The Impact of the COVID-19 Pandemic on Burnout, Compassion Fatigue, and Compassion Satisfaction in Healthcare Personnel: A Systematic Review of the Literature Published during the First Year of the Pandemic

This literature review aimed to determine the level of burnout, compassion fatigue, and compassion satisfaction, as well as their associated risks and protective factors, in healthcare professionals during the first year of the COVID-19 pandemic. We reviewed 2858 records obtained from the CINAHL, Cochrane Library, Embase, PsycINFO, PubMed, and Web of Science databases, and finally included 76 in this review. The main results we found showed an increase in the rate of burnout, dimensions of emotional exhaustion, depersonalization, and compassion fatigue; a reduction in personal accomplishment; and levels of compassion satisfaction similar to those before the pandemic. The main risk factors associated with burnout were anxiety, depression, and insomnia, along with some sociodemographic variables such as being a woman or a nurse or working directly with COVID-19 patients. Comparable results were found for compassion fatigue, but information regarding compassion satisfaction was lacking. The main protective factors were resilience and social support.


Introduction
Because healthcare professionals are especially exposed at the frontline of the COVID-19 pandemic, their quality of life has been put at great risk. Among several potentially harmful factors for the health of professionals, some authors have highlighted the lack of access to adequate protective equipment [1], exhaustion resulting from wearing personal protective equipment throughout the working day, the feeling of having inadequate support [2,3], long working hours and unexpected changes in the type of work [4], concern about trapping or infecting their relatives [5], abandoning their homes to avoid infecting their families [6], lack of access to updated information on constantly changing patterns of action [3,7], uncertainty about disease containment [1], and concerns about seeing patients die [5].
Thus, it seems clear that health professionals are under extreme psychological pressure and, consequently, are at risk of developing several psychological symptoms and mental health disorders [3]. For example, a recent review that included data from more than 7000 professionals [4] found that the prevalence of PTSD symptoms and anxiety and depression ranged from 9.6% to 51% and 20% to 75%, respectively. High levels of stress and somatic symptoms were also reported in Italian health professionals in the study by Barello et al. [8]. Furthermore, a study by Kotera et al. [9] in Japan, found that physicians 1.
What levels of burnout, compassion fatigue, and compassion satisfaction have health professionals who worked during the COVID-19 pandemic experienced? 2.
What variables (risk factors) were related to the COVID-19 pandemic having a greater negative impact on professional quality of life? 3.
What variables (protective factors) corresponded to the COVID-19 pandemic having a lower negative impact on professional quality of life?

Materials and Methods
To complete this work we conducted a systematic review of the scientific literature, following the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines [37] (see Online Supplement S1).

Type of Participants
Health professionals (physicians, nurses, nursing assistants, psychologists, etc.) who carried out their professional activities in the health system (such as primary healthcare centers, emergency departments, intensive care units, palliative care units, or COVID-19 services, among others) during the COVID-19 pandemic were considered in this work.

Study Variables
We considered studies that addressed burnout, compassion fatigue, and compassion satisfaction in health professionals who had cared for patients infected by COVID-19.

Study Types
We included quantitative studies (either cross-sectional or longitudinal) with primary data that addressed burnout, compassion fatigue, and compassion satisfaction in healthcare professionals during the COVID-19 pandemic. Studies published, or that were in press, from 1 January 2020 to 31 December 2020, were considered.

Language
Articles published in English or Spanish were included.

Publication Date
Articles published during 2020 (from 1 January 2020 to 31 December 2020) were considered.

Exclusion Criteria
The following types of work were excluded: studies that did not consider healthcare professionals; did not include our study variables (burnout, compassion fatigue, and/or compassion satisfaction); did not include quantitative primary data (i.e., single case studies, reviews, letters to the Editor, comments, qualitative studies, etc.); were not published in Spanish or English; were not published during the year 2020; and that included data from before the COVID-19 pandemic, even when the work met all the inclusion criteria.

Data Sources and Search Strategy
We searched the CINAHL, Cochrane Library, Embase, PsycINFO, PubMed, and Web of Science databases for relevant articles. Thus, we only used reliable, peer-reviewed databases, platforms, and sources with search tools that allowed us to access the study dates, and thereby, systematically identify studies. These databases included academic literature related to various health disciplines, including health psychology, and therefore represented reliable sources of expert research and information.
The keywords we used were: • Pandemic or COVID-19 or SARS-CoV-2 or Coronavirus, as well as the synonyms for these terms included in the Medical Subject Headings (MeSH) database; and • Burnout or compassion fatigue or stress disorders or compassion satisfaction, as well as the synonyms for these terms included in the MeSH; and • Health personnel or nursing staff or nurses or physicians or psychology, as well as the synonyms for these terms included in the MeSH.
A list of the terms found in the MeSH, together with the equation we used in the final search, is provided in Online Supplement S2.
Regarding the review procedure, first we entered the search equation into each of the databases, filtering them by publication date (1 January 2020 to 31 December 2020) to narrow the results based on the eligibility criteria. Second, the eligible papers were identified based on their title and keywords as well as whether they met the inclusion criteria. Third, we read the abstracts, reserving any studies we believed met the inclusion criteria. Finally, the full texts of these articles were obtained and read. After this reading, we chose the final records for inclusion and performed the data synthesis.

Data Extraction and Synthesis
The data from the publications obtained in the search strategy were extracted into an Excel template that was modified according to the studies we reviewed. The metadata included the author(s), year of publication, country of study, main study objective, design, sample size, types of participating professionals, distribution by gender, mean age, other sample characteristics, assessment instruments, metrics used for each variable, descriptive and inferential results relative to the prevalence, data collection date, risk factors and protective variables for burnout, compassion fatigue, and compassion satisfaction. Specifically:

1.
Means and standard or median deviations and interquartile ranges (for quantitative data), frequencies and percentages (for categorical data) of the prevalence data for burnout, compassion fatigue, and compassion satisfaction.

2.
To study the risk factors and protective variables of burnout, compassion fatigue, and compassion satisfaction, chi-squared tests, contrast of means, and analysis of variance (for categorical variables), Pearson correlations, Spearman correlations, and simple and multiple regressions (for quantitative variables) were used.

Results
When applying the inclusion and exclusion criteria to the results from the six databases, the search equation produced 2856 records. As shown in Figure 1, these were reduced to 2498 records once the publication date was limited. We reviewed all these entries, first by title and then by abstract, leaving a total of 234 total records for full text review. Most of these were excluded because they did not meet one or more of the inclusion criteria (i.e., health professional participants, burnout, compassion fatigue, compassion satisfaction variables, etc.). After reading the full texts of all these entries, 76 records were retained for inclusion in this review. The main characteristics of these tests are summarized in Table 1.  Aafjes-van Doorn (2020) [38] To learn how vicarious trauma affected psychotherapists during the COVID-19 pandemic.
United States of America     [45] To identify the contribution of personaland work-contextual variables (gender, work position, years of experience, and proximity to infected patients) in the dimensions of professional life (satisfaction, burnout, and secondary trauma). To analyze the impact of these dimensions on health workers' mental health.  Çelmeçe and Menekay (2020) [46] To determine the effect of the levels of stress, anxiety, and exhaustion on the quality of life of health professionals who actively worked in hospitals during the COVID-19 pandemic. To assess the prevalence of anxiety and depression symptoms in healthcare workers during the COVID-19 pandemic, and to identify the associated risk factors. Burnout (MBI) and post-traumatic growth (PTGI-SF): Burnout: the depersonalization score was moderate M = 5.5 ± 4.6. Women, critical unit workers, and staff in departments related to COVID-19 had significantly higher depersonalization scores (p < 0.001). The average score for lack of personal accomplishment was M = 19 ± 8.4; participants experienced a small lack of personal accomplishment. Post-traumatic growth: the mean post-traumatic growth score was M = 28.0 ± 11.5; participants scoring in the 60th percentile or higher showed personal growth because of the effects of COVID-19. To assess the prevalence of burnout among physicians and nurses in the emergency services and urgent care centers of a regional health group through a cross-sectional study.  Correia and Almeida (2020) [53] To identify the main psychosocial variables that could have been protective factors for burnout in physicians and nurses in the first 2 months of the COVID-19 pandemic in Portugal. Physicians: there were statistically significant negative correlations between burnout and depersonalization, and income; confidence in COVID-19 policies; peer justice; distributive justice; procedural justice; and professional identification. There was a positive significant association between workload, and burnout and disengagement. Cognitive empathy, meaningful work, patient fairness, and patient family fairness were negatively correlated with disconnection. Male sex was also a risk factor for disconnection. Nurses: significant negative correlations for burnout and depersonalization, and income; confidence in COVID-19 policies; meaningful work; peer justice; patient justice; family patient justice; distributive justice; procedural justice; and professional identification. Burnout was positively associated with affective empathy and negatively associated with age, years of professional experience, and COVID-19 task changes. Female sex was a risk factor for burnout. Disconnection was significantly negatively related to religion. Burnout and disconnection were positively associated with workload.   [57] To explore the relationships between the dimensions of exhaustion and various psychological characteristics in Italian primary care physicians during the COVID-19 emergency. People with elevated levels of burnout showed less resilience and more often adopted a task-oriented coping strategy than the medium-risk group.

Dimitriu et al. (2020) [58]
To measure the prevalence of burnout syndrome during the COVID-19 pandemic in resident physicians. The overall prevalence of burnout syndrome among resident physicians was high. Burnout was significantly more common in residents who worked in regular services (group B) compared to resident physicians who worked in services considered frontline departments (group A; 86% vs. 66%, p = 0.050).
Dincer and Inangil (2020) [59] To investigate the effectiveness of implementation of the emotional freedom technique (EFT) program in the prevention of stress, anxiety, and burnout in nurses treating COVID-19.  Burnout, secondary traumatic stress, and compassion satisfaction (ProQOL-5); depression and anxiety (DASS-21); and post-traumatic stress (PCL-C): Burnout levels were generally medium (90.6%); the oldest participants in the sample (36-55 and < 56) showed more burnout than the younger participants. Burnout was higher in physicians than in nurses and no difference was found between nurses and technicians/assistants. There were no differences in burnout between those who had or had not been in direct contact with COVID-19. Secondary traumatic stress levels were low (0.2% high and 19.2% medium). Compassion satisfaction levels were high (33.2%) or medium (63.1%). The highest levels of compassion satisfaction were found among participants aged 26-35 and 36-55 years. Compassion satisfaction was higher in technicians/assistants than in nurses, while it was higher in nurses than in physicians. Levels of depression, anxiety, stress, and post-traumatic stress were significantly higher in nurses and technicians/assistants than in physicians.  Burnout (OLBI): The occupational stress (p = 0.006) and burnout (p = 0.002) scores in the exposure group were significantly higher than in the non-exposure group. Work stress was the only factor that was significantly linked to COVID-19-related burnout (β = 0.308, p = 0.031).

Hu et al. (2020) [70]
To assess mental health (burnout, anxiety, depression, and fear) and its associated factors among frontline nurses caring for COVID-19 patients in Wuhan, China. To assess the burnout and resilience of frontline emergency nurses in a tertiary care facility.  Burnout (PFI), and depression and anxiety (DASS-21): The group of health workers exposed to COVID-19 had higher scores for burnout compared to those not exposed (46.3% and 33.7%, p = 0.011). The exposed group had a higher prevalence of stress (29.4% and 18.9%, p = 0.016); there were no differences in anxiety (21.6% and 14.9%, p = 0.089) and both groups had similar rates of depression (28% and 26.3%, p = 0.700). Participants who were exposed to patients with COVID-19 reported significantly greater levels of stress compared to those who were not exposed to patients with COVID-19 (    To assess the symptoms of post-traumatic stress, anxiety, depression, and levels of burnout and resilience in Spanish health workers during the COVID-19 pandemic, as well as the relationship between these factors.

Author and Year Aims Country Sample Results
Manzano-García and Ayala-Calvo (2020) [83] To study whether the perception of threat generated by the COVID-19 pandemic explained burnout in nurses, and its moderating effect on the influence of resources and demands on burnout.   Nurses who were dissatisfied with the care they had rendered had higher perceived stress compared to those who felt competent (M = 33.5 ± 9.9, M = 30.9 ± 8.7, t = 7.131, p = 0.028). Nurses with a higher education degree who tested positive for COVID-19 showed more symptoms of depression (p < 0.050).

Ng et al. (2020) [88]
To assess the prevalence of burnout in oncological health professionals during the COVID-19 pandemic.

Sagherian et al. (2020) [91]
To know the prevalence of insomnia, fatigue, and psychological well-being (exhaustion, post-traumatic stress, and psychological distress), and examine the differences in these measures based on the working characteristics of nursing personnel during the COVID-19 pandemic in the USA.  To analyze the effect of psychosocial risks and emotional intelligence on burnout.  To analyze the psychological adjustment of Italian healthcare professionals during the peak of the COVID-19 pandemic in terms of perceived stress, anxiety, depression, and professional quality of life.
Italy n = 627 Healthcare professionals exposed to COVID-19 patients: 306 Healthcare professionals not exposed to COVID-19 patients: 321 Burnout To identify the coping strategies used by emergency and healthcare professionals to deal with stressors related to the COVID-19 pandemic that may be associated with the risk of developing vicarious trauma.  . Those who had seen 10-50 or >50 COVID-19 patients had a 17% and 28% higher risk of exhaustion than those who had seen <10 patients. The limited availability of PPE and shortage of nurses were associated with a risk of burnout > 30% and 18%, respectively. The most common concerns included transmitting the infection to family members (61%), emotional distress and exhaustion (52%), concerns about their own health (44%), and experiencing social stigma from their communities (21%). All health concerns were highest in North America.

Wu et al. (2020) [104]
To compare the prevalence of burnout in physicians and nurses in frontline and non-frontline services.
United States of America n = 190 Frontline services: Men: 28% Women: 72% Non-frontline services: Men: 6% Women: 94% Burnout (MBI): the prevalence of exhaustion was significantly lower in the frontline group than in the non-frontline group (13% vs. 39%; p < 0.001). The prevalence of a low level of personal accomplishment was lower in the frontline group than in the non-frontline group (39% vs. 61%; p = 0.002).
Yörük and Güler (2020) [105] To investigate the relationship between stress, psychological resilience, burnout syndrome, and sociodemographic factors and depression in midwives and nurses during the COVID-19 outbreak.   To assess the psychometric properties of the 10-item Moral Injury Symptom Scale for health professionals (MISS-HP). The research included in this review was all carried out between February and May 2020, with most of the studies having collected data between March and April (that is, Kannampallil et al. [72]; Ruiz-Fernández et al. [95]; Trumello et al. [101]). Most of the study samples included 100 to 400 participants; Chen et al. [48] included the largest number of participants (12,596 people), while the smallest study cohort was limited to 80 participants [59]. As shown in Table 1, physicians and nurses were the most-studied groups, either separately or together, during the health crisis caused by SARS-CoV-2. In addition, several researchers also focused on other medical professionals including residents, assistants, administrative personnel, physiotherapists, and laboratory technicians, among others. In terms of gender, the samples in 83.4% of the studies comprised more than 50% women, with only 16.4% of the articles including more men than women [39,41,42,[50][51][52]54,56,64,74,89,94].
The average level of burnout among healthcare professionals was high, especially on the emotional exhaustion and depersonalization subscales [7,39,43,52,63,64,71,88]. Some studies indicated high scores as a consequence of the pandemic on the personal accomplishment subscale [75,78], although these were lower in other studies [7,39,52,60,84]. Numerous reports pointed out the influence that some variables had on the perception of burnout, although 31% (24) of the studies that evaluated burnout did not study its relationship with other variables. The most-studied variables were gender, profession, and workplace (COVID-19/frontline rooms vs. non-COVID-19/secondline rooms). Women showed higher scores on the emotional exhaustion and depersonalization subscales [43,51,76,85,90,93,96,103,110].
Regarding the professional category, higher burnout scores were reported for nurses in several articles [46,49,65,85,100,103], although others pointed towards higher levels of burnout among physicians [62,94]. In terms of the workplace, the results were also contradictory; some research indicated that health workers on the frontline against COVID-19 suffered less burnout [58,104], while the majority found higher burnout scores among these same health workers [40,63,69,72,93,95,101,106,109]. Compared to the general population, healthcare personnel showed higher burnout scores [55,80]. The number of patients attended to also appeared to influence the level of exhaustion: the more COVID-19 patients seen by the participants, the higher their levels of exhaustion [54].
The risk factors, or those that showed a positive relationship with burnout, were anxiety and depression [82,106,108], insomnia [96,106], and moral damage [106]. Work stress also influenced burnout [69] and the lack of personal protective equipment affected emotional exhaustion [39,57]. Protective factors, or those whose presence was related to lower levels of burnout, included resilience and social support [70], and quality of life [46]. In addition, two studies observed that different interventions positively affected the levels of burnout in health workers. For example, Dincer and Inangil [59] implemented a program of emotional freedom techniques that reduced the level of burnout in healthcare personnel.
Likewise, Lee et al. [79] found that following a coping strategies program resulted in lower levels of burnout among healthcare professionals. Finally, positive correlations were observed between burnout and secondary trauma or compassion fatigue [45].
Regarding the protective and risk factors for compassion fatigue, again, the studies we considered focused on variables such as gender, profession, or workplace. Specifically, working with COVID-19 patients tended to increase secondary trauma scores [44,109]. Being a woman was also associated with higher levels of compassion fatigue [17,91]. Additionally, the professional category seemed to influence the perception of fatigue, although the results were inconclusive. Physicians showed higher compassion fatigue scores in the study by Ruiz-Fernández et al. [95]. Franza et al. [67] found that mental health workers had higher compassion fatigue scores, while the groups of therapists and nurses showed reduced compassion fatigue and lower scores on the burnout and secondary trauma subscales with respect to groups of physicians and psychologists. In any case, studies of this nature were scarce.
Finally, compassion satisfaction was only studied in four (5%) of the studies included in this current review [45,62,91,95] and the ProQOOL-5 questionnaire [23] was used to assess this factor in all these studies. In terms of the levels of compassion satisfaction, the study by Buselli et al. [45] found mean levels of 38.2 ± 7.0 for the sample of physicians and nurses. Along the same lines, Dosil et al. [62], reported high (33.2%) or medium (63.1%) levels of compassion satisfaction in health professionals. The latter authors also observed a relationship between compassion satisfaction and professional category, with higher levels of compassion satisfaction being reported in medical assistants/technicians compared to nurses and physicians. In contrast, Ruiz-Fernandez et al. [95] found that nurses had higher scores for compassion satisfaction than physicians. The last study that evaluated compassion satisfaction did not provide descriptive or inferential data in this regard [91].

Discussion
The main objective of this work was to understand the impact of the COVID-19 pandemic on the quality of life of healthcare professionals, specifically in terms of burnout, compassion fatigue, and compassion satisfaction. To this end, we carried out a systematic review of the literature produced during the first year of the pandemic (2020) which, after screening 2856 records, finally included 76 research papers. The main characteristics of the samples included in the reviewed studies agreed with those previously reported for health professionals in other systematic reviews, in which nurses and women predominated as the main participants [111][112][113]. Considering the results we obtained, it is evident that burnout is still used as the main indicator of emotional well-being in health professionals, much more so than other variables such as fatigue and compassion satisfaction that are used in the more recent literature. The data in this review coincided with those from Mol et al. [113], in which 88% of the articles they examined evaluated exhaustion, while compassion fatigue and compassion satisfaction was considered only in 21% and 5% of the cases, respectively.
Regarding the effect of the pandemic on health workers, we observed a worsening of the level of burnout. Specifically, in many of the studies [7,39,43,52,63,64,71,88], the scores for emotional exhaustion and depersonalization exceeded the medium-high levels obtained in pre-pandemic reviews [111,114,115]. However, for certain professional profiles such as healthcare professionals in the oncology area, elevated levels of emotional exhaustion and depersonalization had already been identified prior to the pandemic [116]. Of note in this present review was the fact that, compared to previous reviews which described very heterogeneous prevalences ranging from 0% to 80% [117], the levels of burnout in the studies we considered were more homogeneous, ranging from 30% to 60% [39,43,55,71].
In the same way that burnout increased in health professionals during the COVID-19 pandemic, an increase in compassion fatigue or vicarious trauma was also observed during the same period. Coinciding with the review by Xie et al. [118] implemented in emergency nurses before the COVID-19 pandemic, our results suggest that healthcare professionals had high scores for compassion fatigue [17,44,45,91,95,101], although other studies [38] have reported medium levels for this factor. In contrast, reviews conducted prior to the COVID-19 pandemic found moderate levels of compassion fatigue among healthcare workers [114,115]. However, very little data regarding compassion satisfaction were available, and some of these studies were inconclusive [91]. The levels of compassion satisfaction were generally medium or high [62], and were similar to those from before the COVID-19 pandemic. For example, the data collected by Xie et al. [118] from 2015 to 2019, found medium compassion satisfaction levels among oncology nurses.
Regarding the risk factors for developing burnout, our results indicate that the variables that influenced professional quality of life were gender (female sex), profession (nursing), and the workplace (attending or not attending patients with COVID-19). Indeed, the first two risk factors have already been recorded elsewhere in the literature [111,119]. Other variables that emerged as risk factors in this current review included anxiety, depression, and insomnia. Along the same lines, Gómez-Urquiza et al. [116] also highlighted these same risk factors for burnout. Furthermore, the same risk factors have also been observed for compassion fatigue. Finally, given the scarcity of results, we were unable to detect risk or protective factors for compassion satisfaction. In agreement with results from before the pandemic, the protective factors against burnout detected in this review included resilience, social support, and participating in interventions to reduce burnout. For example, in research on resilience and burnout, Heath et al. [120] found that preventive strategies, self-care, organizational justice, and having individual and organizational preventive strategies were protective factors against the development of emotional exhaustion. In fact, these interventions were already being implemented, and were equally effective before the COVID-19 pandemic [113].
Finally, it is worth highlighting both the strengths and limitations of this present study. Of note, although some literature reviews from prior to the pandemic focused on burnout among healthcare professionals, very few studies evaluated compassion fatigue, and even fewer studied the effect of compassion satisfaction. Reviews that focused on the impact of COVID-19 were much scarcer, with only one considering compassion fatigue and none having reviewed the literature on compassion satisfaction. Additionally, even though research focusing on burnout was more abundant, a much higher proportion of the relevant academic literature was considered in this present review. For example, the review by Sharifi et al. [35] on burnout among healthcare workers during the COVID-19 pandemic only included 12 studies; Chew et al. considered 23 studies evaluating emotional exhaustion and other variables; and Amanullah and Ramesh [32] only included five articles. Similarly, the only review available on vicarious trauma only included seven studies [36] compared to the 16 considered in this present review. Regarding the limitations of our work, we did not assess the quality of the articles we included in this review. Furthermore, to facilitate the synthesis of the results, we only included quantitative studies; therefore we may have excluded qualitative studies containing relevant information. In this sense, future work could assess the information collected in these qualitative studies.

Conclusions
Based on the results of our work, and in light of the literature we reviewed, we concluded that the quality of life of health professionals was significantly affected by the COVID-19 pandemic. Specifically, burnout levels increased from medium-high to high and compassion fatigue went from medium to high. Healthcare professionals reported high rates of emotional exhaustion, depersonalization, low personal accomplishment, and compassion fatigue, and low rates of compassion satisfaction. In addition, given that research from all five continents was included in this review, these findings can be considered global.
Therefore, in light of the results, we can say that the vulnerability of healthcare professionals to processes such as burnout or compassion fatigue has increased even more as a result of the COVID-19 pandemic. These problems, in addition to affecting the quality of care provided by health personnel, have a negative impact on professionals' well-being and quality of life; this can aggravate the lack of health professionals that health systems have suffered around the world for decades. Of note, the risk factors and protective factors have not changed compared to previous findings, meaning that we already have the scientific knowledge required to implement interventions to mitigate the empathic burnout of our healthcare professionals. We can no longer afford not to implement preventive strategies to prevent processes such as burnout and compassion fatigue in health professionals.
Supplementary Materials: The following supporting information can be downloaded at: https: //www.mdpi.com/article/10.3390/healthcare10020364/s1, Supplement S1 PRISMA checklist, Supplement S2 Keywords and search terms used in the systematic review.