# Interventions to reduce empathy-based stress and enhance compassionate care in mental health wards: a systematic review

## TL;DR

This paper reviews interventions in mental health wards to reduce staff stress and improve compassionate care, finding mixed evidence and potential risks.

## Contribution

The study systematically reviews interventions targeting empathy-based stress and compassionate care in mental health wards, highlighting gaps in evidence and potential iatrogenic harm.

## Key findings

- Multi-level interventions focused on increasing staff resources rather than reducing demands.
- Staff training interventions showed mixed effectiveness, with no clear superior approach identified.
- Two interventions demonstrated evidence of iatrogenic harm, highlighting risks in current practices.

## Abstract

Mental health wards are an important healthcare context with the potential to positively impact patient trajectories. Compassionate care in these wards is important, and can be impacted by staff levels of empathy-based stress (compassion fatigue, burnout and secondary trauma). It is important to consider the evidence-base for mental health ward interventions to improve compassionate care for patients and to reduce empathy-based stress for staff.

A systematic review was conducted of robust evaluations of mental health ward interventions designed to improve compassionate care and/or reduce staff empathy-based stress, with the aim of synthesising interventional evidence on these interventions’ effectiveness, implementation and acceptability. Programme theory papers, outcome evaluations (RCTs and non-RCTs), economic evaluations and process evaluations were included. A meta-integration of intervention content, effectiveness and influence of contextual factors on implementation and acceptability was performed.

18 eligible study reports of 11 interventions were identified. Interventions were multi-level, and aimed to increase staff resources rather than decrease staff demands. Staff training interventions were most evaluated, with mixed evidence for effectiveness. Other approaches included changes to ward approach, environment, use of participatory action research methods and peer-review programmes. There was no clear evidence for a particular intervention type. Two interventions showed evidence of iatrogenic harm. Equity harms and economic effects were not well-evaluated. Mechanisms of change were under-theorised and lacked clear logic models. Patient and public involvement was sporadic.

Current interventions are being offered without a clear evidence-base or guiding model, and risk harming staff. Multi-level interventions using clearer logic models which tackle both job demands and resources are recommended. A model of implementation factors which may help interventions to succeed is proposed. More high-quality controlled intervention studies, considering contextual and process factors, and incorporating co-production, are needed, especially given the risk of iatrogenic harm.

The online version contains supplementary material available at 10.1186/s12913-025-13861-9.