Compassion Fatigue in Out of Home Care Workers: A Systematic Review

Figures & data

Figure 1. PRISMA (2020) flow diagram.

Table 1. JBI critical appraisal checklist for analytical cross-sectional studies.

	JBI Questions
Author	1	2	3	4	5	6	7	8	JBI Score	%
Borjanić Bolić (2019)	N	Y	N	-	N	N	Y	Y	3	43
Bridger et al. (2020)	N	Y	N	-	N	N	Y	Y	5	71
Eastwood and Ecklund (2008)	N	Y	N	-	N	N	Y	Y	3	43
Hannah and Woolgar (2018)	Y	Y	Y	-	N	N	Y	Y	5	71
Harker et al. (2016)	N	Y	N	-	N	N	Y	Y	3	43
Hiles Howard et al. (2015)	N	Y	N	-	N	N	Y	U	2	29
Steen and Berhardt (2023)	Y	Y	N	-	N	N	Y	Y	4	50
Steinlin et al. (2017)	N	Y	N	-	N	N	Y	Y	3	43
Teculeasa et al. (2023)	N	Y	N	-	N	N	Y	Y	3	43
Whitt-Woosley et al. (2020)	N	Y	Y	-	N	N	Y	Y	4	57
Whitt-Woosley et al. (2022)	Y	Y	N	-	N	N	Y	Y	3	43
Zerach (2013)	N	Y	N	-	N	N	Y	Y	3	43

Y = yes, N = no, U = unclear, - = not applicable. Higher total scores and percentages are indicative of higher quality documents. Note JBI criterion can be seen in Supplementary Materials.

Table 2. JBI checklist for quasi-experimental studies (non-randomised) experimental studies.

	JBI Questions
Author	1	2	3	4	5	6	7	8	9	JBI Score	%
Garwood et al. (2020)	Y	-	-	N	Y	Y	Y	Y	Y	6	75

Y = yes, N = no, u = unclear, - = not applicable. Higher total scores and percentages are indicative of higher quality documents. Note JBI criterion can be seen in Supplementary Materials.

Table 3. JBI critical appraisal checklist for qualitative research.

	JBI Questions
Author	1	2	3	4	5	6	7	8	9	10	JBI Score	%
McNamara (2010)	Y	Y	Y	N	Y	N	N	Y	Y	Y	7	70%

Y = yes, N = no, u = unclear, - = not applicable. Higher total scores and percentages are indicative of higher quality documents. Note JBI criterion can be seen in Supplementary Materials.

Table 4. Study and participant characteristics.

Authors	Country	Setting	Type of Worker	Demographic details	Outcome Measure (s)
Borjanić Bolić (2019)	Serbia	Foster and residential care houses	Mixed sample of care workers across a variety of settings	N = 135 85.9% female Age range < 35 to >55 yrs Experience range < 5 to >40 yrs	Secondary Traumatic Stress, Vicarious Trauma
Bridger et al. (2020)	United Kingdom	Foster homes and residential care houses	Foster carers	N = 187 81.3% female Age range 23 to 72 yrs Experience range 2 to 5 yrs	Secondary Traumatic Stress
Eastwood and Ecklund (2008)	USA	Residential care houses	Residential care workers	N = 57 75% female 50.9% tertiary qualifications Median age 29 yrs	Compassion Fatigue
Garwood et al. (2020)	USA	Residential care houses	Child welfare staff including residential care workers	N = 164 93% female Age range < 30 to 51+years Experience range < 1 to 15+yrs	Secondary Traumatic Stress
Hannah and Woolgar (2018)	United Kingdom	Foster home	Foster carers	N = 131 77.1% female 91.6% > 40 yrs 66.4% married 90.1% have children 49.6% tertiary/professional qualifications	Secondary Traumatic Stress
Harker et al. (2016)	Australia	Foster home	Foster carers & Human service professionals	N = 133 79.7% female Age range 20 to 64 yrs	Secondary Traumatic Stress
Hiles Howard et al. (2015)	USA	Foster home	Mixed sample of residential care workers across a variety of settings	N = 192 83.9% female Age range 24 to 71 yrs 59.3% married 60.9% have children 100% tertiary qualification	Secondary Traumatic Stress
McNamara (2010)	Australia	Residential care houses	Residential care workers	N = 12 10 Workers 2 Supervisors	Vicarious Trauma
Steen and Berhardt (2023)	USA	Foster home	Foster carers	N = 47 43% female 26% 31–45 years old Years as foster parent: M = 6.8, SD = 7.0	Secondary Traumatic Stress
Steinlin et al. (2017)	Switzerland	Residential care houses	Residential care workers	N = 319 61% female 36% have children Age range 23 to 65 yrs Experience range 0-38 yrs	Secondary Traumatic Stress
Teculeasa et al. (2023)	Romania	Foster home	Foster carers	N = 165 94% female Age M = 49.4, SD = 8.03 59% high school graduates 58% work experience in child protection services for >10 years 20% looking after > 3 children	Secondary Traumatic Stress Burnout
Whitt-Woosley et al. (2020)	USA	Foster home	Foster carers	N = 1161 Age range 22 to 73 yrs 80.5% female 83.4% married 34.7% tertiary qualifications Years’ experience: M = 4.7, SD = 5.2 Children fostered: M = 11.4, SD = 26.1	Secondary Traumatic Stress Burnout Compassion Satisfaction
Whitt-Woosley et al. (2022)	USA	Foster and residential care houses	Mixed sample of foster parents, child welfare professionals, educators, mental health professionals, health care professionals, and other helping professionals	N = 550 84% female Age M = 42.77, SD = 10.54 77% married 73% foster parents 36% tertiary qualifications	Secondary Traumatic Stress Burnout
Zerach (2013)	Israel	Residential care houses, boarding school houses	Residential care workers (RCW) and educational boarding school workers (BSW)	N = 147 (RCWs) 53.1% male 60.5% single 53.8% tertiary qualifications N = 74 (BCW) 44.6% male 78.4% single 60.8% tertiary qualifications	Secondary Traumatic Stress Burnout Compassion Satisfaction

Note: other outcome measures were investigated in the above studies, including burnout, however we are only reporting the measures used to assess secondary traumatic stress, vicarious trauma or compassion fatigue. Tertiary qualifications refer to certificate, undergraduate or graduate studies beyond secondary or high school level.

Table 5. Study design, measurement tools and results.

Authors	Outcome Measure	Study Design	Data Collection Tool(s)	Summary of Results
Borjanić Bolić (2019)	Secondary Traumatic Stress	Cross-Sectional	ProQOL-V TABS	ProQOL-V STS: M = 50, SD = 10 20% of sample scored “Higher than average” TABS VT: M = 50, SD = 10 15% of sample scored “High” on total scale No relationship between access to supervision and VT/STS
Bridger et al. (2020)	Secondary Traumatic Stress	Cross-sectional	Mixed Methods Quantitative: ProQOL-V Professional Self-Care Scale Trauma Informed Self-Care Scale Toronto Empathy Questionnaire CD-RISC-10 Trauma history screen Qualitative: 2× open-ended questions: (1) What helps you to maintain your own wellbeing, (2) what support do you most need as a Foster Carer that is not available?	Quantitative: ProQOL-V: STS was most strongly associated with burnout (ß = 0.74, p < .001), followed by primary trauma (ß = 0.20, p < .001) and compassion satisfaction ß = 0.19, p < .01). Empathy, resilience and self-care did not show any direct association with STS Qualitative: Q1 most frequent themes: Time with others (e.g., immediate family), exercise and social support Q2 most frequent themes: No concerns/need for further support, time off/respite and professional support
Eastwood and Ecklund (2008)	Compassion Fatigue	Experimental Research	ProQOL-R-111 Self-Care Practices Questionnaire Demographics Questionnaire	ProQOL: Predictor of CF – BO: (p < .001) M = 18.95, SD = 6.80 Feelings of support outside work (p = .025) Reading for pleasure (p < .01) M = 3.16, SD = 1.56 Socialization negative correlation with BO: (p < .05) Self-perception of stress and BO positively correlated (p < .001)
Garwood et al. (2020)	Secondary Traumatic Stress	Experimental Research	Mixed Methods: Quantitative: STS Subscale (ProQOL 5) Qualitative: Sanctuary Model® Assessment (SMA) 3 open ended questions from an 18-item “Sanctuary Model® Assessment” questionnaire measuring trauma informed care knowledge	ProQOL-V prior to SMA training: STS and age: (p < .001) ≤ 30 age group: M = 23.28, SD = 5.84 31–40 age group: M = 21.84, SD = 3.47 41–50 age group: M = 19.00, SD = 4.04 51+ age group: M = 19.14, SD = 3.66 ProQOL-V: after SMA training: Self-care and level of STS: (p < .001) Workplace TIC and STS: (p < .001) Client TIC and STS: (p = .005) Age-group, time & STS after SMA ≤ 30 age group vs 41–50 age group: (p < .04) ≤ 30 age group vs 51+ age group: (p = .05) Qualitative: Key themes: (1) increase in knowledge of the impact of trauma in the workplace; (2) staff more supportive toward each other; and (3) staff had improved communication
Hannah and Woolgar (2018)	Compassion Fatigue Burnout Compassion Satisfaction Secondary Traumatic Stress	Cross-sectional	ProQOL STSS	ProQOL and STSS correlation STSS: (p < .01) BO: (p < .01) CS: (p < .01) Relationship between CF and intent to continue fostering: STS: (p = .006) STS: Low intent M = 37.9, SD = 6.3 STS: High intent: M = 28.5, SD = 9.6 BO: (p < .001) BO: Low intent M = 24.7, SD = 6.5 BO: High intent M = 19.4, SD = 5.4 CS: (p = .036) CS: Low intent M = 40.1, SD = 7.3 CS: High intent M = 43.5, SD = 5.0
Harker et al. (2016)	Secondary Traumatic Stress Burnout	Cross-sectional	ProQOL	Resilience Factor Inventory: High resilience correlated with lower BO: (p < .001) BO: M = 49.40, SD = 9.81 High resilience correlated with lower STS: (p < .001) STS: M = 49.30, SD = 8.48
Hiles Howard et al. (2015)	Secondary Traumatic Stress	Cross-sectional	ProQOL CS score out of 50 Average score 23 or below BO score out of 50 below 23 reflects positive feelings high score 42 or above STS score out of 50 high score 41 or above Resilience Questionnaire Score out of 60 Developing resilience 0–37 Established resilience 38–43 Strong resilience 44–48 Exceptional resilience 49–50 GES Score range 0–9	ACE: Foster carers scores on ACE Scale: (p < .001) Foster carers: M = 2.18, SD = 2.13 Age (p < .05) Higher Education level scored lower on ACE Scale: (p < .01) Higher education: M = 1.95, SD = 2.00 Lower education: M = 2.62, SD = 2.32 Resilience Questionnaire: M = 12.14, SD = 2.24 GES: Education (p < .05) higher education: M = 50.21, SD = 5.65 lower education: M = 52.08, SD = 6.36 ProQOL: Difference in STS levels (p < .001) STS participants M = 24.10, SD 5.35 STS normative sample M = 13, SD = 6.30 Gender (p < .01) Females: M = 24.58, SD = 5.36 Males: M = 21.65, SD = 4.67 participants with children (p < .05) Children: M = 23.46, SD = 4.87 No children: M = 25.11, SD = 5.92
McNamara (2010)	Vicarious Trauma	Experimental Research	Semi-structured Interviews	Qualitative findings: Evaluation of the Staff Support and Supervision Program (SSSP) indicates it was relevant to: (1) identifying, (2) managing and (3) improving issues pertaining to STS and VT of staff. Achieved through: (1) professional development and (2) ways in which supervisors respond to staff with symptoms of STS and VT. Results were positive and justify trialing of SSSP in other youth justice centers.
Steen and Berhardt (2023)	Secondary Traumatic Stress	Cross-sectional	64 question survey Secondary Traumatic Stress Scale (STSS) − 17 questions Posttraumatic Growth Inventory (PTGI) − 25 questions Help seeking questions (n = 12)	STS total score: M = 38.23, SD = 10.28 Multiple regression with STS, Age, Race, Sought assistance from God/Spiritual Beings: Age (under 45 or over 45): foster parents over 45 had lower STS scores (p = .017) Race (White or Of Colour): White foster parents had higher STS scores (p = .21) Sought Assistance from God/Spiritual Beings: Seeking assistance from God/Spiritual Beings had higher STS scores (p = .04)
Steinlin et al. (2017)	Secondary Traumatic Stress Burnout	Cross-sectional	Perceived Collective Efficacy SOC Self-Care Questionnaire Higher the score equals better self-care Physical Wellbeing 0–50 Mental/Emotional/Spiritual Wellbeing 0–50 Professional life/work 0–50 Social life/family 0–50 Questionnaire on Job Satisfaction in Trauma-Sensitive Care Burnout Screening Scale Score >60 indicates burnout	Perceived Collective Efficacy: STS and Perceived collective efficacy: (p < .001) Sense of Coherence: STS and SOC: (p < .001) Self-Care Questionnaire: STS and self-care (work-related factors): (p < .001) Questionnaire on Job Satisfaction in Trauma-Sensitive Care: STS and support from superiors/participation/transparency: (p < .001) STS and communication and support within team: (p < .001) STS and pleasure doing work: (p < .01) STS and institutional structures and resources: (p < .001) Lower STS symptoms correlated to communication and support within the team: (p < .05) Lower STS symptoms and institutional structures and resources: (p < .05)
Teculeasa et al. (2023)	Compassion Fatigue	Cross-sectional	Professional Quality of Life Questionnaire (ProQOL) − 30 questions The quality of foster parent-child relationship − 1 question	ProQOL: BO M = 16.71, SD = 5.29 STS M = 19.73, SD = 6.14 Zero order correlations: Positive association between STS and BO (p < .001) High levels of sensitivity to trauma associated with high levels of BO and STS (p<0.05) Negative correlations between job satisfaction and BO (p < .001) and STS (p < .001)
Whitt-Woosley et al. (2020)	Secondary Traumatic Stress Burnout Compassion Satisfaction	Cross-sectional	STSS Scores Little or no STS < 28 Mild STS 28–37 Moderate STS 38–43 High STS 44–48 Severe STS > 48 ProQOL	STSS: Positive relationship between participants BO and STS: (p < .001) Negative relationship between participants CS and STS: (p < .001) Negative relationship between practical support and STS (p < .001) Negative relationship between emotional support and STS (p < .001) ProQOL: CS: M = 42.36, SD = 5.9 BO: M = 21.98, SD = 5.6
Whitt-Woosley et al. (2022)	Secondary Traumatic Stress Burnout	Cross-sectional	21-item STSS for Diagnostic and Statistical Manual of Mental Disorders 30-item Professional Quality of Life: Compassion Satisfaction and Fatigue Scale Version 5 (ProQOL)	PRoQOL: BO: M = 20.99, SD = 6.02 STSS: M = 36.55, SD = 12.45 Pandemic stress, BO, STS: Positive relationship between increased COVID worry and STS (p < .00) Family conflict/violence positive associated with STS (p <0.00) and BO (p <0.00) Less social support associated with increased STS (p <0.00) and BO (p <0.00) Less food access associated with increased STS (p <0.00) and BO (p <0.00) Lower family income/employment associated with increased STS (p <0.00) More disrupted routines associated with increased STS (p <0.00) and BO (p <0.00)
Zerach (2013)	Secondary Traumatic Stress Burnout Compassion Satisfaction	Cross-sectional	ProQOL Experiences in Close Relationships Scale 36 item self-report questionnaire measuring attachment and close relationships using 7-point scales. Dimensions: anxiety and avoidance Mean score on each dimension calculated Sense of Coherence (SOC) Scale 29-item self-report scale measuring comprehensibility, manageability, and meaningfulness, and an overall score Score range 29–203 with higher scores reflecting higher SOC. Daily Spiritual Experience Scale 16-item self-report scale to assess perception of the transcendent	ProQOL: Difference in CS between groups: (p < .05) RCWs levels CS: M = 39.58, SD = 5.50 BSWs levels CS: M = 37.91, SD = 6.51 No difference between groups for STS or BO Experiences in Close Relationships Scale Difference in attachment-anxiety between groups: (p < .001) RCWs attachment-anxiety: M = 3.01, SD = .94 BSWs attachment-anxiety M = 3.32, SD = 1.01 Attachment anxiety predictive of: STS: (p < .001) BO: (p < .001) CS: (p < .001) SOC: Sense of coherence predictive of: SOC and STS: (p < .001) SOC and BO: (p < .001) SOC and CS: (p < .001) Hierarchical Regression of Factors: Interaction between Age/Gender/Traumatic Experience and STS:(p < .001) RCWs higher CS than BSWs: (p < .001).

STS = Secondary Traumatic Stress.

VT = Vicarious Trauma.

ProQOL = Professional Quality of Life Scale.

TABS = Trauma and attachment belief scale.

GES =Group Environment Scale.

BO = burnout.

CS = Compassion Satisfaction.

Borjanić Bolić, E. (2019). Secondary traumatic stress and vicarious traumatization in child welfare professionals in Serbia. Journal of Public Child Welfare, 13(2), 214–233. https://doi.org/10.1080/15548732.2018.1502117

 Web of Science ®Google Scholar

Bridger, K. M., Binder, J. F., & Kellezi, B. (2020). Secondary traumatic stress in foster carers: Risk factors and implications for intervention. Journal of Child and Family Studies, 29(2), 482–492. https://doi.org/10.1007/s10826-019-01668-2

 PubMed Web of Science ®Google Scholar

Eastwood, C. D., & Ecklund, K. (2008). Compassion fatigue risk and self-care practices among residential treatment center childcare workers. Residential Treatment for Children & Youth, 25(2), 103–122. https://doi.org/10.1080/08865710802309972

 Google Scholar

Hannah, B., & Woolgar, M. (2018). Secondary trauma and compassion fatigue in foster carers. Clinical Child Psychology and Psychiatry, 23(4), 629–643. https://doi.org/10.1177/1359104518778327

 PubMed Web of Science ®Google Scholar

Harker, R., Pidgeon, A. M., Klaassen, F., & King, S. (2016). Exploring resilience and mindfulness as preventative factors for psychological distress burnout and secondary traumatic stress among human service professionals. Work, 54(3), 631–637. https://doi.org/10.3233/WOR-162311

 PubMedGoogle Scholar

Hiles Howard, A. R., Parris, S., Hall, J. S., Call, C. D., Razuri, E. B., Purvis, K. B., & Cross, D. R. (2015). An examination of the relationships between professional quality of life, adverse childhood experiences, resilience, and work environment in a sample of human service providers. Children and Youth Services Review, 57, 141–148. https://doi.org/10.1016/j.childyouth.2015.08.003

 Web of Science ®Google Scholar

Steen, J., & Berhardt, C. (2023). Secondary traumatic stress and posttraumatic growth among foster parents. Journal of Public Child Welfare, 17(2), 375–389. https://doi.org/10.1080/15548732.2022.2036293

 Web of Science ®Google Scholar

Steinlin, C., Dölitzsch, C., Kind, N., Fischer, S., Schmeck, K., Fegert, J. M., & Schmid, M. (2017). The influence of sense of coherence, self-care and work satisfaction on secondary traumatic stress and burnout among child and youth residential care workers in Switzerland. Child & Youth Services, 38(2), 159–175. https://doi.org/10.1080/0145935X.2017.1297225

 Web of Science ®Google Scholar

Teculeasa, F., Golu, F., & Gorbănescu, A. (2023). What mediates the link between foster parents’ sensitivity towards child posttraumatic stress symptoms and job satisfaction? The role of compassion fatigue and foster parent-child relationship. Journal of Child & Adolescent Trauma, 16(2), 309–320. https://doi.org/10.1007/s40653-022-00513-x

 PubMedGoogle Scholar

Whitt-Woosley, A., Sprang, G., & Eslinger, J. (2020). Exploration of factors associated with secondary traumatic stress in foster parents. Children and Youth Services Review, 118, 105361. https://doi.org/10.1016/j.childyouth.2020.105361

 Web of Science ®Google Scholar

Whitt-Woosley, A., Sprang, G., & Eslinger, J. (2022). The impact of COVID-19 and experiences of secondary traumatic stress and burnout. Psychological Trauma: Theory, Research, Practice, & Policy, 14(3), 507. https://doi.org/10.1037/tra0001183

 PubMed Web of Science ®Google Scholar

Zerach, G. (2013). Compassion fatigue and compassion satisfaction among residential child care workers: The role of personality resources. Residential Treatment for Children & Youth, 30(1), 72–91. https://doi.org/10.1080/0886571X.2012.761515

 Google Scholar

Garwood, M. M., Beyer, M. R., Hammel, J., Schutz, T., & Paradis, H. A. (2020). Trauma-informed care intervention for culture and climate change within a child welfare agency. Child Welfare, 98(4), 1–26.

 Web of Science ®Google Scholar

McNamara, P. M. (2010). Staff support and supervision in residential youth justice: An Australian model. Residential Treatment for Children & Youth, 27(3), 214–240. https://doi.org/10.1080/0886571X.2010.501630

 Google Scholar