Compassion fatigue in helping professions: a scoping literature review

Abstract

Background

Generalizing the concept of compassion fatigue across healthcare settings or professions is difficult because compassion fatigue is a complex and abstract concept. Compassion fatigue is described as a result in the form of behaviors and emotions resulting from learning of another person's traumatic event. Compassion fatigue is considered a 'cost of caring.' This study was a scoping literature review that aimed to identify what is known about compassion fatigue in helping professions.

Methods

A systematic search was conducted on electronic databases, namely ScienceDirect, PubMed, and Taylor and Francis. Data analysis was conducted using PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Study results were mapped based on the following criteria: 1) conceptual analysis; 2) predictor factors; and 3) research progress. A total of 43 articles met the inclusion and eligibility criteria for further review in this scoping literature review.

Results

The results showed that it is difficult to imagine how a conceptual model of compassion fatigue could be equally relevant and applicable to various helping professions. Factors that can influence compassion fatigue are divided into personal factors (professional factors and sociodemographic factors), such as resilience, burnout, moral courage, emotional control, mindfulness, work experience, professional competence, and professional efficacy, and work-related factors such as traumatic experiences, life disorders, number of patients treated, job satisfaction, emotional support, social support, and fluctuations in interactions with suffering patients. Research on compassion fatigue has developed a lot, especially in the health sector, especially nursing using experimental, cross-sectional, and literature review research methods.

Conclusion

Further analysis is needed in developing a conceptual analysis of compassion fatigue that focuses on other fields of work more specifically and comprehensively by paying attention to, aspects, determinants, and validity of compassion fatigue symptoms.

Introduction

The issue of compassion fatigue is often overlooked in the guidance and counseling education environment. Many academics and practitioners have comprehensively reviewed the concept of compassion fatigue in various other helping professions, such as doctors, psychotherapists, psychologists, social workers, paramedics, counselors, teachers, and others [1]. From the research findings of the last 20 years, awareness of the negative impact of compassion fatigue and the importance of maintaining quality of life in helping professions has been widely studied. Compassion fatigue is a complex and abstract concept [2]. Over the years, the term compassion fatigue has often been equated or replaced with the terms Secondary Traumatic Disorder (STD) and Burnout [3]. The term compassion fatigue was then first used in the health sector in 1992 by Joinson and was defined as ‘loss of the ability to nurture’, namely the loss of ability to nurture in emergency nurses. However, when examined from the perspective of education, psychology and counselling, Compassion can be defined as a feeling that arises when witnessing the suffering of others and motivates the desire to help [4]. Compassion is also conceptualised as a cognitive, affective and behavioural process that includes five elements that refer to the self and others, namely: 1) Recognising suffering; 2) Understanding the totality of suffering in the human experience; 3) Feeling empathy for the person suffering and relating to the distress (emotional resonance); 4) Tolerating uncomfortable feelings that arise in response to the person suffering (e.g. distress, anger, fear) so as to remain open and accepting of the person suffering; and 5) Motivation to act to alleviate suffering [5].

In the context of cultures in Europe and other countries except ASEAN, including Indonesia and Malaysia, exploring the essence of defining a comprehensive concept of compassion fatigue is important, considering that the literature review mostly examines the concept of compassion fatigue related to one of the helping professions, namely the nursing field. In fact, other occupations related to helping traumatised people can also carry the risk of experiencing pain as a direct reaction to exposure to traumatic events experienced by others. This difference is essential for follow-up, that in 15 years of experience, represents Compassion fatigue is often experienced by helping professionals such as nurses, social workers, psychotherapists, and other professions that often have demands to provide high levels of care to clients [6]. Helping professions are defined as those that involve professional interactions between an expert and a client, fostering growth or addressing a person's physical, psychological, intellectual or emotional condition, through medical treatment, nursing, psychotherapy, psychological counselling, social work, education or coaching [7, 8].

Researchers such as Alshammari & Alboliteeh, Portoghese et al.,, and Timofeiov-Tudose & Măirean, 2023 argue that [9,10,11] argues that compassion fatigue leads to high levels of burnout when seeing patients suffer and has negative consequences for caring that can impact the entire organization. The increasing awareness of the importance of studying work-related stress faced by healthcare workers has led some researchers to view the term 'compassion fatigue' as problematic and vague [2, 12]. For two decades, the term compassion fatigue has brought considerable attention to the nursing profession and health care workers [13]. Research results [14] that the issue of compassion fatigue of individuals who are highly compassionate will have consequences for themselves and cause harm in many situations. Under these conditions, when individuals attempt to see things from the perspective of the person who is suffering, then the individual may also suffer This situation is called compassion fatigue, which is an unintended consequence of work related to people who suffer [3].

Although awareness of compassion fatigue in education has emerged, research exploring the study of compassion fatigue is still limited. Most of the research on compassion fatigue was conducted in the Americas [15,16,17,18]. There are also compassion fatigue studies in other continents, namely Asia [19, 20], European [21], and Middle East [22]. Studies on compassion fatigue in education, especially in Southeast Asia, are scarce. The decision to use the scoping literature review method in this study was based on the observation that many articles deemed relevant to the compassion fatigue review only focus on the nursing profession and workers in the health sector.

The impact of this research not being explored, researchers will be comprehensively disorientated from the unclear definition of compassion fatique philosophically, compassion fatique. will not even know the pattern of emerging research methods, and inaccuracies to find research gaps at the basic, applied, as well as developmental research levels. Another impact will be the confusion for policy makers to make decisions related to curriculum, resources, and regulations. besides the absence of a platform built on the analysis of theoretical and empirical data to support strategy design, implementation in educational settings.

To fill the gap and serve as a foundation for more systematic research on compassion fatigue, this study aims to identify what is known about compassion fatigue in helping professions such as nurses, social workers, psychotherapists, counsellors, psychologists and other helping professions, which includes the conceptualization, predictors, and research development of compassion fatigue in helping professions.

Methodology

This research uses a qualitative approach with the Scoping Literature Review method. Literature Review is a systematic, explicit, and usable method for identifying, evaluating, and synthesizing a collection of works on a topic produced by researchers, academics, and practitioners [23]. A scoping review is a type of review that aims to extract as much relevant data from the literature as possible to provide a complete picture of what has been done [24]. Scoping reviews can identify key concepts, the size of the research pool, the type of evidence available, and research gaps [25].

The steps in conducting a scoping review follow the guidelines developed by Arksey & O’Malley [24], which consists of five stages, including: 1. identifying the research question 2. identifying relevant studies 3. selecting relevant studies 4. mapping the data 5. compiling, summarizing and reporting the results.

Stage 1. Identifying the research question

This study aims to identify what is known about compassion fatigue in helping professions. To achieve this research objective, the following research questions were formulated: 1. "What is the basic concept of compassion fatigue in helping professions?" 2. "What are the predictor factors that can affect compassion fatigue in helping professions?" 3. "How is the development of compassion fatigue research in helping professions?".

Stage 2. Identifying relevant studies

In this study, a systematic literature search was conducted through electronic databases, namely ScienceDirect, PubMed, and Taylor and Francis. The search was conducted using Medical Subject Heading (MeSH) is a comprehensive controlled vocabulary for the puposes of indexing journal articles and book in the life sciences. including compassion fatigue, key terms: Compassion fatique (CF), beyond CF, understanding CF, Helping CF, Needing CF, Predictors CF, Compassion satisfaction, development CF, Effect CF, Prevalence CF, Factor CF, Solution CF, Method CF.. The Boolean indicator 'AND' was also used to narrow the literature search regarding concept analysis, predictor factors, and research developments on compassion fatigue in the context of healthcare, education, psychology, and social workers. The inclusion criteria were: 1. All research designs (qualitative, quantitative, mixed-method, and others); 2. The existence of an abstract; 3. Full text and accessible; 4. The research setting is health, education, psychology, and social work; 5. There are no restrictions on the year of publication; 6. Discuss the concept, model, or theory of compassion fatigue; 7. Discuss the predictors of compassion fatigue; 8. Discuss the development of compassion fatigue research. The exclusion criteria set are: 1. Multiple references; 2. Not using English; 3. Research in other settings; 4. Articles related to the concepts based on criteria of Burnout, Secondary Traumatic Stress, and Vicarious Trauma; 5. Not relevant to the topic; 6. Grey literature (dissertations, reports, letters, etc.). The Eligibility criteria are presented in Table 1 and Fig. 1 Flowchart review process as follows.

Table 1 Eligibility criteria

Fig. 1

Flowchart review process. (Adaptation from PRISMA 2020 flow diagram)

Stage 3. Selecting relevant studies

In selecting relevant literature, this research uses the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) The stages are complete and detailed to conduct a literature review, there are 5 stages used, namely defining eligibility criteria, defining sources of information, literature selection, data collection and data item selection. 2020 flow diagram method which has four flow diagram phases [26]. After removing duplicate literature, the titles and abstracts of all articles were screened by the researchers by identifying exclusion criteria. After that, full text and non-full text were screened. Until the end of the selection stage, the final number of articles that meet the inclusion criteria and eligibility criteria is obtained. The eligibility criteria that must be met by each article are at least 4 of the 6 criteria. For criterion number 3, the star does not apply to articles that discuss the analysis of concepts, models, or theories.

Stage 4. Mapping the data

Data extraction from the selected literature was done using tables. Data extraction components for conceptualizing compassion fatigue include author name, year of publication, title, study type, profession, and purpose. The data extraction component for predictors of compassion fatigue includes the author's name, year of publication, study location, sample, research design, instruments used, and results. The data extraction component for compassion fatigue research development includes the author's name and year of publication, study location, research method, research population, instruments used, and results. All references were managed using Mendeley Desktop.

Stage 5. Synthesize data

The data synthesis stage in this research uses a narrative review approach, which focuses on collecting relevant information that provides context and substance to the author's overall argument [27]. Several characteristics of the studies that had been identified were then collected and summarized. The studies were summarized into a table and analysis was conducted on the tabulated data. Then the content was translated into the main themes, namely conceptualization, predictor factors, and research developments. The findings in this study were then interpreted, compared, and analyzed comprehensively.

The review process as illustrated in Fig. 1, started with 2,121 references retrieved from an electronic database. From the removal of multiple references (n = 43), not in English (n = 3), documents related to similar concepts such as Burnout, Secondary Traumatic Stress, and Vicarious Trauma (n = 138), research in other settings (n = 114), not relevant to the topic (n = 1,639), and grey literature (dissertations, reports, letters, etc.) (n = 2), 182 relevant articles were generated after the first stage of selection. After the first selection stage, the second selection stage was carried out by considering the availability of full text and accessible articles. A total of 182 full-text articles were included in the selection stage by considering the eligibility criteria. The final results showed that 67 articles were excluded and 42 articles met the eligibility criteria to be reviewed in this Scoping Literature Review. Validity and reliability are examined based on the credibility test using a triangulation strategy to check data on the same source with different techniques, then research sources from various reputable journals collected as many as 2121 which are then extracted with Vosviewer analysis to ensure they have accurate links. Transferability test, dependability test to audit the research results that replicate the research process and testing using ICR (intecoder reliability). besides the confirmability test.

Findings

A total of 42 articles met the inclusion criteria and eligibility criteria to be reviewed in this Scoping Literature Review. This research will answer the research questions regarding of the discussion is divided into three, namely: 1) Conceptualization of Compassion Fatigue; 2) Predictor Factors of Compassion Fatigue; and 3) Development of Compassion Fatigue Research.

Conceptualization of compassion fatigue

The following describes the development of the idea of compassion fatigue philosophically from 1992 to 2019. In earlier informal research, Figley [3] argues that the term compassion fatigue was first introduced by Joinson in 1992 to explain the 'loss of the ability to nurture', namely the loss of nurturing ability in emergency nurses. The construct of compassion fatigue was not defined in depth by Joinson, but later the concept of compassion fatigue was adopted by Figley [28]. Figley [3] mentioned the phenomenon of the "cost of caring" which is the loss of self-perception (sense of self) towards the client being served because of listening to the client's story of fear, pain, and suffering so as to feel the same feelings that arise because of caring. The state of stress that arises from this condition is a result of the desire to help people who have experienced traumatic events.

Figley describes compassion fatigue as "behaviors and emotions that result from knowing about traumatizing events" [3]. Pioneered the development of compassion fatigue. The compassion fatigue model by [3, 14] It links empathy with the caregiver's ability to connect with and help clients. This model is a multifactor model, which is based on 10 variables to predict the onset of compassion fatigue in psychotherapists. The eleven variables include: 1. empathic ability; 2. empathic concern; 3. exposure to the client; 4. empathic response; 5. compassion stress; 6. sense of achievement; 7. disengagement; 8. prolonged exposure; 9. traumatic recollections; 10. life disruption.

In concept, Figley [3] suggests that helping professions that are vulnerable to compassion fatigue are therapists who are accustomed to working with traumatized people. There are four reasons why trauma workers are particularly vulnerable to compassion fatigue, including: 1. Empathy is a key strength for trauma workers to help traumatized people. The process of empathy can help understand what the traumatized person is going through, but in the process, empathy can traumatize trauma workers. 2. Most trauma workers have experienced traumatic events in their lives. This can be a danger for trauma workers to over-generalize about their experiences and over-provide methods or ways of coping to clients. 3. Traumatic events recounted by clients can trigger the re-emergence of past traumatic events that have not been resolved by trauma workers. 4. Traumatic events experienced by children can be profocative for the therapist. In general, compassion fatigue occurs in individuals who have demanding jobs, such as informal caregivers who are at risk when caring for family members with dementia [29].

Another compassion fatigue model was developed by Gentry and Baranowsky [30], the Accelerated Recovery Program, a model for understanding the various causes of compassion fatigue. There are several symptoms of compassion fatigue which are divided into three, namely: 1. Intrunsive Symptoms, such as disruption of personal activities by work-related problems, thoughts related to the client's traumatic experiences. 2. Avoidance Symptoms, such as loss of energy, loss of enjoyment in activities, avoiding to hear about the client's traumatic event (silence response). 3. Arousal Symptoms, such as increased anxiety, sleep disturbances, difficulty concentrating, changes in weight/appetite, and others.

A concept analysis was developed by Coetzee & Klopper [28] which defines compassion fatigue in nursing practice. The process of defining compassion fatigue is described into various categories, namely as risk factors, causes, processes, and manifestations. "Risks" are things that create the opportunity or possibility of developing compassion fatigue, such as contact with patients, self-use, and stress that is long-term, intense, and continuous. "Causes" are things that cause compassion fatigue, such as compassion discomfort and compassion stress. The process category describes the sequence of events or sequences of compassion fatigue, while the manifestation category involves the consequences of compassion fatigue and describes the physical, social, emotional, spiritual, and intellectual effects of compassion fatigue. Thus, the definition of compassion fatigue is the end result of a progressive and cumulative process that develops from compassion stress after a period of compassion discomfort caused by prolonged, continuous, and intense contact with patients, self-use, and exposure to stress. It develops from an uncomfortable state of compassion, which if not relieved through adequate rest, will lead to compassion stress that exceeds the nurse's endurance level and ultimately results in compassion fatigue.

Compassion fatigue is medically defined as "cynicism, emotional exhaustion, or selfishness", also defined as "fatigue, emotional distress, or apathy that results from the constant demands of caring for others or from the constant appeals of charitable organizations" [31]. The relationships that occur between individuals experiencing compassion fatigue are based on empathy and have the potential to produce profound responses (physical, psychological, spiritual, and social fatigue) [32]. Figley states that specific consequences as a result of compassion fatigue include sleep disturbances, fear, anxiety, difficulty concentrating, physical sensations such as tense muscles, feeling overwhelmed, tired and overwhelmed with hopelessness and isolation that result.

[12] proposes a transactional compassion fatigue model in physicians, where a physician will behave compassionately in a given situation determined by the dynamic interaction between the physician, patient and family, clinical situation and environmental factors. Physician factors that can influence a physician's compassionate response include gender, personality, basic traits or dispositions, past clinical experience, and communication skills. Patient and family factors include personality, gratitude, compliance and expectations of care. Clinical factors include the extent to which a physician consciously or unconsciously holds the patient "responsible", for their condition, the complexity of the situation and the physician's expertise. Environmental and institutional factors relate to job demands and feelings of control at work [12]. Suggests that it is the interaction between these factors that drives affection or produces inhibition. In detail, the analysis of the summary of included literature of compassion fatigue conceptual analyses by year of publication is given in Table 2.

Table 2 Summary of included literature of compassion fatigue conceptual analyses by year of publication

Factors of compassion fatigue

Factors associated with compassion fatigue have been widely studied in various helping professions. These factors can be categorized as personal factors, which include professional and sociodemographic factors, and work-related factors [33]. Personal factors that influence compassion fatigue include resilience [34], burnout [9], moral courage [9], emotion control [35], empathy, compassionate care, mindfulness, self-judgement [36], compassion satisfaction [37], emotional exhaustion, physical status, number of children [35], female gender, mental health service utilization [38], and self-defeating humour [11]. Professional factors that influence compassion fatigue include professional competence, work experience, working in secondary hospitals, and applying passive coping styles [36], professional efficacy, [35, 39]. Work-related factors that influence compassion fatigue include traumatic experiences, life disruptions [36], job satisfaction [36], the number of patients admitted, the number of beds in service facilities [40], fluctuations in daily testimonies of patients suffering from [10], type of practice, having a multidisciplinary team, and emotional support outside the workplace [38].

A total of 10 of the 11 literatures reviewed in this scoping literature review used a cross-sectional research design. A total of three studies located in Italy, the United States, and Saudi Arabian [9,10,11] makes burnout a factor related to compassion fatigue. Burnout has a positive influence on compassion fatigue. High levels of burnout showed more emotional displays on days when they repeatedly witnessed patient suffering. Another study regarding personal factors, namely resilience is negatively correlated with compassion fatigue, meaning that individuals who have high resilience will have low compassion fatigue [34, 41, 42]. Moral courage has a slight and direct, but negative influence on compassion fatigue [9].

Life disruptions and traumatic experiences significantly predicted compassion fatigue and burnout. Female gender, significant emotional decline, use of mental health services, were predictors of high compassion fatigue. Self-oriented empathy plays an important role in influencing compassion fatigue through mediating mindfulness and counselor self-efficacy. Compassion fatigue effects high levels of burnout when seeing patients suffer. Other predictors: prior history of a severe illness, perspective taking, compassionate care, employee engagement, mindfulness, self-judgement, and over-identification. Other sociodemographic factors included income, marital status, mental health, empathy, mindfulness, and religious activity. The most studied potential predictors were age, gender, working hours, and workload [33]. The results of the literature review found, there is no literature that discusses predictor factors in the education profession.

In detail, The results of the litelature are organised based on the fields of education, psychology and medical which can be seen in the research sample. the analysis of the Summary of included literature of compassion fatigue factor predictor by year of publication is given in Table 3.

Table 3 Summary of included literature of compassion fatigue factor predictor by year of publication

Examination in various professional fields and the global development of compassion fatigue research

The compassion fatique starting from the research methods used, research samples, so that further research will know the follow-up process to fill the research gaps based on research methods and samples or strengthen the study of research methods. The development of compassion fatigue research is found in literature from various countries, such as the United States, China, Portugal, Canada, Iran, and England. Compassion fatigue has been studied by various professional fields, including healthcare [15,16,17,18,19, 22, 43,44,45,46,47,48], education [20, 49], psychology [50], and social workers [14]. The research methods used in the compassion fatigue literature found, namely using quantitative and qualitative approaches with various research designs. Some studies that use the literature review method include [2, 12, 13, 28,29,30,31,32, 51,52,53,54,55,56].

Compassion fatigue research is conducted on various helping professions, ranging from nurses, teachers, doctors, psychologists, coaches, paramedics, psychotherapists, pastors, and police. Research on compassion fatigue in the nursing profession is divided into several contexts, namely the context of prevalence with descriptive methods and cross-sectional survey designs [1, 22, 46], context of intervention with experimental method [44, 45], context of correlation study with descriptive correlation method [18, 47, 57]. There are differences in prevalence rates among nurses based on gender, age, education level, changes in nursing management, and system changes [17, 47]. Compassion statisfaction, compassion fatigue, and hardiness did not change during COVID-19 compared to before the COVID-19 period [22]. A study on interventions for oncology nurses found that mindfulness-based interventions (MBIs) mediated changes in burnout, anxiety and stress, and life satisfaction [58]. Developing sharper self-awareness is essential for recognizing and reducing CF and burnout [45]. A correlational study of mental health professionals and medical social workers found mindfulness to be a protective factor against compassion fatigue regardless of professional or student status [18]. Another study found that poor sleep quality, low job satisfaction, more working hours, and exposure to cigarette smoke were associated with compassion fatigue [57].

Research on compassion fatigue in the education profession found that educators with longer tenure in education and educators of color reported higher levels of compassion fatigue than their peers [49]. The importance of promoting school connectedness with educators in an interactive way to improve educators' occupational well-being. There were significant differences in compassion fatigue levels across helping professions. The highest levels reported were doctors, educators, home caregivers, nurses and psychologists. The lowest CF levels were psychotherapists and trainers which could be due to the poor quality of health and education systems in Central Europe [1]. In detail, the analysis of the Summary of included literature of research on compassion fatigue by year of publication is given in Table 4.

Table 4 Summary of included literature of research on compassion fatigue by year of publication

Discussion

This scoping literature review discusses the concept, predictors, and development of compassion fatigue research in various helping professions. This study reviewed 42 articles that met the inclusion criteria and eligibility criteria. A total of 16 articles were sampled in the discussion of conceptual analysis, 11 articles were sampled in the discussion of predictor factors, and 15 articles were sampled in the discussion of research developments on compassion fatigue.

Most of the literature reviewed in this study revealed that the term compassion fatigue was first introduced by Joinson in 1992 to explain the 'loss of the ability to nurture' in emergency nurses. Nurses feel tired, depressed, angry, ineffective, apathetic and uncaring, and experience somatic complaints such as headaches, insomnia, and indigestion due to heavy workloads and complex patient needs and these responses increase over time as a result of cumulative stress. Theoretically, Joinson argues that the term compassion fatigue is synonymous with the term burnout. Joinson (1992) revealed that intense stress can dominate an individual and interfere with his or her ability to function which makes the individual angry, ineffective, apathetic, and depressed. The symptoms exhibited by individuals in this condition are classified as burnout symptoms, especially if they occur on the job [59]. Explains that elements of burnout can occur in any environment, but there is one unique form of burnout, called compassion fatigue that affects people in the nursing profession. Unlike other burnouts, compassion fatigue is directly linked to specific people: nurses, ministers, counselors, and other caregiving professions. However, the nursing profession is the most vulnerable to compassion fatigue. There are four reasons why individuals should be aware of compassion fatigue and respond immediately, including: 1) Compassion fatigue is emotionally devastating; 2) Leads to the caregiver's personality; 3) External resources that cause it cannot be avoided; 4) Compassion fatigue is almost difficult to detect without a high level of awareness [59]. The three main issues of compassion fatigue in caregivers include: 1) Caregivers may perform some concrete functions, most of which are performed by themselves. They have to renew and rebuild themselves; 2) Human needs are infinite. Caregivers tend to feel that they can always provide help, but actually they cannot; 3) Caregivers perform multiple roles which can cause mental conflict [59]. Explains that nurses are highly valued for putting the needs of other individuals above their own. As they reach more advanced stages in their lives, they become more distant in their sensitivity to stressors as they learn how to stop them. Psychologically, nurses are prone to compassion fatigue. Symptoms of compassion fatigue follow the usual pattern of stress, recognizable symptoms include: 1) Becoming forgetful or having a short attention span; 2) Feeling tired and having periodic stomach aches and headaches; 3) Low resistance and frequent illness [59]. Being aware of symptoms and responding quickly and taking time to assess emotional health is key in dealing with compassion fatigue [59]. Other suggestions for dealing with stress realistically include: 1) Do not feel responsible for solving problems that are not part of the task and do not take over the problem; 2) Give yourself spiritual nourishment. Stay humble about what can and cannot be done [59]. Steps that can be taken for individuals who are trying to get out of compassion fatigue and become effective caregivers include: 1) Try to learn about boundaries; 2) Use humor to emphasize boundaries to others; 3) Give yourself permission to have personal time; 4) Give balance in life and set priorities; 5) Think about self-image; 6) Build a spiritual side (Chase in [59]). Reflect, assess, and renew oneself regularly so that individuals will be emotionally healthy [59].

There is literature that first discusses compassion fatigue, namely by [60] and [61]. [60] discussed her personal experience of feeling that her colleague was affected by compassion fatigue [60]. Is a doctor who has a serious illness that he has been suffering from for 5 years and cannot be told to other colleagues. However, he felt very disappointed because in reality the person who was considered capable of being relied on was the one who did not expect to hear how serious it was for him. This then raises the question that perhaps the biggest reason for the high suicide rate among doctors is because they are afraid to share their difficulties with their colleagues. Other literature by [61] discussed the national conference by Edward Poliandro, PhD, on stress and burnout in healthcare social workers. Increased compassion fatigue in caregivers is caused by the increased volume and frequency of problems, such as drugs, alcohol, violence, that caregivers face every day. Compassion fatigue is especially likely to occur in healthcare because helping professions, who are naturally compassionate people, often put the needs of others first and their own needs last. Putting one's own needs last over a period of time will lead to compassion fatigue and burnout (Poliandro in [61]. Compassion fatigue and burnout are different stages in a series of unity. Compassion fatigue occurs before entering the burnout stage [61]. Defines compassion fatigue as a psychological and emotional state, where the caregiver feels drained, numb, and exhausted. Unlike normal fatigue which can be alleviated by resting, compassion fatigue is chronic. Individuals lack the energy to interact with friends and family and find it difficult to react emotionally to others. Other signs are cynicism, anger, hostility, and irritability which are protective barriers against feeling overwhelmed [61]. If left unattended, compassion fatigue will lead to deeper problems of burnout or clinical depression that are difficult to correct [61]. Burnout usually occurs when chronic stress is left unrecognized for a long time.

Conceptual analysis of compassion fatigue cannot be generalized across healthcare settings or professions [13]. It is difficult to imagine how a conceptual model of compassion fatigue could be equally relevant and applicable to a variety of helping professions, such as a psychotherapist who may be chronically burdened with distressing memories of her clients, a nurse who is experiencing acute depression, a family practitioner who has long been involved in the care of patients with chronic illnesses, and a physician who has expressed difficulty remaining compassionate despite not being exposed to trauma [12]. This is also what is then limited in this study. Second, the antecedents and pathways of compassion fatigue should be based on a conceptual model that specifies the various elements of compassion fatigue, so that their determinants and relationships with each other can be clearly delineated. Currently, conceptual analyses of compassion fatigue tend to focus on limited aspects of compassion (e.g., behaviors, motivators) rather than its overall construction [13]. Compassion is multifaceted, involving benevolence, proactive response, attempts to understand, relational communication, confrontation, and action. Until the risk factors, antecedents, pathways and manifestations of compassion fatigue are identified, based on a valid multifaceted compassion model that is consistent and relevant across multiple healthcare professions, the construct validity of compassion fatigue is increasingly questioned. Third, the presence of any of the more than forty physical, behavioral, psychological and spiritual symptoms can validate the diagnosis of compassion fatigue, although generally more than one symptom must be demonstrated before a healthcare provider is identified as experiencing compassion fatigue [62].

A meta-narrative study states that 'compassion fatigue rests on the most fragile of foundations' [2]. This literature review identifies the concept of compassion fatigue as a euphemism for different types of occupational stress uniquely associated with healthcare providers that has no valid construct and therefore cannot be empirically validated or measured. As a result, researchers often equate compassion, sympathy, and empathy in conceptualizing compassion fatigue, ignoring the characteristics, motivators, outcomes, and responses that differentiate the two in the process. Conceptually, sympathy is understood as "a pity-based response to distressing situations characterized by a lack of relational understanding and self-preservation on the part of the respondent" [13]. Empathy has two components, namely cognitive empathy and affective empathy. Cognitive empathy is "the ability to understand another person's intentions, desires, beliefs resulting from reasoning (cognitively) about the other person's circumstances" and affective empathy is involving emotional resonance or feelings with the person in need. Although the concept of compassion fatigue is used synonymously with other work stress terms, an equally important issue is the unification of the etymological roots on which these are based.

The models developed by experts are aligned in terms of the positive and negative outcomes of caring for clients. The models are more vague in relation to the process or etiology of compassion fatigue, but the main aspect of concern is the balance of resources. [62] further builds on these models and explains the process or etiology of compassion fatigue through the application of conservation of resources (COR) theory to explain resource balance, and social neuroscience of empathy research to explain empathy use and stress appraisal, named the Compassion Fatigue Model.

To explain how resource balance affects the etiology of compassion fatigue or compassion statisfaction, COR theory is applied, as it is an integrated model of stress, and consists of several stress theories. The main principle of COR theory is that because people value resources, they seek to acquire resources they do not have, they defend resources they do have, they protect resources that are threatened, and they develop resources by ensuring that their resources can be put to their best use. Following this principle, COR theory includes two main principles and several secondary consequences. The first and most important principle is that "resource loss is much more important than resource gain." The second principle states that "people should invest resources to protect against resource loss, recover losses, and gain resources." These principles are implemented to show the balance of resources that influence the etiology of compassion fatigue or compassion statisfaction.

To explain how empathy and stress appraisal affect the etiology of compassion fatigue or compassion statisfaction, social neuroscience of empathy research. Empathy is the caregiver's ability to understand, imagine, or infer the client's suffering, grief, or pain, and express motivation to improve the patient's experience, with full awareness of the differences between him or herself and the patient. Social neuroscience has shown that certain neural structures, namely the bilateral anterior insular cortex and medial/anterior cingulate cortex, are associated with empathy for pain, and this overlaps with activation during directly experienced pain. In neuroscience it is also explained that there are two modes of information processing in empathy: experiential or propositional processing modes. The experiential processing mode is an involuntary response or bottom-up approach, whereas the propositional processing mode is usually a voluntary response or top-down approach.

The resources described in this Compassion Fatigue Model (CFM) theory include object, conditional, personal, and energy resources. Object resources are resources that have a physical presence and are valued based on their function or status, such as adequate infrastructure and staff. Conditional resources are structures or states that lay the foundation for access or ownership of other resources, such as spirituality or health. Personal resources are acquired through learning and result from role modeling, education and adoption. Personal resources include personal skills and traits. Personal skills include employability skills and leadership abilities, while personal traits include self-esteem and resilience [63]. Energy resources include actual energy, time, and knowledge [63]. This Compassion Fatigue Model (CFM) suggests that nurses with poor resources are more likely to experience compassion fatigue. While most resources relate to the individual level (conditional, personal, and energy resources), the practice environment (object resources) is an external resource that can be addressed through policies governing the healthcare sector and healthcare facilities and units. A positive practice environment results in better outcomes for nurses and patients [62].

This scoping literature review also sought to identify predictors of compassion statisfiction and compassion fatigue in various helping professions. A total of 16 articles on predictors reviewed in this study showed that most predictors of compassion fatigue were associated with burnout [9,10,11]. Studies that examine factors that predict compassion fatigue in this review are dominated by nurses, other professions are hospital staff and psychologist counselors. Factors that influence compassion fatigue in nurses and hospital staff are resilience, social support and subjective support, burnout, personal competence, moral courage, physical status, number of children, emotional control, professional efficacy, emotional exhaustion, cynicism, social support, work experience, work status, night shift, length of work experience, number of patients admitted, number of beds in the facility, trait-negative affect, empathy, job satisfaction, and self-compassion, life disruption, traumatic experience, prior history of a severe illness, perspective taking, compassionate care, employee engagement, mindfulness, self-judgement, and over-identification. Female gender was also a predictor of high compassion fatigue. In addition, fluctuations in daily interactions with suffering patients were also positively associated with the use of daily positive emotional regulation. For predictor factors that affect compassion fatigue in counselor psychologists, self-oriented empathy has an important role in influencing compassion fatigue through the mediation of mindfulness and counselor self-efficacy. Another factor is that sometimes burnout can start with colleagues. When people around feel tense, impatient, and rushed, individuals will also feel drawn to the same reaction (Joinson, 1992). Colleagues who feel tired, unsympathetic and cynical can sap the energy and enthusiasm of other individuals [59].

A discussion of the development of compassion fatigue research is also reviewed in this study. The development of compassion fatigue research is found in literature from various countries, such as the United States, China, Portugal, Canada, Iran, and England. Compassion fatigue has been studied by various professional fields, including healthcare [15,16,17,18,19, 22, 43,44,45,46,47,48], education [20, 49], psychology [50], and social workers [14]. The research methods used in the compassion fatigue literature found, namely using quantitative and qualitative approaches with various research designs. Some studies that use the literature review method include [2, 12, 13, 28,29,30,31,32, 51,52,53,54,55,56]. Articles that use a cross sectional research design include [9,10,11, 34,35,36,37,38, 64, 65].

The implications of the research results examine the conceptualisation of compassion fatique as a philosophical and theoretical basis developed to deeply understand the series of situations created from the process of research experience, meaning, generation of ideas, construction of thought flow and culture that have an impact on gaining and strengthening understanding of compassion fatique. Scoping the Compassion Fatigue literature has implications for providing comprehensive analyses of the impact of philosophical research, compassion fatigue, patterns of research methods to follow up or explore emerging research, and accurately locate research gaps for basic, applied, and developmental research. Scoping the Compassion Fatigue literature informs decision-making for policy makers related to curriculum, resources, and regulations. Scoping Compassion Fatigue literature becomes a foundational piece in creating a platform that builds on theoretical and empirical data analyses to support strategy design, implementation in educational settings.

Conclusion

The concept of compassion fatigue developed by experts is still unclear in relation to the process or etiology of compassion fatigue. The various models developed cannot be generalized and applied relevantly to various helping professions. The models that have been developed are dominated by the healthcare field. Further analysis is needed to develop a conceptual analysis of compassion fatigue that focuses on other fields of work more specifically and comprehensively. The development of the compassion fatigue model as a conceptual analysis needs to include various elements or aspects of compassion fatigue, a clear depiction of the determining factors and their relationship with each other, as well as the validity and determination of the physical, behavioral, psychological and spiritual symptoms that affect it so that individuals who experience compassion fatigue can be identified appropriately. In the literature found, compassion fatigue is influenced by personal factors which include professional factors and sociodemographic factors as well as work-related factors. Research on compassion fatigue has developed a lot, especially in the health sector, especially nursing using experimental, cross-sectional, and literature review research methods. Expansion of research development is needed in the fields of education and psychology.