Running head: EDUCATION AND COMPASSION FATIGUE

Utilizing Education to Combat Compassion Fatigue in an Outpatient Psychiatric Setting
Elizabeth Peeples
Arizona State University
Archives of Psychiatric Nursing

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EDUCATION AND COMPASSION FATIGUE

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Abstract
Aim: To determine the change in provider’s compassion fatigue after implementing an
education-based intervention in behavioral health.
Materials and Methods: A four-part education-based intervention for compassion fatigue was
implemented over the course of 16 weeks. The Professional Quality of Life instrument was used
to measure compassion fatigue and compassion satisfaction.
Results: Although not statistically significant, mean compassion fatigue scores decreased in the
sample.
Conclusion: Based on these results, further exploration into the causative factors of compassion
fatigue in behavioral health are recommended.
Keywords: Compassion fatigue, behavioral health, psychiatry, education

EDUCATION AND COMPASSION FATIGUE

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Utilizing Education to Combat Compassion Fatigue in an Outpatient Psychiatric Setting
Compassion fatigue is a challenge which can beset even the most resilient of healthcare
professionals. The manifestation of compassion fatigue within an individual or organization
often results in increased staff turnover, decreased workplace initiative, and poor patient
outcomes (Henry, 2014). Causative factors of this phenomenon include lack of regular
screening, failure to practice self care, and ongoing care of patients with high acuity diagnoses
(Franza, Del Buono, & Pellegrino, 2015). Fortunately, several interventions for compassion
fatigue have been identified, with education-based interventions being one of the most
efficacious.
Background and Significance
Compassion fatigue is a state of physical or psychological distress in caregivers, the
consequence of participating in an ongoing and demanding relationship with clients (Henry,
2014). Compassion fatigue can occur in any environment, but it tends to be most pronounced in
acute settings such as psychiatry, oncology, and emergency medicine (Boyle, 2011). Hallmark
symptoms of compassion fatigue include feelings of irritability, frustration, exhaustion,
depression, anger, and avoidance. As such, compassion fatigue can greatly impede an
individual’s ability to effectively assess and provide care for patients. Fatigued caregivers report
difficulty providing safe care, conducting thorough assessments, and therapeutically
communicating with their clients (Boyle, 2011). Additionally, compassion fatigue negatively
impacts the workplace by increasing the number of missed days of work, staff turnover, and by
reducing initiative within the workplace (Henry, 2014).
A number of benefits would be derived from the alleviation of compassion fatigue,
including fewer missed workdays, decreased staff turnover, increased morale, and increased

EDUCATION AND COMPASSION FATIGUE

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initiative in the workplace (Raab, 2014). In reducing compassion fatigue, providers have the
energy, empathy, and patience to initiate, develop, and maintain a therapeutic relationship with
their clients (Boyle, 2011). Overall, a reduction in compassion fatigue has the potential to further
advance staff toward the ultimate goal of providing higher quality patient care.
When analyzing compassion fatigue in a behavioral health care setting, Boyle (2011)
notes that healthcare professionals working with acutely ill psychiatric patients are at great risk
for developing compassion fatigue. In psychiatry, high acuity diagnoses include Cluster B
personality disorders: Antisocial Personality Disorder, Borderline Personality Disorder,
Narcissistic Personality Disorder, and Histrionic Personality Disorder (Franza, Del Buono, &
Pellegrino, 2015). These personality disorders encompass maladaptive patterns of behavior
which are pervasive, inflexible, and often include overly affectual patterns of response, poor
impulse control, unrealistic perceptions and expectations of others, and difficulty engaging in
interpersonal relationships (Barkley, 2015). Additionally, these disorders often present with
angry, aggressive, and dramatic emotional behaviors. This violence can greatly tax the emotional
welfare of mental health professionals, ultimately leading to compassion fatigue (Franza, Del
Buono, & Pellegrino, 2015). Providers with compassion fatigue tend to conduct less thorough
assessments of their patients (Henry, 2014), are more inclined to make medication errors, and are
less likely to report these errors (Reimer, 2013). Additionally, therapeutic engagement, a vital
tool in mental health care, is also negatively impacted (Boyle, 2011). Mental health care
professionals suffering from compassion fatigue report an inability to establish and maintain a
therapeutic relationship with their patients; irritability, lack of patience, emotional exhaustion,
and feelings of numbness act as a blockade in the communication between the provider and the
patient (Boyle, 2011).

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A majority of interventions for compassion fatigue highlight the concept of education.
Awareness and education of symptoms and causative factors of compassion fatigue (Henry,
2014), the regular implementation of mindfulness techniques and coping strategies (Raab, 2014),
and continued, purposeful efforts toward self-care (Henry, 2014), are among the most efficacious
interventions. When used in conjunction, these interventions can greatly reduce feelings of
compassion fatigue among healthcare providers (Mathieu, 2007). The purpose of this evidencebased practice project was to determine the change in healthcare professionals’ compassion
fatigue after implementing an education-based intervention in behavioral health. Thus, providing
educational materials about compassion fatigue which consisted of identifying symptoms,
causative factors, and self-care activities, as compared to current practice, may assist in
decreasing the level of compassion fatigue that is experienced by mental health care
professionals.
The purpose of this study was to determine if an education-based intervention decreased
the perceived level of compassion fatigue in staff in an outpatient psychiatric clinic. Thus, the
compelling clinical question to be answered by this study was: For direct care staff working in an
outpatient psychiatric setting, will providing an educational intervention to increase selfawareness of compassion fatigue consisting of identifying symptoms, causative factors, and
coping strategies, as compared to current practice, decrease the level of compassion fatigue that
is experienced by staff in a 16-week period?
Search Strategy
A search was conducted via CINAHL, Pubmed, PsycINFO, and The Cochrane Library.
Index terms used in the search included compassion fatigue, nursing, psychiatric, mental health,
education, and interventions. Limits included English language, adults: 18+ years, peer-

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reviewed, and publication dates from January, 2011 to January, 2016. The CINAHL search
yielded 6 results, the Pubmed database yielded 8 results, the PsycINFO database yielded 10
results, and The Cochrane Library yielded 6 results.
Critical Appraisal and Synthesis
A literature review was conducted to ensure that all relevant evidence was identified. The
evidence was then appraised via the utilization of rapid critical appraisal (Melnyk & FineoutOverholt, 2014), and ten studies were selected for final inclusion based upon the reliability and
validity of their evidence (Appendix D).
Several themes were derived from the critical appraisal of these studies and their
interventions. All proposed interventions were low-risk, non-invasive, and incorporated either
educational training and/or promotion of self-care (Appendix B). While not every study
exhibited statistical significance, all studies demonstrated a negative correlation between the
education-based intervention and compassion fatigue without any adverse side effects. Each of
the education-based interventions could be conducted in both an inpatient or outpatient setting,
and providers in both medical and behavioral health care derived benefit from implementation of
the interventions. Since evidence suggests that a decrease in compassion fatigue and its
derivatives may reduce staff turnover and requested time off, an education-based intervention
may provide a potential cost benefit and subsequent increase in quality of patient care.
Evidence-Based Practice Model for Implementation
The Rosswurm and Larrabee model served as the Evidence-Based Implementation Model
for this study (Appendix C). The Rosswurm and Larrabee model consists of six formulated steps
which utilize critical-thinking and decision-making skills in order to safely and effectively
implement evidence-based changes (Rosswurm & Larrabee, 1999). These steps include assessing

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a need for change within the practice, linking problem interventions and outcomes, synthesizing
best evidence, designing a practice change, implementing and then evaluating the change in
practice, and finally integrating and maintaining the change in practice (Rosswurm & Larrabee,
1999).
Theoretical Framework
The Theory of Transpersonal Caring was chosen to guide the project, utilizing a
framework that focuses upon the interactions between the caregiver and patient. The framework
is composed of several processes which assist the caregiver in highlighting positive experiences,
such as love and caring, versus negative experiences, such as death, trauma, abuse, and illness
(Zehr, 2015). These processes may be extremely beneficial when utilized by caregivers
experiencing compassion fatigue; when adhered to, the processes assist the caregiver in focusing
upon positive experiences rather than the negative experiences that precede compassion fatigue.
Implementation Plan
Planning: A pre/post design was used to measure the implementation of an educationintervention on compassion fatigue using a convenience sample of 13 staff employed as direct
care providers.
Protection of Human Subjects: The project received Institutional Review Board approval from
Arizona State University as exempt from oversight. Before collecting both the pre and post data
for the project, all participants were informed about the purpose of the project, its duration, and
the procedures involved. Additionally, all participants were reminded that participation was
voluntarily, that they could choose to stop participating at any time, and that their identities and
all data collected during the project would be kept anonymous.
Participants and Setting: The project was conducted in an outpatient psychiatric clinic. All direct

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care providers at the outpatient clinic were invited to participate in the project. The clinic is
located in the Southwestern United States and provides outpatient behavioral health services to
children and adults. Commonly treated diagnoses at the clinic include Attention-Deficit
Disorder, Major Depressive Disorder, Bipolar Disorder, Generalized Anxiety Disorder,
Schizophrenia, and various personality disorders.
Inclusion and Exclusion Criteria: Inclusion criteria consisted of English-speaking full and parttime advanced practice nurses, physician assistants, behavioral therapists, and supporting staff
employed at the outpatient clinic. Individuals were required to be actively providing direct
patient care. All participants were 18 years or older and able to give consent. Those who did not
provide direct patient care, such as administrative and non-clinical staff, were excluded from the
project.
Data Collection: Data was collected before and after a series of three evidence-based educational
presentations on compassion fatigue. Both the pre and post survey instruments were distributed
in a paper-and-pencil format. The first page of the survey was a consent page; participants were
asked to read and checkmark this page before continuing with the rest of the survey. If the
participant chose not to checkmark the consent page, then that participant did not complete the
rest of the instrument and did not participate in the study. To avoid identifying information, the
next page of the survey asked participants to create a randomized code. For post intervention
data collection, the participant was asked to recreate the code in order to link the first and second
survey and thus compare pre and post data.
Demographics: Participants were asked five questions regarding their characteristics, including
gender (male/female), profession (advanced practice nurses, physician assistants, behavioral
therapists, or support staff), years of experience (in number of years), employment status (full

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time/part time), and past recognition of work (ever been recognized by employer yes/no).
Practice Change Implementation: Following the conclusion of monthly, mandatory staff
meetings, participants were asked to voluntarily attend a series of three education-based
interventions to improve their knowledge regarding compassion fatigue and its causative factors
in the field of psychiatry once a month over the course of 16 weeks. The interventions were
designed specifically for the project and given as presentations. The presentations included
visual displays on a large screen and an oral presentation by the primary author to the
participants. Since the literature strongly suggests that compassion fatigue may be alleviated
through an education based-intervention (Henry, 2014, Raab, 2014, Mathieu, 2007), the
presentations consisted of information specific to compassion fatigue and its causative and
alleviating factors in psychiatry. The first educational presentation conveyed information
regarding the definition of compassion fatigue, its hallmark symptoms, and the overall effects of
compassion fatigue on individual and workplace performance. The second presentation
highlighted the potential alleviating factors of compassion fatigue, specifically focused on the
necessity of psychiatric staff regularly engaging in self-care activities. These activities were
explained in great detail during the presentation; including improved sleep and diet, diversified
patient assignments, engagement in a hobby, pursuit of spiritual connectivity, and regular
engagement in supervision and mentorship. The third presentation focused upon the potential
causative factors of compassion fatigue in the field of psychiatry. Thus, the presentation
conveyed information regarding Narcissistic Personality Disorder, Antisocial Personality
Disorder, Borderline Personality Disorder, and Histrionic Personality disorder. Information
regarding the definitions, behavior patterns, and theory of origin were presented for each of the
disorders. Furthermore, the presentation highlighted several methods for improving therapeutic

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engagement with these patients. Attendance to these educational presentations was voluntary and
supported by the facility and leadership but, to participate in the post survey, participants' had to
attend all three presentations. Before the start of each presentation, participants were verbally
reminded that their attendance was not mandatory, and that they could leave the presentation at
any time. Paid time was not offered for attending the presentations.
Quality Improvement Questions: The second survey contained four quality improvement, openended questions regarding the participant's views on compassion fatigue in behavioral health
(Appendix B). The purpose of these questions was to conduct quality improvement by obtaining
additional data on reducing compassion fatigue in staff.
Professional Quality of Life Scale (ProQOL 5): Compassion fatigue was measured using the
Professional Quality of Life Scale (ProQOL version 5) (Stamm, 2010). The ProQOL is a
standardized instrument consisting of 30 questions which are scored on a Likert-type scale. The
scale is then further broken down into three sub-scales which measure compassion satisfaction,
burnout, and secondary trauma. Burnout and secondary trauma are components of compassion
fatigue, and compassion satisfaction is the satisfaction that an individual derives from their work.
When the scales are scored and assessed in conjunction, information regarding the positive and
negative consequences of caregiving, such as compassion fatigue, can be deduced.
Statistical Analysis: The SPSS 24 statistical package program was used to assess the data.
Descriptive analysis, including means, frequencies, and percentages were used to describe the
sample. Spearman correlations were used to examine the relationship between the outcome
variables and the demographic descriptive characteristics of the participants. The Wilcoxon
Signed Ranks Test was used to assess the difference in means between the participants’ pre and
post intervention scores in the outcome variables of burnout, secondary trauma, and compassion

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satisfaction. The level of significance was set at p < 0.05.
Results
Thirty-two out of a potential eighty-six direct care providers initially participated in the
pre intervention data collection with 13 providers completing the post-intervention. The
recidivism rate was 40.6%. The majority of the 13 participants were female (76.9%), employed
full-time (92.3%), working as behavioral therapists (46.2%), and had not received any past
awards or recognition related to their work performance (69.2%). Participants had either 1- 4
years of work experience (38.5%), or 5-10 years (38.5%) (Figure A1). Per the ProQOL selfscoring measure, this population also exhibited lower than average mean scores for burnout and
secondary traumatic stress; the mean burnout score was 20.54 (SD = 4.50), and the mean
secondary traumatic stress score was 20.31 (SD = 3.38). Per the ProQOL self-scoring measure,
this population also exhibited average mean scores for compassion satisfaction; the mean
compassion satisfaction score was 40.69 (SD = 3.90) (Figure A2).
Nonparametric analysis using a Wilcoxon Signed Ranks Test determined that no
statistically significant relationship existed between the pre and post intervention scores; burnout
(p= .205, p< 0.05), secondary traumatic stress (p= .556, p<0.05), and compassion satisfaction
(p= .234, p<0.05).
Each of the 13 participants completed the four quality improvement, open-ended
questions regarding the participant's views on compassion fatigue in behavioral health. Common
themes identified within the responses included subjective feelings of compassion fatigue related
to high patient volume and high workload (Appendix B).
Discussion
The purpose of this EBP project was to evaluate whether the implementation of an

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education based intervention reduced compassion fatigue in behavioral health providers.
Although staff had anecdotally reported strong feelings of compassion fatigue before the start of
the study, study results indicated the sample demonstrated average levels of burnout, secondary
traumatic stress, and compassion satisfaction according to published cutoff levels by the ProQOL
manual. However, the scores found in this sample align with previously published burnout,
secondary trauma, and compassion satisfaction scores for nurses in the literature (Flarity et. al,
2016; Hunsaker, Chen, Maughan, Heaston, 2015; Kelly, Runge, Spencer, 2015). One
explanation may be the established normative values are based on a sample of all professions
that submit scores for inclusion in the ProQOL database. Additionally, this discrepancy in
subjective versus objective data may be explained by the fact that negative perceptions of the
workplace may possibly be correlated with subjective feelings of burnout (Thompson, Amatea,
Thompson, 2014). Indeed, participants’ negative perceptions of the workplace were captured via
the quality improvement questions administered during the post ProQOL. According to themes
identified in the responses (Appendix B), participants expressed dissatisfaction with the high
number of patients that must be seen each day, and the short amount of time allotted to see these
patients. In a previous study conducted by Yada et al. (2014), psychiatric nurses were found to
have greater than average workloads when compared to other nursing fields. This is because
behavioral health does not solely focus upon mental health. Rather, psychiatric nurses are
required to care for both the mental and physical needs of patients. When coupled with severe
time restraints and high volume, these increased care demands can result in increased
quantitative overloads of physical and mental workloads which, in turn, can lead to an overall
increase in subjective feelings of stress and exhaustion (Yada, Lu, Omori, Abe, Matsuo, Ishida,
& Katoh, 2014). Although participants’ burnout levels are not yet significant, evidence suggests

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that compassion fatigue may develop if the negative perceptions of the workplace persist.
Another important finding deduced includes participants reporting causative factors
which differed from those identified in the literature. According to the literature, patients
exhibiting impulsive, violent, and dramatic behaviors (such as individuals with cluster B
personality disorders), are one of the greatest causative factors of compassion fatigue in
behavioral health (Boyle, 2011). However, according to the themes identified in the responses to
the quality improvement questions administered during the post ProQOL (Appendix B),
participants did not identify the cluster B personality disorders as a causative factor of
compassion fatigue. Rather, most participants reported that they were more negatively affected
by the high number of patients which they were required to see each day, and the substantial
workload which accompanies each of these patients. Indeed, the literature suggests that large
caseloads coupled with lack of leadership support can increase workplace stress and thus
potentially lead to burnout and increased compassion fatigue (Flarity, Rhodes, & Reckardl,
2016). In behavioral health, literature suggests that perceptions of workload have a significant
influence upon the provider’s emotional exhaustion and tendencies toward depersonalization,
and thus high workloads may indeed increase the likelihood of compassion fatigue development
in behavioral health professionals (Bogaert, P., Clarke, S., Wouters, K., Franck, E., Willems, R.,
& Mondelaers, M, 2013). Thus, further study regarding the causative factors of compassion
fatigue in behavioral health may be warranted.
Although evidence suggests that education-based interventions are one of the most
efficacious methods for alleviating compassion fatigue, the implemented EBP project did not
result in a statistically significant decrease in compassion fatigue. However, although not
statistically significant, levels of burnout and secondary traumatic stress decreased after the

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education intervention, demonstrating positive trends for improvement possibly subsequent to
the implementation of the education-based intervention (Figure A2).The goal of the education
based intervention incorporated the current evidence regarding the symptoms and causative
factors of compassion fatigue (Henry, 2014), and the importance of continued, purposeful efforts
toward self-care (Henry, 2014), to result in reduced feelings of compassion fatigue among
healthcare providers.
Strengths and Limitations of the EBP Project
Several possible limitations may explain the outcome. First, data may have been skewed
by the unequal number of participants in the pre and post interventions; although 32 staff
members initially participated, the project consisted of 13 pre and post paired compassion fatigue
assessments for analysis. The small sample size may have skewed the results in that those who
participated may have differed from those who did not. Secondly, the education-based
intervention may require revision. Data analysis demonstrated a patterned decrease in burnout
and secondary traumatic stress and an increase in compassion satisfaction which suggests that an
education-based intervention may indeed be an efficacious means of alleviating compassion
fatigue in behavioral health. However, the intervention may need to be implemented in a shorter
time span rather than over 16 weeks. Additionally, the education regarding causative factors of
compassion fatigue may need to be revised to include high workload and volume rather than
Cluster B personality disorders. Despite its limitations, it should be noted that the project also
exhibited several strengths. As a whole, the project was evidence-based and utilized an
intervention supported by the literature. A validated tool, the ProQOL, was used as the
instrument of measurement, and the participants of the project were interprofessional and thus
created a well-rounded and diverse sample group.

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Future Implications and Conclusion
Although this study did not find a statistically significant decrease in compassion fatigue
after implementing the evidence-based intervention, the findings contribute to the current body
of knowledge regarding compassion fatigue in behavioral health, and advanced quantitative
studies should be conducted to further determine the causative factors of compassion fatigue in
psychiatry. Additionally, this information should then be incorporated into an education-based
intervention and implemented within a psychiatric setting determined to have higher than
average burnout and secondary traumatic stress scores. This will allow behavioral health
professionals to self-identify, deduce the cause of, and independently engage in activities which
will inhibit the development of compassion fatigue. In turn, these professionals will experience
improved energy, empathy, morale, and therapeutic communication. Overall, knowledge of
compassion fatigue in behavioral health will result in improved quality of patient care. In
conclusion, future studies will provide additional insight into using education-based
interventions to combat compassion fatigue in behavioral health.
Conflict of interests
None.

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Appendix A

Table 1.
Demographic Characteristics (n: 13).

Gender

Provider

Employment

Years of Experience

Past Award/
Recognition*

Male
Female
Total
Advanced Practice
Nurse
Therapist
Other
Total
Full Time
Part Time
Total
1-4
5-10
11-19
20-30
Total
Received Recognition
No Recognition
Total

Frequency
3
10
13
3

Percent
23.1
76.9
100.0

6
4
13
12
1
13
5
5
1
2
13
4
9
13

46.2
30.8
100.0
92.3
7.7
100.0
38.5
38.5
7.7
15.4
100.0
30.8
69.2
100.0

*Measured as have you ever received an award/recognition for your work (such as Employee of the Month, a DAISY
nomination, etc)?

Table 2.
The Descriptive Statistics of the Pre and Post

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ProQOL 5 Scoring Measures

N
Burnout

Mean

Std.
Z
Deviation
4.50
4.08
-1.267

Asymp.
Sig. (2 -tailed)

Pre-Intervention 13
Post-Intervention 13

20.54
19.15

Secondary
Traumatic
Stress

Pre-Intervention

13

20.31

3.38

Post-Intervention

13

19.85

3.83

-.589

.556

Compassion
Satisfaction

Pre-Intervention 13
Post-Intervention 13

40.69
41.46

3.90
3.67

-1.191

.234

.205

*Note. Significance at the p<0.05 level.
Table 3.
The pre and post mean scores of
BO, STS, and CS per provider type.

Provider

Burnout
Pre Mean
Post Mean

Advanced
16.333
Practice Nurse
(n=3)
Behavioral
22.16
Therapist
(n=6)
Other Direct
21.25
Care Provider
(n=4)

Secondary Trauma
Pre Mean
Post Mean

15.67

19.0

20.67

Compassion Satisfaction
Pre Mean
Post
Mean
42.67
42.67

21.17

21

20.83

39.17

39.5

18.75

20.25

17.75

41.5

43.5

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Appendix B
Table 1
Themes identified within the QI questions.

What is one thing you
learned about compassion
fatigue?

Theme 1

Increased awareness of
the signs and symptoms
of compassion fatigue.

Theme 2

The risks of compassion
fatigue, including
physical, emotional, and
mental exhaustion.

Theme 3

Managing, understanding,
and relieving compassion
fatigue through self-care.

With regard to working in
behavioral health, what
do you believe increases
your feelings of
compassion fatigue?
Increased
workload/larger
caseloads increase the
risk of developing
compassion fatigue.
Lack of support from
management increases
the risk of developing
compassion fatigue.

What can you do to
reduce your feelings of
compassion fatigue?

Being aware of personal
health and recognizing
signs of compassion
fatigue.
Engage in activities to
decrease stress and
increase well-being, and
engage in therapeutic
communication with
friends, family, and
coworkers.

SIGNIFICANCE OF COMPASSION FATIGUE

22
Appendix C

2. Link problem
intervention and
outcomes

1. Assess need for
change in practice







Internal evidence
- project site
reported
subjective
feelings of CF
External evidence
- psychiatric
providers are at
risk for
developing CF
(Boyle, 2011)
CF can increase
staff turnover,
decrease
workplace
initiative, and
result in poor
patient outcomes
(Henry, 2014)









Awareness and
education of
symptoms (Henry,
2014)
Continued,
purposeful efforts
toward self-care
(Henry, 2014)
Education-based
interventions which
stress self-care and
self-awareness may
reduce BO and STS,
and increase CS
(Mathieu, 2007)
Reduced CF may
result in increased
patient safety and
quality of care
(Boyle, 2011)









Search conducted via
CINAHL, Pubmed,
PsycINFO, and The
Cochrane Library
Evidence was
appraised via rapid
critical appraisal
(Melnyk & FineoutOverholt, 2014)
Ten studies were
selected for final
inclusion
All proposed
interventions were
low-risk, noninvasive, and
incorporated either
educational training
and/or promotion of
self-care

5. Implement and
evaluate change in
practice

4. Design
practice change

3. Synthesize best
evidence







Series of evidencebased presentations
designed to
decrease
compassion fatigue
in outpatient
behavioral health
providers
CF measured using
validated ProQOL
instrument
Rigorous pre/post
design used to
measure
implementation of
intervention on CF







Average burnout and
secondary trauma
scores decreased after
the education
intervention,
however, not a
statistically
significant decrease
Average compassion
satisfaction scores
increased after the
education based
intervention, although
not a statistically
significant increase
Common themes
identified in QI
questions included
subjective feelings of
CF related to high
patient volume and
high workload

6. Integrate and
maintain change
in practice







Thorough synthesis
of literature
contributes to the
knowledge
regarding CF in
behavioral health
Advanced
quantitative studies
should be
conducted to
further determine
the causative
factors of CF in
behavioral health
Knowledge of CF
in behavioral health
may result in
improved quality of
patient care

SIGNIFICANCE OF COMPASSION FATIGUE

23
Appendix D

Table 1
Evaluation Table: Interventions for Compassion Fatigue in Health Care Providers
Citation

Conceptua
l
Framewor
k

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurem
ent

Data
Analysis

Findings

Smart, D. (2014).

Stress
Process
Framework

Design:
CrossSectional
Study

N= 139
SS=1
IP=1
OP=0

IV1: CS
IV2: ST

ProQOL-V

ANOVA

Purpose: To
investigate
compassion
satisfaction
and
compassion
fatigue
levels in a
community
hospital in
the United
States.

Role
Physicians=
2%

Negative
correlation
between
CS and BO
r = -0.788,
P < 0.001

Compassion fatigue and
satisfaction: A cross‐
sectional survey among
US healthcare workers.
Country: United States
Funding: NA
Stakeholders: NA
Bias: None noted

Direct Care
RNs= 54%
CNA= 44%
Race
Caucasian=
96%

DV1: BO

SPSS
version
17.0)

Negative
correlation
between
CS and ST
r = -0.320,
P < 0.001
Positive
correlation
between ST
and BO

Level/Quality of
Evidence; Decision
for practice/
application to
practice
Level of Evidence:
Level III
Strengths: Lowrisk, noninvasive
intervention,
measurement and
data analysis tools
are reliable and
valid.
Weaknesses:
Small sample group,
little variability in
demographics of
sample group, only
1 SS.

APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM –emotional
management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review;
M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR –mental relaxation; MS-mean score;
n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-RCT- non-randomized controlled trials; NR-none
reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional
quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate;
S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic
stress scale

SIGNIFICANCE OF COMPASSION FATIGUE

24

Other=4%

r = 0.580, P
< 0.001

Conclusions:
If CS is >, BO can
be decreased. CS
can be improved via
stress-reduction
practices and selfcare.
Level/Quality of
Evidence; Decision
for practice/
application to
practice
Level of Evidence:
Level III

Citation

Conceptua
l
Framewor
k

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurem
ent

Data
Analysis

Findings

Tarantino, B (2013).

Stress
Process
Framework

Design:
CrossSectional
Study

N= 82
SS=1
IP=0
OP=1

IV1: Self-care
program

Perceived
Stress
Scale (PSS)

Analysis of
Variance in
PSS

PI S = 16.9

Purpose:
To deduce if
an
integrative
self-care
program can
decrease
stress and
thus
improve
functioning
and

Role
RNs and
APNs =
90%

Qualitative and
quantitative evaluation
of a pilot integrative
coping and resiliency
program for healthcare.
Country: United States
Funding: NR
Stakeholders:NA
Bias: PSS conducted by
staff members directly
involved in self-care

Social
workers and
therapists =
10%
.

DV1: S

S after 8
weeks of
interventio
n= 11.7
PoI S =
14.4

Strengths: Lowrisk, noninvasive
intervention,
measurement tool is
reliable and valid,
post-intervention
assessment included
a 12 month followup.
Weaknesses:
Selection bias due to
participants being
self-selected.

APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM –emotional
management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review;
M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR –mental relaxation; MS-mean score;
n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-RCT- non-randomized controlled trials; NR-none
reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional
quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate;
S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic
stress scale

SIGNIFICANCE OF COMPASSION FATIGUE
training, thus incurring
possible sampling bias.

25

wellbeing
for nurses
and other
healthcare
providers.

Randomized and
controlled design
not utilized. Possible
sampling bias.
Conclusions:
Healthcare workers
who engage in selfcare activities may
experience
decreased stress.

Citation

Zeidner, M. (2013).
Personal factors
related to compassion
fatigue in health
professionals.
Country: Israel

Conceptua
l
Framewor
k

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurem
ent

Data
Analysis

Findings

General
Adaption
Syndrome
Theory

Design:
CrossSectional
Study

N=182
SS= 10
OP= 3
IP=7

IV1= EI
IV2= EM

Schutte
self-report
inventory
(SSRI)

Hot Deck
imputation
procedure

Purpose: To
examine the
role of some

Setting
Seven major
hospitals

EI and EM
are
inversely
related to
CF.
EI: B=-.19,
t=-2.78,
p<.01

DVI = CF

Emotionmanageme
nt subscale

Level/Quality of
Evidence; Decision
for practice/
application to
practice
Level of Evidence:
Level III
Strengths: Low-risk,
noninvasive
intervention, multiple
measurement tools,
multiple SS, varied

APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM –emotional
management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review;
M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR –mental relaxation; MS-mean score;
n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-RCT- non-randomized controlled trials; NR-none
reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional
quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate;
S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic
stress scale

SIGNIFICANCE OF COMPASSION FATIGUE

Funding: NA
Stakeholders: NA
Bias: None noted

personal and
professional
factors in
compassion
fatigue
among
health-care
professional
s.

and six
private
clinics in
Northern
and Central
Israel.
Role
Mental
Health
Providers:
49%
Medical
Health
Providers:
51%

26
of the
MayerSalo
veyCaruso
emotional
intelligence
test
(MSCEIT)
Coping
inventory
for stressful
situations
situation
specific
coping
(CISSSSC)
Mood
subscales
of the
Dundee
stress state
questionnai
re

EM: B = .17, t= 2.45, p<.01

demographic of N.
Weaknesses: Time
limitation, study was
not designed to
address the dynamic
relationship between
negative emotional
states, S, and CF.
Conclusions:
Increased EI and EM
may act as protective
factors against CF. EI
and EM can be
increased via
utilizing effective and
healthy coping
strategies.

ProQOLIII

APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM –emotional
management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review;
M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR –mental relaxation; MS-mean score;
n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-RCT- non-randomized controlled trials; NR-none
reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional
quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate;
S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic
stress scale

SIGNIFICANCE OF COMPASSION FATIGUE
Citation

Zehr, Kathryn. (2015).
The effect of
education on
compassion fatigue as
experienced by staff
nurses.
Country: United States
Funding: NR
Stakeholders:
Unit director and
CNO of Hospital X
Bias: None noted

27

Conceptua
l
Framewor
k

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurem
ent

Data
Analysis

Findings

The Theory
of
Transperso
nal Caring

Design:
Case-control
study

N= 33
SS =1
IP=1
OP=0
MA = Mid
twenties –
late fifties
F = 100%

IV1= Educational
Training

ProQOL-V

ANOVA

AS for
ST =20.7

Purpose:
Purpose of
study was to
increase
awareness
about CF
risks,
symptoms,
and coping
mechanisms
through
educational
training for
registered
nurses in an
effort to
decrease
levels of CF.

All
participants
were RNs
who worked
on a
medicalsurgical unit
at Hospital
X, a level II
trauma
center in
northern
Indiana.

DV1 =
Compassion
Fatigue

AS for CS
=39.1
PI
MS=39.1
PoI MS
=39.7
1-month
PoI MS =
39.1
3 month
PoI MS
=38.4
P value for
CS = 0.617
P value for
ST = 0.118

Level/Quality of
Evidence; Decision
for practice/
application to
practice
Level of Evidence:
Level III
Strengths: Low-risk,
noninvasive
intervention,
measurement tool
credited with being
reliable and valid,
PoI analysis was
conducted
immediately after
intervention and at 1
and 3 month PoI.
Weaknesses:
Variability in the
educational sessions,
sessions were only 30
minutes in length,
small N.
Conclusions:
Educational training
is best practice to

APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM –emotional
management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review;
M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR –mental relaxation; MS-mean score;
n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-RCT- non-randomized controlled trials; NR-none
reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional
quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate;
S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic
stress scale

SIGNIFICANCE OF COMPASSION FATIGUE

28
decrease levels of CF
among staff nurses.

Citation

Conceptua
l
Framewor
k

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurem
ent

Data
Analysis

Findings

Ruotsalainen J.,
Verbeek J., Mariné
Albert., & Serra C.
(2015).

Physiologic
Theory

SR based on
Cochrane
review
criteria.

n = 58
n, RCT = 54
n, non-RCT
=4

IV1: PR
(Massage)

GRADE
System

Standardize
d Mean
Differences
(SMDs)

PR: SMD 0.48, 95%
CI -0.89 to
-0.08

Purpose=
To evaluate
the
effectiveness
of work and
person
directed
intervention
s compared
to no
intervention
or
alternative
intervention
s in
preventing

N =7, 188
MP = 100%

Preventing occupational
stress in healthcare
workers.
Country: NR
Funding: NR
Bias: None noted

Inclusion
Criteria =
RCTs of
intervention
s aimed at
preventing
psychologic
al stress in
healthcare
workers. For
organization
al
intervention

IV2: MR
(Meditation)
IV3: CBT with
Relaxation
IV4: CBT without
Relaxation
IV5: OC
DV1: Stress

MR:
SMD -0.50,
95%
CI -1.15 to
0.15
OC:
SMD -0.55,
95%
CI -0.84 to
-0.25
CBT w/
and w/out
Relaxation:
SMD -0.27,

Level/Quality of
Evidence; Decision
for practice/
application to
practice
Level of Evidence:
Level I
Strengths:
Low risk and noninvasive intervention,
high level of
evidence, majority of
studies reviewed
were RCTs, large N.
Weaknesses:
More RCTs are
needed with at least
120 participants that
compare the
intervention to a
placebo-like
intervention.

APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM –emotional
management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review;
M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR –mental relaxation; MS-mean score;
n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-RCT- non-randomized controlled trials; NR-none
reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional
quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate;
S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic
stress scale

SIGNIFICANCE OF COMPASSION FATIGUE
stress at
work in
healthcare
workers.

s,
interrupted
time-series
and
controlled
before-andafter (CBA)
studies were
also eligible.

29
95%
Cl -0.66 to
0.13

Conclusions:
Low-quality evidence
that CBT with or
without relaxation
was no more
effective in reducing
stress/burnout
symptoms than no
intervention.

Search
Method:
Cochrane
Central
Register of
Controlled
Trials
(CENTRAL
),
MEDLINE,
EMBASE,
PsycINFO,
CINAHL,
NIOSHTIC2 and Web
of Science
up to
November
2013.

APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM –emotional
management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review;
M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR –mental relaxation; MS-mean score;
n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-RCT- non-randomized controlled trials; NR-none
reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional
quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate;
S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic
stress scale

SIGNIFICANCE OF COMPASSION FATIGUE

30

Citation

Conceptua
l
Framewor
k

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurem
ent

Data
Analysis

Findings

Franza, F., Del Buono,
G., & Pellegrino, F.
(2015).

General
Adaption
Syndrome
Theory

Design =
Case control

SS: 1
IP: 1
OP: 0

IV1: Acuity of
Patient Diagnosis

EZAnalyze
3.0/Excel
Platform

IV2: Participation
in Balint Groups

Brief
Psychiatric
Rating
Scale
(BPRS)

T0 vs T1=
31.07+/14.99 vs
22.75 vs.
8.96

DV1: Job Burnout

Ham-D

DV2: CF

PANSS

Psychiatric caregiver
stress: clinical
implications of
compassion fatigue.
Country: Italy
Funding: NR
Bias: None noted

Purpose =
To
investigate
the stress of
mental
health care
workers and
its
relationship
with
psychiatric
inpatients,
and to assess
the ways in
which
psychiatric
health care
providers
may be
affected by

Group I
(Inpatients)
N=237
M=152
F=85
Group II
(Psychiatric
Staff)
N= 47
M=23
F=24
Setting:
Inpatient
mental
health
facility in
Italy which

YMRS

P Value =
p<0.00000
1
CBI P
Values=
Nurses 0.00280
Psychiatrist
s – 0.16190
Social
Workers –
0.22900
Operators –
0.02340

Level/Quality of
Evidence; Decision
for practice/
application to
practice
Level of Evidence:
Level III
Strengths:
Low-risk,
noninvasive
intervention, utilized
two tools to assess
for CF, large N of
Group 1.
Weaknesses:
No control group –
all providers
participated in
Balint groups, no
clear methodology
explained for
relationship between
CF and patient
acuity, small N of
Group2.

APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM –emotional
management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review;
M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR –mental relaxation; MS-mean score;
n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-RCT- non-randomized controlled trials; NR-none
reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional
quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate;
S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic
stress scale

SIGNIFICANCE OF COMPASSION FATIGUE
CF.

provides day
care and
rehabilitatio
n.

31
sCFs P
Values=
Nurses0.000020
Psychiatrist
s–
0.057700
Social
Workers0.221100
Operators0.009000

Conclusions:
Psychiatric health
care providers are
highly at risk for
CF.
Psychiatric nurses
have highest
percentage of CF.
Higher acuity
(bipolar,
schizophrenia,
severe MDD,
personality
disorders), of
patients can result in
higher levels of CF.
In psychiatry, CF
results in
misjudgments,
clinical errors, poor
treatment planning,
and poor therapeutic
communication.
Balint groups can
represent a
management

APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM –emotional
management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review;
M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR –mental relaxation; MS-mean score;
n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-RCT- non-randomized controlled trials; NR-none
reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional
quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate;
S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic
stress scale

SIGNIFICANCE OF COMPASSION FATIGUE

32
strategy for CF.

Citation

Conceptua
l
Framewor
k

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurem
ent

Data
Analysis

Findings

Potter, P., Deshields, T.,
& Rodriguez, S. (2013).

King’s
General
System’s
Framework

QuasiExperimenta
l Study

SS= 1
IP= 1
OP = 0

IV1 – Resiliency
program
consisting of selfcare promotion,
educational
sessions, and an
off-site retreat.

ProQOL RIV

Self-Report
Survey
Codes

PI N – 389
PoI N- 85

Developing a
systematic program for
compassion fatigue.
Country: United States
Funding: Hospital’s
Charitable Foundation
Bias: None noted

Initial N =
389
F = 92.7%
M=7.3%
MA (mean
age) = 40.5
Role
RN/APN
=73.0%
Allied
health=
9.1%
Tech/Clerica
l= 3.8%
Interpreters=
0.5%
Others =
0.8%

DV1 – CF

ProQOL
Scores
PI BO –
48.1
PI ST –
38.3
PoI BO –
23.5
PoI ST21.2
BO
t=4.50
P < .01
ST
t= 4.72
P < .01

Level/Quality of
Evidence; Decision
for practice/
application to
practice
Level of Evidence:
Level III
Strengths:
Low-risk, noninvasive
intervention. EB
tool utilized as the
instrument of
measurement. Large
N of PI.
Weaknesses:
Poor response rate.
PI N was 389, PoI N
was 85. No control
group – all hospital
employees received
intervention.
Conclusions:
ProQOL is a reliable

APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM –emotional
management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review;
M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR –mental relaxation; MS-mean score;
n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-RCT- non-randomized controlled trials; NR-none
reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional
quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate;
S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic
stress scale

SIGNIFICANCE OF COMPASSION FATIGUE

33
and valid instrument
for measurement of
CF.
Feelings of CF/BO
were reduced after
implementation of
resiliency program.

Citation

Conceptua
l
Framewor
k

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurem
ent

Potter, P., Deshields, T.,
Berger, J.A., Clarke,
M., Olsen, S., & Chen,
L. (2013).

Dorothea
Orem’s
Self-Care
Theory

QuasiExperimenta
l Study

SS = 1
IP =0
OP = 1

Purpose: To
evaluate a
resiliency
program
designed to
educate
oncology
nurses about
CF.

N=13
F= 100%

IV1 – Resiliency
Program (consists
of education about
CF, including
causative factors
and symptoms,
and promotion of
self-care).

Maslach
Burnout
Inventory
(MBI)–
Human
Services
Survey

DV1 – CF

ProQOLIV

Evaluation of a
compassion fatigue
resiliency program for
oncology nurses.
Country: United States
Funding: NR
Bias: None noted

Setting:
A National
Cancer
Institute–
designated
comprehensi
ve cancer
center in the
midwestern

Impact
Event
ScaleRevised
(IES-R)

Data
Analysis

SAS®,
version 9.2.

Findings

IES-R
Improved
significantl
y overall
X
difference
= 1.24
P-value =
0.04, 95%
CI = 0.04,
2.45
ST

Level/Quality of
Evidence; Decision
for practice/
application to
practice
Level of Evidence
= Level III
Strengths
Low risk,
noninvasive,
financially fiscal,
data collection
occurred at multiple
intervals.
Weaknesses=
Small N, time
demands for
participation in the
five week program

APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM –emotional
management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review;
M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR –mental relaxation; MS-mean score;
n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-RCT- non-randomized controlled trials; NR-none
reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional
quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate;
S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic
stress scale

SIGNIFICANCE OF COMPASSION FATIGUE
United
States.
Inclusion
Criteria:
Staff RNs,
aged 20
years or
older,
provides
direct
patient care,
employed at
SS, willing
to
participate
in all 5
weeks of
intervention.
Exclusion
Criteria:
Actively
suicidal or
currently
abusing
substances,
as
determined
by selfreport.

34

Nursing
Job
Satisfaction
Scale

Overall
reduction
PI MS =
19.76

may have acted as a
barrier to
participation.
Conclusions

PoI MS =
16.23
P-value =
.044

Relaxation and selfcare exercises were
reported to be the
most helpful aspect
of the IV1.
Participants reported
benefit from
learning that many
individuals suffer
from CF.
Education regarding
causative factors of
CF, and selfvalidation,
connection, and selfcare assists in
alleviating CF.

APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM –emotional
management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review;
M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR –mental relaxation; MS-mean score;
n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-RCT- non-randomized controlled trials; NR-none
reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional
quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate;
S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic
stress scale

SIGNIFICANCE OF COMPASSION FATIGUE

35

Citation

Conceptua
l
Framewor
k

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurem
ent

Data
Analysis

Findings

Flarity, K., Gentry, J.
E., & Mesnikoff, N.
(2013).

Peplau’s
Interperson
al Theory

Design:
QuasiExperimenta
l Study

SS: 2
OP: 0
IP: 2

IV1 – Resiliency
Program
(included
education
regarding
symptoms,
causative factors,
and effects of CF,
and promotion of
self-care and
mindfulness).

ProQOL-V

Statistical
Package for
the Social
Sciences
Version 20

RR: 100%

The effectiveness of an
educational program on
preventing and treating
compassion fatigue in
emergency nurses.
Country: United States
Funding: Colorado
State Emergency
Nurses Association,
Colorado Nurses
Foundation, and the
Memorial Health
Auxiliary.
Bias: None noted

Purpose:
To examine
the
treatment
effectiveness
of a
multifaceted
education
program to
decrease CF
BO
symptoms
and increase
CS of
emergency
nurses
participating
in the

N: 73
20+ years
experience =
38%
8- years
experience =
58%

DV1 – ST
Setting:
Two EDs in
Colorado
Springs, CO.
Both
facilities
were Level
II trauma
centers.

DV2 – BO
DV3 - CS

PI BO
MA= 23.9
PI CS
MA= 40.3
PI ST
MA =23.5
PoI BO
MA= 20
P-Value =
0.001
PoI CS
MA= 42.2
P-Value=
0.004
PoI ST
MA= 21.4

Level/Quality of
Evidence; Decision
for practice/
application to
practice
Level of Evidence:
Level III
Strengths
Low risk,
noninvasive
intervention. IV1
was low-cost and
easy-to-implement.
High RR. Reliable
and valid
measurement.
Weaknesses
Need to repeat the
posttest after a
longer lapse of time
and then repeat
again at 1 year.
Conclusions
A four hour
resiliency program

APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM –emotional
management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review;
M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR –mental relaxation; MS-mean score;
n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-RCT- non-randomized controlled trials; NR-none
reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional
quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate;
S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic
stress scale

SIGNIFICANCE OF COMPASSION FATIGUE

36

training.

P-Value=
0.001

resulted in increased
CS, decreased BO,
and decreased ST
(CF).
Demonstrated a
low-cost, easy-toimplement method
for both enhancing
CS and diminishing
the negative effects
of work-related
stress.

Citation

Conceptua
l
Framewor
k

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurem
ent

Data
Analysis

Findings

Beck, C. T. (2011).

The Theory
of
Transperso
nal Caring

Design: SR

n= 7
RCTs = 0
non-RCTs=
7

IV1 – Continuing
education

Compassio
n Fatigue
Self Test
for Helpers

Secondary
Traumatic
Stress
Scale

Risk of ST
in RN’s

Secondary traumatic
stress in nurses: A
systemic review.
Country: United States
Funding: NR

Purpose:
To review
the literature
on
secondary
traumatic
stress in
nurses

Inclusion
Criteria:
Sample
included
nurses, the

DV1 - ST

Compassio
n Fatigue
ScaleRevis
ed

High Risk=
26.4%
Moderate
Risk=
52.3%

Level/Quality of
Evidence; Decision
for practice/
application to
practice
Level of Evidence:
Level I
Strengths
Multiple data
sources, study
results are
applicable and easy
to implement.

APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM –emotional
management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review;
M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR –mental relaxation; MS-mean score;
n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-RCT- non-randomized controlled trials; NR-none
reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional
quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate;
S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic
stress scale

SIGNIFICANCE OF COMPASSION FATIGUE
Bias: None noted

ST stress
symptoms
were
measured,
and the
language
was English.
Data
Sources:
CINAHL,
PubMed,
and
PsycINFO
databases
were
searched for
the years
1981 to the
present.

37
Low Risk=
21.3%

Weaknesses
Small samples and
the use of different
instruments in the
studies hindered the
ability to make
comparisons across
study findings. No
RCTs.
Conclusions
ST is present in RNs
in a number of
different clinical
specialties.
LR found a lack of
published studies on
ST in psychiatric
nurses – a specialty
which frequently
cares for acute,
traumatized patients.
This gap in the
knowledge base
needs to be rectified.
RNs need education
about vulnerability
to and symptoms of

APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM –emotional
management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review;
M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR –mental relaxation; MS-mean score;
n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-RCT- non-randomized controlled trials; NR-none
reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional
quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate;
S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic
stress scale

SIGNIFICANCE OF COMPASSION FATIGUE

38
compassion fatigue.
Education regarding
coping strategies
should be instituted.

APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM –emotional
management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review;
M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR –mental relaxation; MS-mean score;
n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-RCT- non-randomized controlled trials; NR-none
reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional
quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate;
S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic
stress scale

SIGNIFICANCE OF COMPASSION FATIGUE

22
Appendix D

Table 2
Synthesis Table: Interventions for Compassion Fatigue in Health Care Providers

Beck
Study Characteristics
Year
2011
SS
OP
IP
RCT
0
Cross-Sectional
Non-RCT
7
Case-Control
SR
X
QE
Level of
I
Evidence
Population Demographics
N
n
7
Male Gender
(%)
Female Gender
(%)
Profession
RN
Independent Variables
ET
X
OC
CS
ST

Zeidner

Flarity

Franza

Tarantino

Smart

Potter, Deshields, & Rodriguez

Potter et al.

Ruotsalaine

Zehr

2013
10
3
7

2013
2
0
2

2015
1
0
1

2013
1
1
0

2014
1
0
1

2013
1
0
1

2013
1
1
0

2015

2015
1
0
1

X

X

54
X

4
X

X
X

III

X
III

III

III

III

X
III

X
III

182

73

47

82

139

389

13

48%

7.3%

0%

0%

52%

92.7%

100%

100%

MP

RN

X
X

X

MP

RN

RN/BH
T

X

X

MP

MP

X
X

I

III

7,1888
58

33

MP

RN

X
X

SIGNIFICANCE OF COMPASSION FATIGUE

Beck
Zeidner
Independent Variables Continued
Acuity of
Diagnosis
SC
EI
X
EM
X
Dependent Variables
CF
X
ST
X
BO
CS
S
Measurement
BPRS
Ham-D
PANSS
YMRS
ProQOL
X
MBI
IES-R
NJSS
ANOVA
PSS
STSS
X
Outcome
IV resulted in
No
Yes
reduction of DV

Flarity

Franza

40

Tarantino

Smart

Potter, Deshields, & Rodriguez

Potter et al.

Ruotsalaine

X

X

X

X

X

Zehr

X
X

X

X
X
X
X

X

X
X
X

X
X

X
X
X
X
X

X

X

X
X
X
X

X

X

X

X

Yes

Yes

X

Yes

Yes

Yes

Yes

Yes

Yes

SIGNIFICANCE OF COMPASSION FATIGUE
22