To determine the effects of burnout and compassion fatigue on registered nurses' ability to deliver patient care

Methods

A narrative review methodology was used following the standards of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines (PRISMA, 2020). A comprehensive search of three databases CINAHL, Medline and EMBASE was conducted on 11 December 2022.

In order to obtain relevant literature, a list of search terms was assembled to aid the searching process. Four key terms were derived from the research question ‘What are the effects of burnout and compassion fatigue on registered nurses' ability to deliver patient care?’. These included ‘burnout’, ‘compassion fatigue’, ‘registered nurses’ and ‘patient care’. Synonyms, alternative key words and spellings were identified. For the full list of search terms used see Table 1. The Boolean operators ‘OR’ and ‘AND’ were used to combine the search terms to conduct a comprehensive search of the literature. Limiters including ‘English language’, ‘Peer-reviewed’ and ‘Published in the last 10 years’ were applied.

Inclusion criteria were studies that followed quantitative or qualitative methodologies, narrative reviews, systematic reviews and meta-analysis to provide diversity and increase reliability. Studies that addressed the research question and discussed burnout or compassion fatigue and delivery of patient care in nursing have been included. To ensure the literature was of an acceptable standard only peer-reviewed studies were included. Due to translation issues only studies in the English language were included. To ensure up-to-date literature only studies published in the last 10 years were included. Exclusion criteria were studies that did not address the research question and examined burnout or compassion fatigue in nurses without any mention of how it affects patient care. Studies that were not peer-reviewed, not written in English, exceeded past-10-years limit and inaccessible electronically or through contacting the author were excluded.

Of the 12,212 studies found in the initial search, 20 articles met the inclusion criteria. The Critical Appraisal Skills Programme (CASP) (2018) and the National Heart, Lung and Blood Institute (NIH) quality assessment tools were used to critically appraise the literature (Tod et al, 2022). Each of the 20 articles scored over 80%, meeting the general quality criteria. Thematic analysis and coding were used to combine recurrent ideas that emerged from the literature (Braun and Clarke, 2006).

Findings and discussion

Scientific production by country and year

In 12 countries, several publications attributed to the development of studies on healthcare worker burnout and compassion fatigue. These countries were geographically distributed in China, Greece, Indonesia, Iran, Japan, Jordan, Lebanon, Saudi Arabia, Slovakia, Thailand, United Kingdom and the United States (Figure 2). The publication trend of burnout and compassion fatigue of the healthcare workers reflects a homogenous linear trend from year 2016 to year 2023 (Figure 3).

Delivery of care

Following a critical analysis of the 20 full texts, it is evident that ten out of the 20 papers reviewed examined delivery of care when burnout or compassion fatigue is present in the registered nurse (Dall'Ora et al. 2020; Jun et al. 2021; Kakeman et al. 2021; Manomenidis et al. 2019; Nantsupawat et al. 2016; Russell, 2016; Sagherian et al. 2017; Schlak et al. 2021; Teuku et al. 2022; White et al. 2019). All ten papers included in this theme observed burnout and compassion fatigue as having an unfavourable effect on the delivery of care. This suggests that half of the nursing population in the literature reviewed experienced this phenomenon. This correlates with the 41.4% of the nurses experiencing burnout in the RN4CAST study (Scott et al. 2011). It is compelling that even though this paper is outside of the inclusion criteria and databases searched, there is a similarity in the prevalence of burnout.

In a secondary analysis of a cross-sectional survey by White et al. (2019), the relationship between nurse burnout, job dissatisfaction and missed care in 687 registered nurses was examined. The results established that burnout negatively impacts the performance and productivity of registered nurses. From the total of 687 registered nurses, 30% exhibited high levels of burnout, with 95% of burnout nurses missing one or more care tasks. It was highlighted that nurses suffering from burnout are five times more likely to leave necessary care undone. This included comforting or talking to patients, performing patient surveillance and teaching or counselling patients and families. Another cross-sectional study by Kakeman et al. (2021) examined the association between burnout and quality of patient care. Likewise, the findings illustrated that performance and productivity was negatively impacted by burnout. From the total of 1,104 registered nurses that participated in the survey, 51% of them did not have enough time to pay attention to their patients, which resulted in an overall dissatisfaction of care, leading to 71.7% patient and family verbal abuse and 48.5% patients or family complaints.

While the research design of both White et al. (2019) and Kakeman et al. (2021) are similar, the research methodologies are different. For instance, White et al. (2019) collected secondary data from the 2015 RN4CAST-US survey, while Kakeman et al. (2021) collected primary data by conducting a questionnaire. In addition, both studies use the same data analysis method of utilising a statistical software platform to carry out a logistic regression to predict a binary outcome. It can be highlighted that the use of a survey compared to a questionnaire can be considered a limitation in itself. This is because unlike a questionnaire, a survey may omit details of the registered nurses' point of view by having a set criteria of answers to choose from.

Sagherian et al. (2017) explored the association between fatigue, work schedules and perceived work performance among 77 registered nurses in a cross-sectional study. The findings reflected that compassion fatigue in registered nurses is negatively associated with job performance (p value of < 0.001) and safety practices. Performance in areas related to physical tasks or tasks requiring physical strength are omitted. Registered nurses suffering from compassion fatigue perceived less alertness and concentration when providing patient care and less ability to communicate with peers, patients, and family members (Sagherian et al. 2017). Similarly, in a systematic review by Dall'Ora et al. (2020) where the relationship between burnout and other variables was examined, it was observed that feelings of emotional exhaustion were negatively associated with nurses' performance and productivity, lower self-rated and supervisor-rated job performance, and increased absenteeism, whereas feelings of low personal accomplishment were surprisingly positively associated with productivity.

A systematic review by Jun et al. (2021) examined the associations between nurse burnout, patient, and hospital organizational outcomes. A recurrent theme throughout this paper was that burnout is negatively associated with patient's experience of care. It was argued that the strain of exhaustion, the lack of meaningfulness in one's work, and the desire to quit might all be readily sensed by patients in the course of their interactions with the registered nurse. Additionally, in a cross-sectional study by Russell (2016) where perceptions of burnout in 61 registered nurses were examined using the Inpatient Oncology questionnaire, it was observed that as burnout occurs, depersonalisation is present which may result in a disconnection between oneself and the care provided to patients, leading to an inability to provide compassionate care and therefore affecting interactions with patients' family, friends or visitors. It can be highlighted that burnout is prevalent not only in general nurses but also in oncology nurses. Moreover, its revealed that registered nurses experiencing feelings of emotional exhaustion were related to patient dissatisfaction of care (Jun et al. 2021). Contrastingly, Dall'Ora et al. (2020) found that only experiencing feelings of both emotional exhaustion and of low personal accomplishment were associated with patient dissatisfaction of care and a reduced sense of emotional and professional commitment to their organizations. In addition, the above systematic reviews have similar methodological patters regarding the tools used for identifying burnout and data analysis methods. However, Jun et al. (2021) synthesised the data by entering it into a matrix, while Dall'Ora et al. (2020) identified common categories through a coding frame which may have contributed to their minor differences in their findings.

Adding onto that, it was highlighted by Jun et al. (2021) that patients were more satisfied in all aspects of their care when the registered nurse felt an increased sense of meaningfulness in their work. In a cross-sectional study, Teuku et al. (2022) examined compassion fatigue and its impact on quality of nursing services on 214 registered nurses. Data was collected using the Copenhagen Psychological questionnaire. The findings showed that there is a corelation between compassion fatigue and delivery of care, with a significant corelation between compassion fatigue and workload (p value = 0.000), work and family conflict (p value = 0.000) and job control (p value = 0.003). On the other hand, Sagherian et al. (2017) disagrees stating that compassion fatigue in registered nurses and their ability to deliver care is negatively associated by personal and social life only. While both studies are cross-sectional, the data collection methods of Teuku et al. (2022) and Sagherian et al. (2017) differ. Teuku et al. (2022) uses a questionnaire providing a larger platform for the registered nurses to express their own personal opinions and experiences, while on the other hand Sagherian et al. (2017) uses a survey which gives rise to the possibility that these personal opinions and experiences may have been omitted. The data collection methods may be a factor of the studies' different results.

Nantsupawat et al. (2016) in a cross-sectional study investigated the effect of nurse burnout on nurse reported quality of care and patient adverse events and outcomes in 2,084 registered nurses. The statistical findings agreed with White et al. (2019) and Teuku et al. (2022) stating that registered nurses experiencing both job dissatisfaction and compassion fatigue were 2.6 times more likely to leave necessary care undone alongside having significantly higher missed care rates. Furthermore, it was highlighted by White et al. (2019) that 72% registered nurses reported missing one or more care tasks while increasing to 83% of registered nurses when experiencing job dissatisfaction. Jun et al. (2021) stated that burnout is negatively associated with higher rates of workaround during medication administration and increased absenteeism overall affecting the delivery of care. On top of that, the large data sets in the above cross-sectional studies provides resonance that international burnout and dissatisfaction of care delivered is prevalent in explicit cases.

A secondary analysis of a single centre randomized trial of 40 registered nurses carried out by Manomenidis et al. (2019) examined weather job burnout reduced hand hygiene compliance among staff nurses. Data was collected using a diary following the Maslach Burnout Inventory and hand hygiene observation tool. The results showed that burnout negatively affects hand hygiene compliance (p value < 0.001), ranging between 14% to 63%. Registered nurses reporting higher levels of burnout were less likely to comply with hand hygiene regulations (p value < 0.001). In addition, Jun et al. (2021) emphasized that burnout did not only affect hand hygiene compliance but was a negative predictor of nurses' adherence to infection control precautions. Even though Manomenidis et al. (2019) sample pool is smaller compared to other studies, the findings reinforced the message that burnout in registered nurses is negatively associated with performance and therefore affected the delivery of care provided.

Schlak et al. (2021) explored the relationship between nurse burnout and mortality, failure to rescue, and length of stay of 20,496 registered nurses in a secondary analysis of a cross-sectional survey. Data was collected using the 2015-2016 RN4CAST-US survey and the 2016 American Hospital Association annual survey. The findings showed that burnout is negatively associated with patient safety. The study revealed a significant relationship between registered nurse burnout and 30 day in hospital mortality (p value = 0.023), with a 5% increase in the odds of failure rescue (p value = 0.037) and a 2% increase in the overall length of stay (p value = 0.013). A survey may limit the level of description nurses can use when attempting to share their own experiences. Even though a survey was used to collect the data, the large sample size used allowed to control the risk of reporting any false or inaccurate results. Kakeman et al. (2021) highlighted that 72.7% of burnout registered nurses make mistakes without negative consequences to patients, 33.5% make mistakes with negative consequences to patients whilst 44.7% perform procedures without appropriate training. According to Jun et al. (2021), registered nurses experiencing feelings of emotional exhaustion and depersonalisation were less likely to report near misses and adverse events. In contrast, Dall'Ora et al. (2020) and Jun et al. (2021) conclude that only emotional exhaustion was negatively associated with reporting behaviours whilst being a significant predicter for increased patient mortality.

It is evident from the literature that burnout and compassion fatigue does negatively impact nurses' ability to deliver patient care. The performance and productivity of registered nurses is reduced, leading to various missed care tasks. Physical tasks or tasks requiring physical strength are more strenuous. Communication with other health care workers and patients is low leading to an overall dissatisfaction of care. There is also a reduced hand hygiene compliance and a negative association with patient safety when burnout occurs. Higher rates of workaround during medication administration are also present and increased absenteeism. This reflects the exhausting effort required by registered nurses to continue to care for patients when burnout is present. It highlights the need for a change to be implemented in the nursing industry to combat burnout and therefore enhance the process of delivering care by having a healthy nursing workforce.

Quality and safety of care

Eighteen out of the 20 papers reviewed examined quality and safety of care when burnout or compassion fatigue is present in the registered nurse (Abraham et al. 2021; Abusamara et al. 2022; Chao et al. 2016; Cimiotti et al. 2012; Dall'Ora et al. 2020; Eltaybani et al. 2021; Hall et al. 2016; Jun et al. 2021; Kakeman et al. 2021; Majarabi et al. 2021; Nantsupawat et al. 2016; Russell, 2016; Sagherian et al. 2017; Slayers et al. 2016; Schlak et al. 2021; Soosova, 2021; Tawfik et al. 2019; Teuku et al. 2022). Fifteen out of the 18 papers examined burnout and compassion fatigue negatively affecting quality and safety of care (Abraham et al. 2021; Cimiotti et al. 2012; Dall'Ora et al. 2020; Eltaybani et al. 2021; Hall et al. 2016; Jun et al. 2021; Kakeman et al. 2021; Majarabi et al. 2021; Nantsupawat et al. 2016; Russell, 2016; Sagherian et al. 2017; Slayers et al. 2016; Schlak et al. 2021; Soosova, 2021; Tawfik et al. 2019; White et al. 2019). Whilst three papers (Abusamara et al. 2022; Chao et al. 2016; Teuku et al. 2022) examined no corelation between burnout and compassion fatigue and quality and safety of patient. This suggests that while most studies examined the effect burnout and compassion fatigue has on the quality and safety of patient care, there were mixed feelings regarding burnout and compassion fatigue negatively affecting the quality and safety in itself with the majority of the literature leaning in favour of burnout and compassion fatigue leading to lower patient care.

In a secondary analysis of a cross-sectional survey, Abraham et al. (2021) investigated the relationship between primary care nurse practitioner burnout on perceptions of quality of care in 396 registered nurses. Data was collected using the Nurse Practitioner Primary Care Organizational Climate questionnaire. The study reported that the odds of receiving higher quality of care was 85% less for registered nurses experiencing burnout compared to those not experiencing burnout. Russell (2016) highlighted that only experiencing feelings of emotional exhaustion and a low personal accomplishment play a role in the quality of care delivered. For example, registered nurses experiencing feelings of emotional exhaustion can result in an inability to complete daily duties due to feeling overextended whilst experiencing feelings of a low personal accomplishment illustrates feelings of inadequacy with regards to the care provided. In contrast, Jun et al. (2021) disagreed, concluding that experiencing feelings of emotional exhaustion, depersonalisation a low personal accomplishment were all significantly associated with playing a role in poor quality of patient care. Analysing Russell (2016) and Jun et al. (2021) side by side highlights a drastic difference not only in the research designs but also in the sample sizes. Russell (2016) has a sample size of only 77 registered nurses which drastically smaller compared to Jun et al. (2021) which has a sample size of 138,663 registered nurses. The larger sample size in Jun et al. (2021) paper provides more accurate average results, allowing the risk of a false negative or a false positive to be controlled. This may explain the differences in the findings between the two studies.

This isn't the only evidence to support Jun et al. (2021) findings. Nantsupawat et al. (2016) results also reflect those feelings of emotional exhaustion, depersonalisation a low personal accomplishment were all significantly associated with playing a role in poor quality of care. It was emphasized that feelings of emotional exhaustion are associated with a 2.63 times increase in the odds of reporting quality of care as fair or poor, feelings of depersonalisation are associated with a 3.21 times increase in the odds of reporting quality of care as fair or poor, while experiencing a low personal accomplishment was associated with a 1.73 times increase in the odds of reporting quality of care as fair or poor. Supporting these claims, statistical findings from their meta-analysis of 108 studies, Salyers et al. (2016) revealed that compassion fatigue is negatively associated with quality of patient care (correlation coefficient r = −0.26). The relationship between compassion fatigue and quality of patient care was strongest for emotional exhaustion (correlation coefficient r = −0.27) or overall compassion fatigue (correlation coefficient r = −0.25), whereas effects for depersonalisation (correlation coefficient r =−0.21) and reduced personal accomplishment (correlation coefficient r = −0.20) were weaker but still significant. It can be highlighted that like Jun et al. (2021), Nantsupawat et al. (2016) and Salyers et al. (2016) both contained very large sample sizes. Even though different data analysis methods were used, the results remained the same throughout the papers, reinforcing the hypothesis that emotional exhaustion, depersonalisation, and a reduced personal accomplishment contributed to a lower quality of patient care.

Tawfilk et al. (2019) concluded in a systematic review that the association between burnout and quality of patient care is highly heterogeneous. Of 114 studies, 58 indicated burnout related to poor quality of patient care, 6 indicated burnout related to high quality of patient care, and 50 showed no significant effect. In addition, three other studies showed no corelation between burnout and quality of patient care. The first study carried out by Abusamara et al. (2022) examined the relationship between nursing care delivery models, nurses' emotional exhaustion, and quality of nursing care in 160 registered nurses. This paper had a cross-sectional design where data was collected using a survey. The results highlighted no statistically significant difference in the scores of quality of patient care and compassion fatigue (p value > 0.05). The findings also reflected no significant correlation between burnout and care-related activities (p value = 0.65), preconditions for care (p value = 0.077) and nursing environment (p value = 0.251). The second study by Chao et al. (2016) investigated the relationship between burnout and patient rated quality of care in 98 registered nurses. A cross-sectional design was observed where data collection was carried out using a survey. The results showed no corelation between burnout and quality of patient care (correlation coefficient r = 0.12). The third and final cross-sectional study by Teuku et al. (2022) identified factors that influence nurses' burnout and its impact on the quality of nursing services in 214 registered nurses. Data was collected using a survey. The study revealed no relationship between burnout and the quality of patient care. It can be highlighted that a methodological pattern of identical research designs, identical data collection methods and similar sample sizes can be observed between the three papers. Since the data collection methods and analysis methods were identical, it gives rise to the possibility that these similarities may provide a likely explanation for not observing a corelation between burnout and quality and safety of care.

A cross-sectional study carried out by Majrabi et al. (2021) on 119 registered nurses assessed compassion fatigue, resilience, and the association with safety culture. Data was collected using the Safety Altitude questionnaire. The findings reflected that compassion fatigue is negatively associated with patient safety and resilience. Patient safety is statistically correlated with emotional exhaustion (p value < 0.05), depersonalisation (p value < 0.05) and low personal achievement (p value < 0.05). On the other hand, Dall'Ora et al. (2020) highlighted that only emotional exhaustion and depersonalisation are associated with negative patient safety grades and perceptions. In addition, findings from Salyers et al. (2016) concluded that compassion fatigue is negatively associated with patient safety (correlation coefficient r = −0.23) and with a stronger relationship with perceptions of safety (correlation coefficient r = −0.28) than events (correlation coefficient r = −0.16). Furthermore, a systematic review by Jun et al. (2021) determined that burnout is negatively associated with patient safety in all studies showing that emotional exhaustion is negatively associated with perceived patient safety. However, in a second systematic review by Hall et al. (2016) it can be observed that while there is an agreement that burnout is negatively associated with patient safety outcomes and errors in all studies, it was highlighted that one study was in complete disagreement.

Soosova, (2021) in a cross-sectional descriptive study evaluated the association between nurse compassion fatigue and patient safety grades and adverse events in 117 registered nurses. Data was collected using the Hospital Survey on Patient Safety Culture. The results, in agreement with Jun et al. (2021) findings, reported that burnout is negatively associated with patient adverse events. Dall'Ora et al. (2020) also agrees that burnout is negatively associated with adverse events, concluding that feelings of depersonalisation and low personal accomplishment predicted a higher rate of adverse events in all studies except one, where only emotional exhaustion predicted adverse events. In addition, 26.2% of registered nurses fall short in terms of the quality of care they provide to patients, with burnout leading to 26.1% infusion or transfusion reactions. However, feelings of depersonalization was found to increase the risk of adverse events, while on the other hand, feelings of emotional exhaustion had no impact on any adverse events (Kakeman et al. 2021). Even though different research designs and methodological patters can be observed from Soosova, (2021), Jun et al. (2021) and Dall'Ora et al. (2020), the results remained similar throughout the papers, reinforcing the idea that burnout affects safety of patient care.

A secondary analysis of a cross-sectional survey by Eltaybani et al. (2021), including 3,218 registered nurses, examined the association between staff nurses' burnout and selected objective quality metrics in long term care wards. It was observed that feelings of a low personal accomplishment are associated with high rated of tube feedings (p value = 0.018). Additionally, Jun et al. (2021) also mentioned that burnout is negatively associated with infections, while Nantsupawat et al. (2016) emphasises that emotional exhaustion is associated with a 1.32 times increase in the odds of reporting infections, while on the other hand feelings of depersonalization were associated with a 1.74 times increase in the odds of reporting infections. Moreover, Dall'Ora et al. (2020) agrees that burnout is negatively associated with infections, with one study stating that emotional exhaustion was associated with catheter associated urinary tract infections (UTIs) and surgical suite infections, and in another study, feeling of depersonalisation was associated with nosocomial infections. In another study, Cimiotti et al. (2012) examined job related burnout in registered nurses and determined whether it accounts for patient infections on 2,084 registered nurses in a secondary analysis of a cross-sectional survey. The findings reflected that burnout in registered nurses is highly associated with urinary tract infections (p value = 0.02) and surgical site infections (p value < 0.01). Adding on to this it is highlighted that burnout leads to 29.0% surgical wound infections (Kakeman et al. 2021), with with feelings of emotional exhaustion being associated with high rates of pneumonia (p value = 0.036) and increased rates of both urinary tract infection and surgical site infections (Eltaybani et al. 2021). All of these studies suggest that burnout does negatively affect the quality and safety of patient care, resulting in numerous adverse events.

Sagherian et al. (2017) and Soosova (2021) both agree that burnout and compassion fatigue in registered nurses is negatively associated with medication errors, with Soosova (2021) adding that compassion fatigue also corelates with patient safety and adverse events. Dall'Ora et al. (2020) also agrees that burnout is negatively associated with medication errors, highlighting that feelings of emotional exhaustion, depersonalisation and low personal accomplishment predicted medication errors in all studies except one, where only depersonalisation was associated with medication errors. Contrastingly, Jun et al. (2021) disagrees concluding that only depersonalisation was associated with an increase in medication errors. However, it has been concluded that burnout led to 48.6% medication errors, with feelings of personal accomplishment reducing the risk of the occurrence of medication errors (Kakeman et al. 2021). Additionally, Nantsupawat et al. (2016) emphasises that emotional exhaustion is associated with 1.47 times increase in the odds of reporting medication errors, depersonalisation is associated with a 1.83 times increase in the odds of reporting medication errors and a low personal accomplishment among registered nurses was associated with a 1.49 times increase in the odds or reporting medication errors.

Adding on to that, Dall'Ora et al. (2020) and Kakeman et al. (2021) state that burnout is negatively associated with 28.2% patient falls, with feelings of depersonalisation and a low personal accomplishment being significant predictors. On the other hand, Jun et al. (2021) disagrees, underlining that only depersonalisation was associated with an increase in patient falls. Nantsupawat et al. (2016) emphasises that depersonalisation showed an association with 2.06 times increase in the odds of registered nurses reporting patient falls and feelings of a low personal accomplishment among registered nurses was associated with a 1.61 times increase in the odds of reporting patient falls. In addition, Eltaybani et al. (2021) and Kakeman et al. (2021) state that burnout is negatively associated with higher rates of pressure ulcers only. It can be highlighted that while both studies are in agreement, Eltaybani et al. (2021) states that feelings of emotional exhaustion are associated with pressure ulcers (p value = 0.032) while on the other hand, Kakeman et al. (2021) states that feelings of emotional exhaustion, depersonalisation and a low personal accomplishment were all associated leading to 35.4% pressure ulcers. Contrastingly, Dall'Ora et al. (2020) disagrees, underlining that burnout is not associated with any hospital acquired pressure ulcers. It needs to be highlighted that while the research design for Eltaybani et al. (2021) and Kakeman et al. (2021) are identical, the research design for Dall'Ora et al. (2020) differs. On the other hand, Dall'Ora et al. (2020) uses the original the Maslach Burnout Inventory as their burnout measurement tool, while Eltaybani et al. (2021) used the Japanese edition and Kakeman et al. (2021) used the Parisian edition, which may have led to their differences.

Overall, the literature determined that burnout and compassion fatigue does negatively impact the quality and safety of patient care. Not only is the quality of patient care and patient safety lowered, but resilience also lessened, leading to numerous adverse events. Such adverse events include infusion or transfusion reactions, medication errors, patient falls and infections such as urinary tract infections, surgical site infections and surgical wound infections. This reflects the gravity of being cared by registered nurses suffering from burnout, highlighting the need for strategies to be implemented into the workplace to combat burnout and compassion fatigue in registered nurses and therefore increase the quality and safety of patient care.

Conclusion

The aim of this literature review was to determine the effects of burnout and compassion fatigue on registered nurses' ability to deliver patient care. Following critical analyses of twenty full texts, two prominent themes were highlighted. The first theme discussed burnout and compassion fatigue and delivery of care, whilst the second theme discussed burnout and compassion fatigue on quality and safety of care.

The reviewed literature demonstrates that burnout and compassion fatigue negatively impact the performance and productivity of registered nurses, resulting in missed care tasks such as comforting or talking to patients, teaching or counselling patients and families and performing patient surveillance. Additionally, physical tasks or tasks requiring physical strength were omitted. Communication with other health care workers and patients was low. It was highlighted that registered nurses did not have enough time to pay attention to their patients if burnout and compassion fatigue was present, resulting in an overall dissatisfaction of care leading to patient and family verbal abuse and patients or family complaints. As depersonalisation occurred, a disconnection between oneself and the care provided to patients also occurred, leading to an inability to provide compassionate care therefore affecting interactions with patients' family, friends, or visitors. This had a domino effect establishing a lower self-rated and supervisor-rated job performance and increased absenteeism. However, in some instances it's been observed that burnout was positively associated with productivity. Moreover, it has been underlined that burnout is negatively associated with delivery of care such as higher rates of workaround during medication administration, increased absenteeism, a reduced hand hygiene compliance and a negative association with patient safety.

This review reflects that burnout and compassion fatigue are negatively associated with quality of patient care in 15 studies, whilst reflecting no corelation in 3 studies. It was highlighted that registered nurses experiencing feelings of emotional exhaustion can result in an inability to complete daily duties due to feeling overextended whilst experiencing feelings of a low personal accomplishment illustrates feelings of inadequacy with regards to the care provided. The findings reflected that burnout and compassion fatigue are negatively associated with patient safety and resilience, adverse events such as infusion or transfusion reactions, infections such as urinary tract infections, surgical site infections, surgical wound infections, medication errors and lastly patient falls.

The studies included in this review are based on the nursing industries of 12 different countries. Having nurse burnout and compassion fatigue affect patient care at a global scale highlights the need for a change in the nursing industries across the world. Some limitations were observed throughout the literature. Firstly, the use of a measurement tool other than the Maslach Burnout Inventory may have impacted the data collection and findings. Secondly, a larger sample pool is ideal to avoid biased results, however, a low sample pool is present in some of the studies. Thirdly, the use of different data collection methods present is some studies may omit critical key information from being collected. For example, the use of simple surveys and questionnaires may lack description of the nurses' personal point of view. Lastly, as a word count was imposed on the literature review, there was a limitation to the depth 20 studies may have been discussed, analysed, and contrasted.

The reviewed literature highlights the need for strategies to be implemented into the workplace to combat burnout in registered nurses and therefore increase the quality and safety of delivery of care. There is a gap in the literature of studies examining the effects burnout and compassion fatigue has on the long-term effects on the quality, safety and delivery of patient care alongside the health of the registered nurses, which needs to be addressed going forward.

KEY POINTS