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Compassion fatigue is a significant occupational psychological issue among emergency department nurses, with profound implications for both their well-being and organizational performance. This review aims to synthesize qualitative evidence on emergency nurses’ experiences of compassion fatigue, identify its contributing factors, enhance understanding of its manifestations and consequences, and provide an evidence base to inform the development of prevention and intervention strategies by healthcare managers. A qualitative meta-synthesis. This review employed a meta-aggregative approach. A systematic search was conducted for qualitative studies in The Cochrane Library, PsycINFO, Embase, Web of Science, CINAHL, Ovid, PubMed, and Medline with no restriction on the start date (i.e., all available years were included) and the search was updated to June 20, 2025. The review adhered to the PRISMA reporting guidelines. The methodological quality of included studies was appraised using the Joanna Briggs Institute criteria, and the confidence in the qualitative findings was evaluated using the ConQual system. A Meta-phenomenological approach was used to synthesize ten qualitative studies, resulting in 48 key findings. These findings were organized into nine categories and further consolidated into three overarching themes: facilitating conditions, the double-edged effect, and response strategies. These themes encompassed eight sub-themes: insufficient basic resources, negative feedback catalysis, negative effects, positive effects, social security, avoidance strategies, positive attitude, and problem- and transcendence-oriented coping. Compassion fatigue among emergency department nurses is a multifactorial psychological phenomenon arising from their specific work environment. Its impact is characterized by both the multidimensional depletion of nurses’ cognitive, physical, behavioral, and emotional resources, and growth-promoting effects. Effective prevention and mitigation require not only strategies to enhance nurses’ individual coping skills but also organizational-level interventions that provide adequate support. Not applicable.