Fatigue due to compassion in health professionals and coping strategies: a scoping review

Desgaste por empatía en el contexto de los profesionales de salud y estrategias de enfrentamiento: scoping review

ABSTRACT

Objectives:

to identify the current state of knowledge on compassion fatigue in the work context of healthcare professionals; and how coping strategies are established in this scenario.

Method:

a scoping review with search applied to the databases: MEDLINE, LILACS, CINAHL, Scopus. Temporal limit: 2009 to 2019. The data was analyzed and synthesized in narrative form

Results:

thirty articles were selected, synthesized into two categories: a) Health work and compassion fatigue: conceptual analysis, context, and manifestations; b) Coping strategies for compassion fatigue.

Conclusions:

this study presented: a descriptive and general panorama about compassion fatigue in healthcare professionals, identifying a greater consolidation of the concept between 2015 and 2018; and some coping strategies. The association between health and spirituality is highlighted as one of the strategies in this scenario, enabling new research to be conducted in view of the importance of the theme in life, health work.

Descriptors:
Compassion Fatigue; Health Personnel; Psychological Adaptation; Work; Review

RESUMEN

Objetivos:

identificar el estado actual del conocimiento sobre desgaste por empatía en el contexto laboral de profesionales de salud; y como las estrategias de enfrentamiento se establecen en ese escenario.

Métodos:

scoping review con búsqueda aplicada en las bases de datos: MEDLINE, LILACS, CINAHL, Scopus. Límite temporal: 2009 a 2019. Datos analizados y sintetizados de manera narrativa.

Resultados:

seleccionaron 30 artículos, sintetizados en dos categorías: a) Trabajo en salud y desgaste por empatía: análisis conceptual, contexto y manifestaciones; b) Estrategias de enfrentamiento del desgaste por empatía.

Conclusiones:

estudio presentó: un panorama descriptivo y general sobre desgaste por empatía en profesionales de salud, identificando una mayor consolidación del concepto entre 2015 y 2018; y algunas estrategias de enfrentamiento. Resaltando la relación entre salud y espiritualidad como una de las estrategias en ese escenario, posibilitando que nuevas investigaciones sean realizadas delante importancia del tema en la vida, en el trabajo en salud.

Descriptores:
Desgaste por Empatía; Personal de Salud; Adaptación Psicológica; Trabajo; Revisión

RESUMO

Objetivos:

identificar o estado atual do conhecimento sobre fadiga por compaixão no contexto do trabalho de profissionais de saúde; e como as estratégias de enfrentamento se estabelecem nesse cenário.

Métodos:

scoping review com busca aplicada nas bases de dados: MEDLINE, LILACS, CINAHL, Scopus. Limite temporal: 2009 a 2019. Os dados foram analisados e sintetizados de forma narrativa.

Resultados:

selecionaram-se 30 artigos, sintetizados em duas categorias: a) Trabalho em saúde e fadiga por compaixão: análise conceitual, contexto e manifestações; b) Estratégias de enfrentamento da fadiga por compaixão.

Conclusões:

o estudo apresentou: um panorama descritivo e geral sobre fadiga por compaixão em profissionais de saúde, identificando uma maior consolidação do conceito entre 2015 e 2018; e algumas estratégias de enfrentamento. Ressalta-se a associação entre saúde e espiritualidade como uma das estratégias nesse cenário, possibilitando que novas pesquisas sejam realizadas diante da importância do tema na vida, no trabalho em saúde.

Descritores:
Fadiga por Compaixão; Pessoal de Saúde; Adaptação Psicológica; Trabalho; Revisão

INTRODUCTION

The transformations that have occurred in the world of work have contributed to changes in the quality of life and in the physical, mental, and psychological health of workers. The themes “work” and “worker’s health” have been recurrent in many studies, researches, and interventions, especially in the health area. In them, it has been found that health professionals are often affected by work-related diseases that generate physical and even psychological suffering.

“Suffering begins when the man-organization relationship of work becomes blocked; that is, when the worker uses his intellectual, psycho-affective, learning, and adaptive faculties to their fullest” ⁽¹⁾.

The work of these professionals is an action of multiple situations and confrontations, which can be a source of pleasure and suffering, being a potential cause of several health problems, with consequences at work or outside it.

It is worth remembering that “health professionals are all those workers who have the mission and job of reducing the pain of others, not restricted only to doctors and nurses”⁽²⁾.

The performance of health care professionals is extremely important for society, due to the possibility of providing quality care to the user. When this does not occur, there is an impact on the professional (ethical and legal responsibility) and on the community (increased costs with the service). Thus, it is established that a negative impact on the work activity of these workers, caused by internal or external situations, can result in risk to patient safety and quality care.

Health work goes beyond a technical, mechanical, and objective perspective; it should generate an involvement and commitment of one human being to another. The working condition of this professional, within this perspective, can put his physical and mental health at risk.

The act of sharing the pain of others remains an intrinsic characteristic of the health professional’s work, aiming at humanized and quality care⁽²⁾. Compassion is a central element of this condition and needs to be evaluated to better understand the state of health and illness linked to this worker, because it can lead him to develop the deterioration of mental health, with the manifestation, for example, of burnout syndrome, stress, fatigue, among others.

Compassion fatigue (CF) is a form of suffering that originates from work activity and can cause physical and mental illness. It “is represented by physical and/or mental fatigue as a result of compassion that can be experienced by health professionals”⁽²⁾.

Work-related positive (compassionate satisfaction) and negative (compassionate fatigue) aspects influence the quality of work life. CF is divided into two parts. The first part concerns conditions such as exhaustion, frustration, anger, and depression typical of burnout; and the second, secondary traumatic stress, which is a negative feeling caused by fear and work-related trauma, either some direct (primary) trauma or a combination of primary and secondary trauma. Therefore, burnout and secondary traumatic stress are not synonymous with CF⁽³⁾.

Compassion fatigue is the result of a progressive and cumulative process, which is caused by prolonged, continuous and intense contact with patients whose demand is suffering⁽⁴⁾. CF manifests itself with pronounced physical, social, emotional, spiritual, and intellectual changes that increase in intensity⁽⁵⁾. Therefore, when the professional cannot cope in a healthy way, that is, does not establish mental and physical care that allows empathy without absorption of the pain in oneself and for oneself, compassion fatigue can occur⁽²⁾.

The work relationship in health is strongly marked by ambivalence translated into terms of suffering and pleasure, because what defines the threshold between these two possibilities are the actions and behaviors of each individual when facing the work.

In view of this, implementing coping strategies as prevention and/or treatment measures becomes a challenge and a differentiator in healthcare organizations. Intervention programs can show great promise for health professionals, minimizing the impact of CF on their work and personal lives.

The prevalence of compassion fatigue in health professionals, recognized as a condition related to the labor process, demonstrates the need for organizations and institutions to develop resilience programs, since the teams that form the workforce are the most vulnerable interfaces in this process⁽⁶⁾.

The search for balance becomes a great source of social, personal, and human meaning. In this context, the individual is stimulated at various moments in life to search for this balance, well-being, and for coping strategies: on one hand, there are the demands of interpersonal relationships with the environment in which he or she is inserted; on the other hand, the maintenance of physical, mental, social, and, why not, spiritual well-being.

The dimension of spirituality has a direct relationship with the term “compassion”. Currently, it is a resource used to cope with illness and suffering by providing adequate support for better physical and mental health; it benefits patients, the multidisciplinary team, and the healthcare system itself⁽⁷⁾. However, the conditions and precepts of the relationship between work, compassion fatigue, and coping strategies are still peripheral issues to society and organizational institutions.

The proof of the use of religious/spiritual coping as a benefit, therapy and determination of positive outcomes in various diseases has been a challenge for medical science, given the complexity in measuring the impact of religious and spiritual experiences on the individual⁽⁸⁾.

Thus, the review may contribute to mapping the panorama of professional reality and the influence of CF on the work activities of health care workers and also foster discussion about the possibilities of coping. All this may favor an increase in the control of adverse factors, preventing situations of discomfort and psychic suffering for health professionals. In this way, the reach of personal, collective and institutional benefits is made possible, in the sense of favoring a greater knowledge in relation to the theme, opening the field for new research.

OBJECTIVES

To identify, in the literature, the current state of knowledge about compassion fatigue in the context of health professionals’ work; and how coping strategies are established in this scenario.

METHODS

Study carried out by means of scoping review according to the proposal of the Joanna Briggs Institute (JBI), whose approach is broader, with the objective of mapping the main concepts in the literature that support an area of research, providing an overview of a theme⁽⁹⁾.

In scoping review, the initial question is broad, open-ended; inclusion/exclusion criteria may be established a posteriori; the choice of studies does not focus on the quality of the research; may or may not involve data extraction; the synthesis is primarily qualitative and rarely quantitative; it is used to identify variables and gaps in the literature^(9-10).

In this sense, the following steps were adopted: identification of the research question; identification of relevant studies; selection of studies; structuring of data; grouping, summarizing and reporting of results; and communication of results^(11-12).

The construction of the research question was carried out using the “Population, Concept and Context” strategy⁽¹³⁾, where: P - health professionals; C - compassion fatigue; C - health work. For the search and selection of the studies, the following guiding question was established: “What has been studied about compassion fatigue in healthcare professionals and what are the coping strategies?”

The following databases were used for data collection: Latin American and Caribbean Literature on Health Sciences (LILACS), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and Medical Literature Analysis and Retrieval System Online (MEDLINE). Consultations were made in the months of May to July 2019.

The search was performed by two independent researchers, according to JBI criteria⁽¹³⁾, respecting the guidelines recommended by PRISMA ScR for scoping review. The descriptors and/or their synonyms were used, according to the Descriptors in Health Sciences (DeCS) and Medical Subject Headings (MeSH), for each item of the strategy. For the combination of descriptors, the Boolean terms AND and OR were considered according to the search system of each database. Thus, the following strategy was used (Chart 1).

Chart 1
Search Strategy

Population (P):	"Health Personnel" [Mesh] OR "Personnel, Health" OR "Health Care" OR "Providers" OR "Health Care Provider" OR "Provider, Health Care" OR "Providers, Health Care" OR "Healthcare Providers" OR "Healthcare Provider" OR "Provider, Healthcare" OR "Providers, Healthcare" OR "Fieldworkers" OR "Fieldworker" OR "Field Workers" OR "Field Worker" OR "Worker, Field" OR "Workers, Field"
Concept (C):	"Compassion Fatigue" [Mesh] OR "Fatigue, Compassion" OR "Vicarious Trauma" OR "Trauma, Vicarious" OR "Traumas, Vicarious" OR "Vicarious Traumas" OR "Secondary Trauma" OR "Secondary Traumas" OR "Trauma, Secondary" OR "Traumas, Secondary" OR "Secondary Traumatization" OR "Secondary Traumatizations" OR "Traumatization, Secondary" OR "Traumatizations, Secondary" OR "Secondary Traumatic Stress" OR "Stress, Secondary Traumatic" OR "Stresses, Secondary Traumatic" OR "Traumatic Stress, Secondary" OR "Vicarious Traumatization" OR "Traumatization, Vicarious"
Context (C):	"Adaptation, Psychological" [Mesh] OR "Adaptation, Psychologic" OR "Psychologic Adaptation" OR "Psychological Adaptation" OR "Coping Behavior" OR "Behavior, Coping" OR "Behaviors, Coping" OR "Coping Behaviors" OR "Coping Skills" OR "Coping Skill" OR "Skill, Coping" OR "Skills, Coping" OR "Behavior, Adaptive" OR "Adaptive Behavior" OR "Adaptive Behaviors" OR "Behaviors, Adaptive"

These were the inclusion criteria used to select the studies: to be a theoretical and original research article that is related to the theme; to have been published in English, Spanish, and Portuguese; to have been carried out with health professionals between the years 2009 and 2019. As the scoping review is exploratory, all types of studies were included: qualitative, quantitative, mixed, and review. Studies with poorly defined or unexplained research design or objectives; and editorials, conference abstracts and posters, letters, commentaries, and theses were excluded.

After reviewing the titles, the abstracts of the eligible primary studies were analyzed, considering the inclusion and exclusion criteria, and those that were not related to the theme were eliminated. The selection process was carried out by two authors/reviewers independently, and after comparing the results, disagreements were resolved by consensus.

For data extraction, we used an instrument structured by the researchers themselves according to JBI recommendations⁽¹³⁾. The items selected for analysis were: title; authors; country of origin of the study; year of publication; methodological design; sample; HR assessment instrument; and coping strategy. The variables corresponding to these characteristics are presented in Table 2 and also follow the JBI guidelines: title; authors; methodological design; year of publication; country of origin of the study; sample; CF assessment instrument; and coping strategies⁽¹³⁾.

Chart 2
Studies analyzed according to title, authors, methodological design, year of publication, country of origin of the study, sample, compassion fatigue assessment tool and coping strategies, Uberaba, Minas Gerais, Brazil, 2019

	Data base	Title	Author	Methodological design	Year	Country of origin of the study	Sample	CF Assessment Instrument	Confrontation Strategy
A1	MEDLINE	Reducing Compassion Fatigue in Inpatient Pediatric Oncology Nurses	Sullivan, King, Holdiness, Durrell, Roberts, Spencer(16).	Quantitative - Quasi-experimental	2019	USA	59 nurses - pediatric oncology unit	ProQOL V (STAMM)	Organizational interventions: self-care, health and wellness, spiritual assistance, break room
A2	MEDLINE	Caring for the caregivers: Evaluation of the effect of an eight-week pilot mindful self-compassion (MSC) training program on nurses' compassion fatigue and resilience	Delaney(17).	Mixed method - phenomenology and quantitative	2018	United Kingdom	13 nurses - various sectors of the hospital	ProQOL V (STAMM)	Intervention for self-compassionate improvement
A3	MEDLINE	Compassion fatigue in nursing: A concept analysis	Peters(18).	Literature Review - Conceptual Analysis	2018	USA	26 selected articles	-	-
A4	MEDLINE	Cognitive reactions of nurses exposed to cancer patients' traumatic experiences: A qualitative study to identify triggers of the onset of compassion fatigue	Fukumor, Miyazaki, Takaba, Taniguchi, Asa (19).	Qualitative Semi-structured interview	2018	Japan	30 nurses from six cancer hospitals	-	-
A5	MEDLINE	Integrative Review of Facility Interventions to Manage Compassion Fatigue in Oncology Nurses	Wentzel, Brysiewicz(20)	Integrative review	2017	South Africa	-	-	-
A6	MEDLINE	Palliative care professionals' care and compassion for self and others: a narrative review	Mills, Wand, Fraser(21).	Narrative review	2017	Australia	-	-	-
A7	MEDLINE	Compassion Fatigue among Healthcare, Emergency and Community Service Workers: A Systematic Review	Cocker, Joss(22).	Systematic review	2016	Australia	13 selected articles	-	-
A8	MEDLINE	Perceived Quality of Work Life and Risk for Compassion Fatigue Among Oncology Nurses: A Mixed-Methods Study	Giarelli, Denigris, Fisher, Maley, Nolan(23).	Mixed Method - Self-report questionnaire and interview	2016	USA	20 oncology nurses	ProQOL V (STAMM)	-
A9	MEDLINE	The Prevalence of Compassion Fatigue and Burnout among Healthcare Professionals in Intensive Care Units: A Systematic Review	Van Mol, Kompanje, Benoit, Bakker, Nijkamp(24).	Systematic review	2015	The Netherlands/ Belgium	30 selected articles	-	-
A10	MEDLINE	A pilot study examining the impact of care provider support program on resiliency, coping, and compassion fatigue in military health care providers	Weidlich, Ugarriza(25).	Quantitative - Prospective cohort study	2015	USA	93 military and civilian nurses and doctors at an Army Medical Center (28 returned questionnaires)	ProQOL V (STAMM)	Army professional support group training in resilience
A11	MEDLINE	Palliative Care Professionals' Inner Life: Exploring the Relationships Among Awareness, Self-Care, and Compassion Satisfaction and Fatigue, Burnout, and Coping With Death	Sansó, Galiana, Oliver, Pascual, Sinclair, Benito(26).	Quantitative Cross-sectional study with application of a questionnaire	2015	Spain	385 professionals (doctors, nurses, psychologists, nursing assistants, and social workers)	ProQOL IV (STAMM)	-
A12	MEDLINE	Stress, burnout, compassion fatigue, and mental health in hospice workers in Minnesota	Whitebird, Asche, Thompson, Rossom, Heinrich(27).	Quantitative - Cross-sectional study with application of a questionnaire	2013	USA	557 staff members from 13 palliative care programs	ProQOL RIII (STAMM)	-
A13	MEDLINE	Personal factors related to compassion fatigue in health professionals	Zeidner, Hadar, Matthews, Roberts(28).	Quantitative Cross-sectional study with application of a questionnaire	2013	Israel	182 participants (89 mental health professionals and 93 physicians)	ProQOL RIII (STAMM)	-
A14	MEDLINE	Evaluation of a compassion fatigue resiliency program for oncology nurses	Potter, Deshields, Berger, Clarke, Olsen, Chen(6).	Quantitative - Quasi-experimental	2013	USA	13 outpatient oncology nurses	ProQOL IV (STAMM)	Enfrentamento por meio da resiliência
A15	MEDLINE	Compassion fatigue in nurses	Yoder(29).	Mixed Method - Interview and questionnaire	2010	USA	106 home care, emergency care, ICU, and oncology nurses	ProQOL IV (STAMM)	-
A16	MEDLINE	Compassion satisfaction, burnout, and compassion fatigue among emergency nurses compared with nurses in other selected inpatient specialties	Hooper, Craig, Janvrin, Wetsel, Reimels(30).	Quantitative - Cross-sectional	2010	USA	114 emergency, oncology, nephrology, and intensive care nurses	ProQOL IV (STAMM)	-
A17	MEDLINE	Compassion fatigue: a nurse's primer	Lombardo, Eyre(31).	Qualitative - Case Study	2011	USA	Two case studies with a reactive and a proactive nurse	-	-
A18	MEDLINE	The experience of secondary traumatic stress upon care providers working within a children's hospital	Robins, Meltzer, Zelikovsky(32).	Quantitative - Questionnaire application	2009	USA	314 health professionals (doctors, nurses, psychologists, social workers, speech therapists, occupational therapy, physiotherapy)	Escala de FC (FIGLEY; STAMM, 1996)[	-
A19	CINAHL	Compassion Fatigue in Military Healthcare Teams	Owen, Wanzer(33).	Systematic review	2014	USA	25 selected articles	-	-
A20	MEDLINE	Compassion Fatigue Among Palliative Care Clinicians: Findings on Personality Factors and Years of Service	O'Mahony, Ziadni, Hoerger, Levine, Baron, Gerhart(34).	Quantitativo - Aplicação de questionário	2018	USA	66 professionals (doctors, nurses, social workers, chaplains and other palliative care professionals)	ProQOL V (STAMM)	-
A21	MEDLINE	Quality of Life and Compassion Satisfaction in Clinicians: A Pilot Intervention Study for Reducing Compassion Fatigue	Klein, Riggenbach-Hays, Sollenberger, Harney, McGarvey(35).	Quantitative - Quasi-experimental	2018	USA	15 doctors, nurses and counselors	ProQOL V (STAMM)	Mindfulness training program for stress reduction with three 90-minute sessions
A22	MEDLINE	An Evolutionary Concept Analysis of Compassion Fatigue	Sorenson, Bolick, Wright, Hamilton(36).	Literature review - Rodgers Evolutionary Model	2017	USA	15 selected articles	-	-
A23	MEDLINE	Reducing the "cost of caring" in cancer care: Evaluation of a pilot interprofessional compassion fatigue resiliency programme	Pfaff, Freeman-Gibb, Patrick, DiBiase, Moretti(37).	Mixed method	2017	Canada	Quantitative (n = 32) and qualitative (n = 12) of an interprofessional team	ProQOL V (STAMM)	Resilience training program on CF
A24	MEDLINE	Compassion Fatigue and Mindfulness: Comparing Mental Health Professionals and MSW Student Interns	Brown, Ong, Mathers, Decker(38).	Quantitative - Questionnaire application	2017	USA	40 Mental Health America (MHA) staff and 111 MSW interns	ProQOL BH (STAMM)	-
A25	MEDLINE	Compassion Satisfaction, Compassion Fatigue, and Burnout in Spain and Brazil: ProQOL Validation and Cross-cultural Diagnosis	Galiana, Arena, Oliver, Sansó, Benito(39).	Quantitative - Cross sectional study	2017	Brazil/ Spain	161 Brazilian and 385 Spanish palliative care professionals	ProQOL BH (STAMM)	-
A26	MEDLINE	Compassion fatigue: A meta-narrative review of the healthcare literature	Sinclair, Raffin-Bouchal, Venturato, Mijovic-Kondejewski, Smith-MacDonald(40).	Metanarrative review	2017	Canada	90 selected studies	-	-
A27	MEDLINE	The Impact of Combat Deployment on Health Care Provider Burnout in a Military Emergency Department: A Cross-Sectional Professional Quality of Life Scale V Survey Study	Cragun, April; Thaxton(41).	Quantitative -Cross sectional study	2016	USA	105 professionals (diagnostic technicians, nurses) and 33 physicians	ProQOL BH (STAMM)	-
A28	MEDLINE	Understanding Compassion Fatigue in Healthcare Providers: A Review of Current Literature	Sorenson, Bolick, Wright, Hamilton(42).	Integrative review	2016	USA	43 artigos selecionados	-	-
A29	MEDLINE	The Relationship between the Supervision Role and Compassion Fatigue and Burnout in Genetic Counseling	Allsbrook, Atzinger, He, Engelhard, Yager, Wusik(43).	Quantitative - Questionnaire application	2016	USA	391 genetic counselors	ProQOL (STAMM)	-
A30	MEDLINE	Who is at risk for compassion fatigue? An investigation of genetic counselor demographics, anxiety, compassion satisfaction, and Burnout	Lee, Veach, MacFarlan, LeRoy(44).	Mixed Method - Questionnaire and interview	2015	USA	402 genetic counselors	ProQOL V (STAMM)	-

After the steps of separation, summarization and report of the essential elements found in each study, the organization of the results was performed in a thematic way. They were divided into categories in order to allow the analysis and compilation of data, facilitating the ordering of the theme so that further research can broaden the discussion.

In the final stage, the results were compiled and communicated, with the intention of presenting an overview of the material. The main focuses were analyzed by means of the defined analysis categories, revisiting the full texts when necessary. Thus, it was possible to synthesize the findings in a narrative way to enable the structuring of knowledge about the theme.

RESULTS

A total of 263 studies were identified through the database search. After reading the titles and abstracts, 71 articles were selected to be read in full. After full analysis of these selected studies, 30 were included because they answered the research question and met the research inclusion and exclusion criteria. For the presentation of the results, the surveys were numbered from 1 to 30. The detailed description of the article selection and inclusion process is shown in the flowchart in Figure 1.

Figure 1
Flowchart of cross-references and search results⁽¹³⁾

The temporal limit defined for the search of the publications comprised the interval from 2009 to July 2019, aiming to contemplate the current state of work-related CF in healthcare after the modifications of the activity over the generations and greater visibility of the topic in recent years.

Regarding the year of publication, seven articles (23%) published in the year 2017 were identified; five (17%) in 2016 and five in 2018; four (13%) in 2015; three (10%) in 2013; two (7%) in 2010; one (3.3%) in 2009, one in 2011, one in 2014, one in 2019; and none in 2012.

As for the country of origin, 19 (63%) studies were conducted in the United States, 2 (7%) in Australia, 2 in Canada, and 1 (23%) study for each of the other countries (United Kingdom, Japan, South Africa, Spain, Israel, Brazil/Spain and Belgium/Netherlands).

Concerning methodology, 14 studies (46.6%) were quantitative, 9 (30%) were review articles, 5 (16.7%) were mixed methodology, and two (6.7%) were qualitative.

In relation to the CF assessment instrument, of the 14 quantitative studies, 13 (92.9%) employed Stamm’s ProQOL Quality of Work Life Scale (version IV, V and RIII); and 1 (7.1%) used Figley and Stamm’s 1996⁽¹⁴⁾; the five mixed methodology studies adopted the ProQOL Quality of Working Life Scale.

The Professional Quality of Life (ProQOL) measures the negative (compassion fatigue) and positive (compassion satisfaction) effects of helping people who have some type of suffering and/or trauma. This instrument has subscales for compassion satisfaction (CS), burnout, and secondary traumatic stress associated with caring, and has been in use since 1995⁽¹⁵⁾.

Regarding coping strategies for CF, of the 30 selected studies, 6 (20%) implemented some coping strategy for health professionals, such as: self-care practice, self-awareness, spiritual assistance, self-compassion, mindfulness training program for stress reduction, coping exercise through resilience and empathy.

DISCUSSION

The scoping review allowed us to verify that there was a growth in the production of studies on the theme between the years 2015 and 2018, with 21 articles (70%), all published in English. It is noted the lack of papers in Portuguese, demonstrating the importance of research on this topic in Brazil. It is noticed that, in the last four years, studies on CF have developed considerably in the international context.

By reading and analyzing the 30 articles in question, it was possible to define the categories that nucleated discussions and allowed advancing to conclusions about coinciding and divergent points of view. The purpose was to systematize, detail and evidence, in the contents, the central aspects related to the problem investigated, in an attempt to present an overview that allows the structuring of knowledge on the theme.

After reading, analyzing, and synthesizing the studies, the results were thematically divided into two categories: a) Health work and compassion fatigue: conceptual analysis, context, and manifestations; b) Coping strategies for compassion fatigue. They are described below.

Health work and compassion fatigue: conceptual analysis, context, and manifestations

The exercise of compassion by health professionals needs to be encouraged, as it extends beyond empathy and seeks to alleviate the pain of others by connecting with the other as an individual. A health approach rooted in compassion helps to see beyond oneself, prioritizes the good of the other, and can be conceived as a human and social phenomenon⁽⁴⁵⁾, but can have both positive and negative consequences for the worker.

The conception of compassion fatigue, most often cited by the selected articles, was elaborated by Figley^{(6,16-17,20,22,24,26,28-33,36-38,40,42-44)}and by Stamm^{(6,17,26,28-30,33,39,44)}. The literature consulted presented concepts of CF as being an acute loss of work-related emotional and physical energy⁽⁴⁾ and characterized by exhaustion, feelings of disillusionment and worthlessness, as a result of prolonged exposure to suffering and stress⁽³⁾. These authors also add the importance of the study of CF, because some essential issues emerge concerning behavior, feelings, emotions and values, which can influence and affect the worker.

Compassion has its origin in an empathic response to suffering, however, circumstances internal and external to the individual, such as dissatisfaction in professional relationships, can contribute to the emergence of CF, and the presence of stress and negative affect have a synergistic effect on its development. On the other hand, positive affect and solidarity have a synergistic effect on its development⁽⁴⁶⁾.

Compassion fatigue tends to be reflected in the performance of professionals, in the form of low self-esteem, higher turnover of health professionals, absenteeism, job dissatisfaction, inability to make decisions, as well as physical, emotional, mental and cognitive consequences^{(6,16,18,20,22,24,27-28,30-31,33-37,39-40,42-44)}. It has a strong relationship with the sectors “workload and work environment” and “organizational culture”. This is in line with other CF-causing symptoms cited by Figley in 1995⁽⁴⁾, among which are those referring to the condition and organization of work; the emotional stress factor; and pathological changes of a physical nature.

In the selected studies, the field surveys of health care professionals in which the presence of CF was assessed were conducted in the following sectors: five (28%) in Palliative Care units^{(21,26-27,34,39)}, five (28%) in Oncology Care^{(6,16,19-20,23)}, three (17%) with Military Service Professionals^(25,33,41), two (11%) in Medical/Surgical Practice^(31,35), two (11%) with professionals responsible for Genetic Counselling ^(43-44) and one (5%) in Intensive Care Units⁽²⁹⁾.

Coping strategies for compassion fatigue

Compassion fatigue can affect health professionals in the process of providing empathic support, which consists of the ability to understand the patient’s feelings according to his/her point of view, because being assertive and providing empathic care is what is expected from these professionals⁽³¹⁾. Some studies report the relationship between feeling empathy and compassion with the possibility of developing CF^{(6,16-18,20,22,24-25,31-32,34,40,44)}. In other studies, it was observed that health professionals experience a conflict in admitting their own suffering, believing that they should not or cannot show their fragility and vulnerability, thus configuring a lack of protection and a feeling of impotence that comes from the impossibility of solving the problem^(19-20,29).

The meaning of work in the lives of health professionals includes the challenge of rethinking oneself and searching for something that can give meaning to events, to work, and to life. This search for balance can be related to coping strategies, as described in some articles^{(6,16-18,20-22,24,26-29,31,35,37-38,40)}when referring to self-knowledge, self-consciousness, emotional intelligence, dimensions of self-care, self-compassion.

Coping strategies such as positive attitudes of love, kindness, and compassion may be associated with positive mental states and protective measures of work-related ill-health in healthcare workers⁽¹⁷⁾, may involve individual, professional and organizational support⁽¹⁶⁾. In another study, in which participants reported moderate or high levels of stress, the individual coping strategies used were seeking support in their relationships, physical activity, “saying no” more often⁽²⁷⁾. In the same study, some coping pathways were explored at the organizational level, such as the opportunity to better connect with co-workers, workload reduction, encouragement of self-care, relaxation and meditation exercises, and support groups for stress and bereavement situations.

In the literature, coping strategies in health work are highlighted through the development of resilience skills that allow the management of stressful factors^{(6,16-18,25,27,35,37,42)}. Being aware of feelings of psychic inadequacy and discomfort in relation to work, as well as the importance of coping strategies, may equip health professionals in the daily practice of care, transforming suffering at work into pleasure through the subject’s achievements.

Other authors attribute spirituality as a coping strategy for physical, mental and emotional suffering in health professionals^{(26,31-32,34)}, in an attempt to build the inner life of the individual. Values such as compassion, beneficence, and spirituality can provide greater meaning and satisfaction at work, creating an upward spiral of care, promoting the individual’s balance, and minimizing the negative effects of uneasiness at work⁽³⁴⁾.

Research endorses the need to reconsider the integrative approach between health and spirituality, with evident growth in health care. This interconnection has been widely disseminated in medical and nursing education, both nationally and internationally, with the objective of promoting the recognition of the spiritual dimension of the patient and, in turn, a more humanized care⁽⁴⁷⁾. However, when recognizing the importance of spirituality in care, it is necessary to also include the health professional within this dimension.

The interface between spirituality and the processes of health and illness, from an emotional point of view, evidences characteristics of social support and positive psychology, which studies virtuous aspects and the personal strengths of the human being, and can provide more hope, forgiveness, comfort, love, and other benefits⁽⁴⁸⁾.

The Brazilian Society of Cardiology (BSC) has published its Brazilian Guidelines on Spirituality and Psychosocial Factors, in which spirituality is included for the prevention of cardiovascular diseases⁽⁴⁸⁾. Besides the behavioral aspects, studies demonstrate the beneficial relationship between spirituality and physiological and pathophysiological variables in clinically important outcomes, such as blood pressure, neuro-hormonal activation, influence on some metabolic variables, cardiorespiratory arrest and markers of inflammation and immunity⁽⁴⁹⁾. The action of caring does not only refer to biological issues, but also to a care that transcends what is perceptible to the eye, which is the spiritual dimension⁽⁵⁰⁾.

Health work that oscillates between fatigue and compassionate satisfaction is described in certain articles^{(16-17,26,30,32,34-35,37,39,44)}. The sense of purpose and passion can explain the ambiguous sensations, present in the process of health work, which translate into feelings of satisfaction or compassion fatigue. In a humanistic view, the work of the health care professional can be perceived beyond a profession, but as the essence of human development. The challenge lies in developing the ability of health professionals to share the pain of others in a healthy way, that is, one that does not cause them illness.

Study limitations

This study has limitations such as the inclusion of articles in only three languages (Portuguese, English, and Spanish), not evaluating the quality of evidence of the studies, and the choice of the temporal limit in the search, which was only between 2009 and 2019. However, the production of knowledge through a scoping review does not end with a particular study. A research is worth not only for the answers to what is not known, but also for the possibilities it poses to what is not known enough.

Contributions to the field of Nursing, Health or Public Policy

The results of this review will be useful for future research in nursing, as well as for other healthcare professionals, whether for the improvement of patient care, or for hospital organizations and Public Policies. This is because they allow for an understanding of the relationship between work and compassion fatigue, as well as possible coping strategies for this work-related malaise in healthcare. Further research needs to be conducted to assess the potential implications of CF on the life and work of health professionals.

FINAL CONSIDERATIONS

This scoping review found 30 studies that responded to the initial objective, and of these, 21 (70%) were published in the period between 2015 and 2018, all in the English language, of which 63% were conducted in the United States. The most commonly used methodology was quantitative, with the vast majority using the ProQOL Stamm Scale of Professional Quality of Life (version IV, V, and RIII). Considering coping strategies for compassion fatigue, 20% of the studies presented the implementation of some coping strategy to health professionals.

The research presents a descriptive and general overview of CF in health professionals and their coping strategies. This is essential for the advancement of new research on the topic, as it gains greater visibility in a growing consolidation of the concept of CF. Furthermore, we emphasize the important association between health and spirituality as a coping strategy. Therefore, considering the spiritual dimension within the reality of health professions will allow new knowledge gaps to be filled.

It is worth pointing out that being a health professional does not predetermine happiness or unhappiness at work - for there is no pure state of life and life at work - but rather signals the search for a balance between pleasure and suffering, between satisfaction and CF. Furthermore, the way in which compassion fatigue can influence strategies for humanizing care needs to be clarified. It will be up to hospital organizations and the professional themselves to find and cultivate structuring mechanisms that can allow for an even greater understanding of the reflections of work on the individual and the individual on work.

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Edited by

EDITOR IN CHIEF: Dulce Barbosa

ASSOCIATE EDITOR: Carina Dessotte

Publication Dates

• Publication in this collection
  16 Aug 2021
• Date of issue
  2021

History

• Received
  12 Mar 2020
• Accepted
  18 May 2021