress and demands of COVID- 19 (Muller et al., 2020), healthcare organizations must acknowledge the economic and psychosocial impacts of CF, including the daily “brain drain” that is occurring. The impact of CF on MH nurses results in clear physical and emo- tional consequences for individual nurses (Melvin, 2012; Nolte et al., 2017; Todaro- Franceschi, 2019), including feeling physically ex- hausted and angry (Boyle, 2011), filled with a sense of helplessness and disconnectedness (Harris & Griffin, 2015) and reduces a nurses ability to feel empathy towards consumers and their families (Jenkins & Warren, 2012). Despite the economic, emotional and physical im- pacts of CF, the concept has received limited attention within the MH nursing research. Although CF has been recognized as a global area of concern across a variety of contexts and disciplines, the aetiology of CF is inconsistent. It has been suggested CF is perpetuated by personal, work- related and psychological factors (Yang & Kim, 2012). Other studies have noted significant differences in the aetiology of CF across varied areas of specialization (Branch & Klinkenberg, 2015; Yoder, 2010). The concept of CF was first defined as a unique form of burn- out that is inherent in caregiving work (Joinson, 1992). The term CF was later adopted by Figley (1995) and described as “a state of exhaustion and dysfunction, biologically, physiologically, and emo- tionally, as a result of prolonged exposure to compassion stress” (p. 34). Other authors contend CF may be better understood as moral distress (Forster, 2009), or as empathic distress fatigue (Klimecki & Singer, 2012). This review defines CF as being the end result of prolonged, cumulative exposure to stress and trauma (Ainsworth & Sgorbini, 2010; Coetzee & Klopper, 2010; Figley, 1995, 2002). Initial measures of CF focused only on the negative aspects of care and included subscale measures of burnout (BO) and later secondary traumatic stress (STS). These include the 40- item Compassion Fatigue Self- Test (CFST) that consisted of CF and BO subscales (Figley, 1995; Figley & Stamm, 1996). This was later re- vised to become the 30- item Compassion Fatigue Scale- Revised (CFS- R) containing BO and CF subscales (Adams et al., 2006). The concepts of BO and CF have been closely related from the outset, with the impacts of BO resulting in similar physical, emotional and cognitive impacts (Maslach, 1998). However, the most used mea- sure of CF today is the Professional Quality of Life scale (ProQOL) (Stamm, 2010). The ProQOL is a measure of the positive and nega- tive aspects of care work. The current version ProQOL- V consists of 30 items across three subscales consisting of compassion sat- isfaction (CS), BO and secondary traumatic stress (STS) (Stamm, self- care and personal well- being may protect mental health nurses against compas- sion fatigue. Discussion: Future research is needed on mental health nurses lived experience of compassion fatigue and their understandings of compassion. Implications for Practice: Interventions should focus on increasing awareness of com- passion fatigue and building individual and organizational resilience. Both organiza- tions and individuals should be aware of the role they play in maintaining the capacity and capability for mental health nurses to provide sustainable and compassionate mental healthcare. K E Y W O R D S compassion fatigue, mental health nurse, nurses, resilience, self- care, systematic review 13652850, 2022, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/jpm .12812 by U niversity O f N otre D am e, W iley O nline L ibrary on [20/07/2023]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense | 531MARSHMAN et Al. 2010). In previous versions, the STS subscale has measured CF, however, in the current version CF is defined as consisting of two components, BO and STS (Stamm, 2010). The most substantial change in measures of CF is the inclusion of the CS subscale. The term CS is defined as positive feelings derived from a person's work with others (Stamm, 2010). Its inclusion recognizes the po- tential protective impact positive aspects of the helping relation- ship may have in reducing the risk of CF. The ProQOL measure has been instrumental in researching the issue of CF globally and across healthcare disciplines. Studies have been conducted in America (Hunsaker et al., 2015), New Zealand (Severn et al., 2012), Australia (Hegney et al., 2014) and Korea (Lee & Yom, 2013) and within emergency departments (Hamilton et al., 2016; Hunsaker et al., 2015), intensive care units (Mason et al., 2014), oncology (Potter et al., 2010) and paediatrics (Branch & Klinkenberg, 2015). The consequences of CF have been iden- tified within various disciplines besides nurses including physi- cians (Huggard & Dixon, 2011); midwives (Beaumont et al., 2016); nursing students (Mason & Nel, 2012); and social workers (Adams et al., 2006). There are no consistently identified protective factors for CF across the literature. Potentially protective factors include in- creased age and experience (Berger et al., 2015; Sinclair et al., 2017); post- graduate education (Jakimowicz et al., 2018; Zhang et al., 2018); self- care (Alkema et al., 2008; Dasan et al., 2015), self- compassion (Beaumont et al., 2016), maintaining work– life bound- aries (Bourassa, 2012; Perry et al., 2011; Peters, 2018), emotional intelligence (Zeidner et al., 2013), positive teams (Dasan et al., 2015), and group cohesion and organizational commitment (Li et al., 2014). While some larger studies include data from MH nurses, for example Hegney et al. (2014), our understanding of perpetuating and protec- tive factors that may be unique to MH nursing is limited and is an area requiring further research. Our current understanding of the prevalence of CF in MH nursing is poorly understood. The prevalence of CF in healthcare providers is also unclear (Cavanagh et al., 2020). Additionally, de- spite the amount of research on CF across health care, two re- cent systematic reviews of interventions for CF have found limited evidence for any strategy to address CF (Blomberg et al., 2016; Cocker & Joss, 2016). In healthcare systems already overbur- dened from the COVID- 19 pandemic, the consequences of not acknowledging and attempting to address the impacts of CF are evident in recruitment and retention issues and have significant economic costs for healthcare organizations. However, ultimately, the impacts of CF fall upon MH nurses and the consumers and families for whom they care. 1.1 | Aims and questions This review aims to explore and describe the prevalence of CF in MH nurses in any MH care context and to consider the variables that influence CF. The research questions were as follows: 1. What is the prevalence of compassion fatigue in mental health nurses? 2. What variables affect compassion fatigue in mental health nurses? 2 | METHODS 2.1 | Search strategy The review was conducted in MEDLINE, EMBASE, PsychINFO, Emcare, Web of Science, Scopus, CINAHL, ProQuest dissertations and thesis global. Additionally, a search was undertaken of Google search engine. The search was conducted on 9 February 2021. Search terms included Community Mental Health Nursing/ OR Psychiatric nursing/ OR “mental health nurs*” OR “mental health clinician” OR “psychiatric nurs*” OR “psychiatric clinician” AND Compassion Fatigue/ OR “secondary trauma” OR “vicarious trauma” OR ProQOL OR “professional quality of life” OR “secondary trau- matic stress scale.” Related terms, such as secondary trauma and vicarious trauma, were included to ensure all relevant articles were captured during the search. Table 1 outlines the search strategy. 2.2 | Inclusion/exclusion criteria Studies were included if they utilized a quantitative design and a validated measure of CF within a population of nurses working in TA B L E 1 Review parameters Databases searched MEDLINE, EMBASE, PsychINFO, Emcare, Web of Science, Scopus, CINAHL, ProQuest dissertations and thesis global, and Google search engine Search terms Community Mental Health Nursing/ OR Psychiatric nursing/ OR “mental health nurs*” OR “mental health clinician” OR “psychiatric nurs*” OR “psychiatric clinician” AND Compassion Fatigue/ OR “secondary trauma” OR “vicarious trauma” OR ProQOL OR “professional quality of