Introduction
Working as a psychiatric health nurse is a challenging task, as it involves dealing with individuals who have specific and multifaceted needs [1]. Therefore, compassion is considered a key component of the nurse-patient relationship, which serves as the cornerstone for all nursing care provided to psychiatric patients. Providing compassionate care to psychiatric patients is an essential nursing competency that contributes to positive patient outcomes [2]. However, prolonged exposure to patients’ emotional pain and trauma, the inability to disengage emotionally after offering compassionate and empathetic care, as well as staff overload and shortage, workplace violence, and limited resources, all contribute to compassion fatigue [3‐5].
Compassion fatigue is a comprehensive decline in physical, emotional, and spiritual abilities, resulting in decreased energy and stamina, emotional exhaustion, a drop in empathetic capacity, and a sense of despair and inability to recover. These are caused by the continuous and persistent exposure of healthcare providers to others’ suffering and trauma, as well as high levels of occupational self-involvement without proper boundaries or self-care practices [6, 7]. Compassion fatigue is a process that begins with compassion discomfort, develops into compassion stress, and ultimately results in compassion fatigue [8‐10]. Hence, compassion fatigue is a blend of secondary traumatic stress and burnout [11]. In addition, working with patients with severe and persistent mental illness creates a stressful environment with restricted freedom for decision-making and forced treatment, which consequently inhibits psychiatric nurses from conducting their essential tasks and contributes to many adverse effects such as burnout, decreased standard of provided care, and moral distress and consequently leaving the profession.
Anzeige
Moral distress has been recognized as a workplace hazard for healthcare providers caring for vulnerable populations, especially nurses working in mental health settings [12, 13]. Moral distress has been defined as a situation where someone faces a dilemma between their own ethical beliefs about care and the directives given by higher authorities [14]. Eventually, moral distress leads to feelings of anger, frustration, guilt, sadness, failure, inadequacy, bad consciousness and being fragmented [15]. Finally, Moral distress left affected nurses physically and emotionally exhausted, especially those who distance themselves from both their patients and their inner selves, adversely affecting patient care, nursing professional performance, and psychiatric nursing staff retention [16, 17].
Moral distress in a mental health setting can stem from multifaceted reasons [18], such as involuntary admissions, the use of restraints [19], coercive administration of medicines, incompatible demands, shortage of resources, and rapid discharges that lead to superficial management. Other reasons include working under staff shortages, feelings of inadequacy [15], witnessing unsafe patient care, inadequate clinical communication, and the pressure to maintain efficiency in provided care [20].
Stereotypes and prejudgments against psychiatric patients are redirected and transferred toward mental health professionals based on their affiliations and their close interaction with individuals who have mental illnesses [21, 22]. Stigma is defined as negative perceptions, beliefs, and attitudes regarding certain groups of people because of their life circumstances [23]. It has a devastating impact on an individual’s capacity to live a complete, satisfactory, and fulfilling life [24]. Psychiatric nurses often face associative stigma, which is defined as the discrimination that mental health professionals encounter because of their affiliations with individuals from a socially stigmatized category, specifically those with mental health disorders [25].
Adverse and stigmatizing beliefs about mental health professionals not only undermine the valuable contributions they make but also, more importantly, dismiss the needs of those seeking mental healthcare. Additionally, these negative perceptions may intensify the stigma surrounding mental illnesses [26]. Associative stigma can influence psychiatric nurses’ perceptions of their professional identity, ultimately affecting the care provided to individuals with mental health concerns [27‐29]. Consequently, associate stigma leads to low self-esteem, depersonalization, more emotional exhaustion, and poor job satisfaction [30], which affects career decisions and workplace retention [25, 31].
Anzeige
The previously mentioned challenges facing psychiatric nurses can interplay, resulting in a compound aftermath. To our knowledge, even though current studies singularly address the levels of moral distress, compassion fatigue, and associative stigma among psychiatric nurses, no research has yet examined the relationship and the interaction of these three concepts collectively and how they affect each other in the context of psychiatric nursing practice.
Theoretical framework
Watson’s theory focuses on empathy as an essential component and underlines the significance of demonstrating compassion and empathy in caring for favorable patient outcomes and experiences [32]. Further, Watson emphasized the significance of using self by promoting one’s energy for caring. If nurses are overwhelmed by associative stigma, their ability to care for themselves and their patients can be severely reduced, leading to exhaustion and reduced effectiveness in their role. In addition, associative stigma can cause nurses to detach themselves emotionally from their patients to avoid the stigma. This detachment damages the empathetic, caring relationships central to Watson’s theory, leading to less compassionate care. At this stage, nurses may encounter a conflict between their ethical obligation to provide compassionate care and the embarrassment and constraints of the stigma they face, ultimately leading to moral distress.
The hypothesized model (Fig. 1)
Fig. 1
Path Diagram
×
![]()
Based on findings from previous studies [12, 33, 34] and the adopted conceptual model mentioned above, we hypothesize that associative stigma is a triggering factor affecting compassion fatigue and moral distress in which compassion fatigue may act as a mediating factor among psychiatric and mental health nurses. Thus, we hypothesized that (1) Associative stigma positively correlates with moral distress. (2) Compassion fatigue is positively correlated with Moral distress. (3) Associative stigma is positively correlated with compassion fatigue. (4) Compassion fatigue mediates the correlation between associative stigma and moral distress.
Materials and methods
Study design
A descriptive cross-sectional research design was used to conduct the current study. This study followed the STROBE statement, guidelines for reporting observational research studies.
Setting
The study was conducted at Erada Hospital in Riyadh. Erada Hospital (Al Amal Mental Health Complex in Riyadh) is considered one of the most prominent medical complexes specializing in treating addiction and mental illness in the capital city of Saudi Arabia. This complex is distinguished by the availability of two integrated hospitals equipped with various advanced facilities, each providing specialized and diverse therapeutic services. The complex consists of two departments, one for females and another for males, with 503 beds. The complex also includes several sections, the most important of which are emergency, addiction, clinics, rehabilitation, and laboratories.
Participants
A convenience sampling technique was utilized to recruit nurses from Erada Hospital in Riyadh. This hospital hires psychiatric nurses from different nationalities, such as Saudia Arabia, Egypt, Sudan, Jordan, Syria, India, and the Philippines. Inclusion criteria include Saudi and non-Saudi nurses, male and female, with all educational qualifications, working at any department in Erada Hospital, and willing to participate in the study voluntarily. Nurses diagnosed with psychiatric disorders were excluded from the study.
Sample size
To determine the necessary sample size for conducting a multivariate linear regression analysis for the factors affecting the moral distress score, the compassion fatigue score, and the stigma score, we utilized the “pwr” package in the R programming language, considering several key input parameters. These parameters encompassed an alpha level of 0.05 (representing the probability of type I error), up to 23 predictors within the model, an expected medium effect size of 0.15 (f2), and a desired statistical power of 0.80. This computation’s result showed that a minimum sample size of 142 was needed to meet these criteria.
Anzeige
Data collection
Data was collected from January 10 to April 22, 2024. After obtaining the IRP approval from KAIMRC, the approval was sent to Erada Hospital along with an extensive explanation of the study aims and the study’s importance to facilitate the researchers’ task. Then, the survey link was distributed online via social media such as WhatsApp. The link was sent to all psychiatric nurses working at the hospital with an invitation that briefly described the study and ensured voluntary participation and the confidentiality of the participants’ information. Participants were not allowed to answer the questionnaire more than once to prevent repetitive responses.
Ethical considerations
The researchers obtained approval from the College of Nursing’s research unit, followed by IRP approval from King Abdullah International Medical Research Center (KAIMRC) (Approval No: 3094/23) before starting the study. They informed participants that there were no anticipated risks from participating and assured them they could withdraw at any time without penalty. Privacy and security were fully safeguarded, with responses kept anonymous and confidential. No personal information was disclosed, and participant confidentiality was maintained throughout. Additionally, written informed consent was obtained from all participants before they completed the questionnaire.
Data was collected using the following tools:
1.
Sociodemographic data included (age, sex, marital status, nationality, level of education, years of experience, and years of working in the psychiatry department).
2.
Compassion fatigue scale (CFS): It was used to measure psychological distress among social workers and assess emotional exhaustion after dealing with clients who experienced trauma. This scale was done by Adams, Boscarino, and Figley [35], and it includes 13 items utilizing a 10-point Likert scale with visual analogy (never equal 1 to very often equal 10). CFS Scale can be used as a reliable CF measurement. Each scale exhibited good internal reliability with a Cronbach’s alpha of 0.8 for the Secondary Trauma Scale and 0.9. For the 13 elements, the alpha value was 0.9. The scoring for this scale is (> 15 suggests that vicarious trauma may be present, and > 30 suggests that job burnout may be present).
3.
The Clinician Associative Stigma Scale (CASS): Yanos et al. [36] created this scale to assess associative stigma among psychiatric nurses. It is composed of 18 statements used to evaluate the nurses’ experiences with stigma by association in psychiatric hospitals. This Likert scale has a 4-rating point which are: Never (in case the experience hadn’t happened); Rarely (if it happened once or two times); Occasionally (in case it happened frequently but inconsistently); and Often (in case it happened frequently). The scores vary from 18 to 72, where higher values revealing more perceived associated stigma. The alpha score for the CASS has been reported to be between 0.69 and 0.95. This is good for excellent internal consistency.
4.
The Moral Distress for Healthcare Professionals (MMD-HP): The MMD-HP scale aims to capture the complex ethical dilemmas healthcare professionals face and their subsequent emotional responses. It consists of a 27-item and utilizes a 4 points Likert scale to measure the distress frequency where 4 is given for very frequently and 0 for never) and for severity (0 corresponds to none, 4 corresponds to very distressing), the step of multiplying distress scores (0–4) by frequency (0–4) item scores resulted in aggregate values, which were then summed (0–16). MMD-HP’s total scores range (0-432), where higher scores indicate higher levels of moral distress. The Cronbach's α of the MMD-HP = 0.93, which means strong reliability; in addition, it shows strong validity in both physicians and nurses [37].
Anzeige
Data management and analysis plan
All analyses were conducted using R software version 4.2.2. Continuous variables, including age, years of experience, and years working in the psychiatric department, were described using descriptive statistics such as standard deviations and means for quantitative data. For categorical variables, such as marital status, sex, education level, and nationality (Saudi or non-Saudi), we used frequency distributions and percentages. The items of the Compassion Fatigue Scale (CFS), Clinician Associative Stigma Scale (CASS), and Moral Distress Scale (MDS) were summarized numerically using medians and interquartile ranges. In contrast, the total score of each scale was summarized using means and standard deviations. Multiple linear regression models were conducted for each of the three scales. In all analyses, a significant level of 0.05 was applied. A mediation analysis was conducted using the Preacher & Hayes method with 1,000 bootstrap samples via the ‘mediation’ package in R. Subsequently, a structural equation model was fitted to these relationships using the ‘lavaan’ package, with the items from the CASS, CFS, and MDS scales as indicators for their respective latent constructs. The SEM fit to the data was evaluated by Chi-square statistic/degree of freedom, Comparative Fit Index (CFI), Tucker Lewis Index (TLI), the Root Mean Square Error of Approximation (RMSEA), and the Standardized Root Mean Square Residual (SRMA). χ2/df < 5 means an acceptable fit [38], a CFI greater than 0.90 indicates an acceptable fit [39], while a TLI greater than 0.90 also reflects an acceptable fit [40]. According to RMSEA, a value of 0.05 or lower demonstrates a good fit, whereas a value of 0.1 or higher indicates a poor fit [41]. For SRMR, a value below 0.08 is considered acceptable [42]. The corresponding path diagram was generated using the ‘semPlot’ package.
Results
Sociodemographic characteristics
Table 1. Shows the demographic and professional data of 328 psychiatric nurses, the mean age of the participants was 34.4 years ± 6.7 years., 55.5% of them were male, more than half of nurses (54.0%) were married. In terms of nationality, 76.8% were Saudi nationals, 93.9%, lived in urban areas. Regarding education, 55.2% of the nurses held a bachelor’s degree, with 32.9% of the total sample having more than ten years of experience.
Table 1
Demographic data of participants (N = 328)
Variable | N | % / Mean ± SD |
|---|---|---|
Age (years), Mean ± SD | 34.4 | ± 6.7 |
Age | ||
18–28 | 69 | 21.0 |
29–38 | 171 | 52.1 |
39–48 | 79 | 24.1 |
49+ | 9 | 2.7 |
Sex | ||
Female | 146 | 44.5 |
Male | 182 | 55.5 |
Marital status | ||
Married | 177 | 54.0 |
Single | 95 | 29.0 |
Divorced | 48 | 14.6 |
Widowed | 8 | 2.4 |
Nationality | ||
Non-Saudi | 76 | 23.2 |
Saudi | 252 | 76.8 |
Area of living | ||
Rural | 20 | 6.1 |
Urban | 308 | 93.9 |
Highest level of education | ||
Bachelor | 181 | 55.2 |
Master | 63 | 19.2 |
Other | 29 | 8.8 |
Undergraduate Diploma | 55 | 16.8 |
Years of nursing experience | ||
< 1 year | 28 | 8.5 |
1 to < 5 year | 106 | 32.3 |
5 to < 10 years | 86 | 26.2 |
> 10 years | 108 | 32.9 |
Years working in psychiatry department | ||
< 1 year | 30 | 9.1 |
1 to < 5 year | 117 | 35.7 |
5 to < 10 years | 95 | 29.0 |
> 10 years | 86 | 26.2 |
Levels of compassion fatigue scale (CFS), the clinician associative stigma scale (CASS), and moral distress (MD)
Regarding the compassion fatigue levels the mean job burnout and secondary traumatic stress were 49.4 ± 26.1 and 31.3 ± 16.2 respectively. Overall, the total compassion fatigue score among the nurses was 80.8 ± 42.0 and when expressed on a percentage scale, it was 57.9 ± 35.9. In relation to the levels of the Clinician Associative Stigma Scale (CASS) among psychiatric nurses, the total CASS Mean ± SD was 56.4 ± 15.7. In addition, moral distress among psychiatric nurses was 198.3 ± 156.7 (Table 2).
Anzeige
Table 2
Clinician Associative Stigma (CASS), Moral Distress for Healthcare professionals (MMD-HP) and Compassion fatigue (CF) among Psychiatric nurses
Variables | Mean ± SD |
|---|---|
Clinician Associative Stigma (CASS) | 56.4 ± 15.7 |
Moral Distress for Healthcare Professionals (MMD-HP) | 198.3 ± 156.7 |
Compassion Fatigue | 80.8 ± 42.0 |
Predictors of compassion fatigue, associative stigma, and moral distress among psychiatric nurses
Table 3 illustrates the outcomes of multiple linear regression analyses exploring predictors of the three variables focusing on significant associations.
Table 3
Results of multiple linear regression analyses examining the predictors of compassion fatigue, stigma, and moral distress among psychiatric nurses
term | Compassion fatigue | Stigma | Moral distress | ||||||
|---|---|---|---|---|---|---|---|---|---|
β (SE) | 95% CI | p | β (SE) | 95% CI | p | β (SE) | 95% CI | p | |
(Intercept) | 104.2 (18.8) | (67.3, 141.1) | < 0.001* | 55.3 (6.9) | (41.9, 68.8) | < 0.001* | 287.6 (68.6) | (153.1, 422.0) | < 0.001* |
Age | 0.2 (0.4) | (-0.7, 1.0) | 0.673 | 0.4 (0.2) | (0.0, 0.7) | 0.025* | 1.9 (1.6) | (-1.2, 5.1) | 0.230 |
Sex (reference: female) | |||||||||
Male | -6.5 (4.6) | (-15.5, 2.4) | 0.152 | -3.5 (1.7) | (-6.8, -0.3) | 0.035* | -32.4 (16.6) | (-64.9, 0.2) | 0.052 |
Marital status (reference: married) | |||||||||
Single | -11.8 (5.8) | (-23.1, -0.5) | 0.041* | -2.8 (2.1) | (-6.9, 1.4) | 0.190 | -37.3 (21.0) | (-78.4, 3.8) | 0.076 |
Divorced | 14.0 (6.4) | (1.3, 26.6) | 0.031* | 6.3 (2.3) | (1.7, 10.9) | 0.008* | 37.2 (23.4) | (-8.7, 83.2) | 0.113 |
Widowed | 36.0 (14.9) | (6.9, 65.2) | 0.016* | 12.0 (5.4) | (1.3, 22.6) | 0.028* | 100.3 (54.2) | (-6.0, 206.5) | 0.065 |
Nationality (reference: Non-Saudi) | |||||||||
Saudi | -2.8 (5.8) | (-14.2, 8.6) | 0.629 | 0.7 (2.1) | (-3.5, 4.9) | 0.749 | -20.7 (21.3) | (-62.4, 20.9) | 0.330 |
Area of living (reference: rural) | |||||||||
Urban | 2.4 (9.2) | (-15.6, 20.5) | 0.791 | 1.0 (3.4) | (-5.6, 7.6) | 0.777 | -4.5 (33.7) | (-70.4, 61.5) | 0.895 |
Highest level of education (reference: bachelor) | |||||||||
Master | 18.6 (6.4) | (6.1, 31.1) | 0.004* | 6.9 (2.3) | (2.3, 11.5) | 0.003* | 83.8 (23.2) | (38.3, 129.3) | < 0.001* |
Other | 4.6 (9.0) | (-13.1, 22.3) | 0.611 | 3.8 (3.3) | (-2.6, 10.3) | 0.245 | 44.9 (33.0) | (-19.7, 109.5) | 0.174 |
Undergraduate Diploma | 3.8 (6.1) | (-8.2, 15.9) | 0.532 | 2.7 (2.2) | (-1.7, 7.1) | 0.230 | 23.3 (22.4) | (-20.5, 67.2) | 0.297 |
Years of nursing experience (reference: < 1 year) | |||||||||
1 to < 5 year | -21.6 (8.9) | (-39.2, -4.1) | 0.016* | -6.3 (3.3) | (-12.7, 0.1) | 0.053 | -111.4 (32.6) | (-175.4, -47.5) | 0.001* |
5 to < 10 years | -20.0 (10.4) | (-40.4, 0.4) | 0.056 | -8.0 (3.8) | (-15.4, -0.5) | 0.037* | -126.0 (38.0) | (-200.5, -51.5) | 0.001* |
> 10 years | -2.5 (11.9) | (-25.8, 20.8) | 0.835 | -2.3 (4.3) | (-10.8, 6.2) | 0.598 | -90.9 (43.4) | (-175.9, -5.8) | 0.037* |
Years working in psychiatry department (reference: < 1 year) | |||||||||
1 to < 5 years | 4.3 (9.2) | (-13.7, 22.2) | 0.639 | 0.3 (3.3) | (-6.3, 6.8) | 0.940 | 38.1 (33.4) | (-27.3, 103.6) | 0.254 |
5 to < 10 years | -21.0 (11.2) | (-43.0, 0.9) | 0.062 | -10.8 (4.1) | (-18.8, -2.8) | 0.009* | -57.1 (40.8) | (-137.2, 22.9) | 0.163 |
> 10 years | -49.0 (13.0) | (-74.5, -23.5) | < 0.001* | -20.5 (4.7) | (-29.8, -11.2) | < 0.001* | -139.0 (47.4) | (-232.0, -46.0) | 0.004* |
For compassion fatigue, results revealed many significant predictors among psychiatric nurses. Being single was associated with a decrease in compassion fatigue (β = -11.8, 95%), whereas, being divorced (β = 14.0, 95%) and widowed (β = 36.0, 95%) were linked to an increase in compassion fatigue. Nurses with a master’s degree had higher compassion fatigue in comparison to those with a bachelor’s degree (β = 18.6, 95% CI: 6.1 to 31.1, p = 0.004). Additionally, nurses from 1 to less than 5 years of experience had lower levels of compassion fatigue (β = -21.6, 95% CI: -39.2 to -4.1, p = 0.016), and those with more than 10 years of experience in the psychiatry department had significantly lower compassion fatigue (β = -49.0, 95% CI: -74.5 to -23.5, p < 0.001).
For associative stigma results, Age was positively correlated with stigma in associative stigma outcomes (β = 0.4, 95% CI: 0.0 to 0.7, p = 0.025). The stigma experienced by male nurses was considerably lower than that of female nurses (β = -3.5, 95% CI: -6.8 to -0.3, p = 0.035). Higher stigma was linked to being widowed (β = 12.0, 95% CI: 1.3 to 22.6, p = 0.028) and divorced (β = 6.3, 95% CI: 1.7 to 10.9, p = 0.008). The stigma was larger among master’s degree nurses than bachelor’s degree nurses (β = 6.9, 95% CI: 2.3 to 11.5, p = 0.003). Stigma was lower among nurses with 5–10 years of experience (β = -8.0, 95% CI: -15.4 to -0.5, p = 0.037). Nurses with 5years and more of experience in the psychiatry department also reported significantly lower stigma.
For moral distress results, there was a significant difference in moral distress between nurses with a master’s degree and those with a bachelor’s degree (ß = 83.8, 95% CI: 38.3 to 129.3, p < 0.001). The moral distress was significantly lower among nurses with 1–5 years of nursing experience (ß = -111.4, 95% CI: -175.4 to -47.5, p = 0.001), 5–10 years of experience (ß = -126.0, 95% CI: -200.5 to -51.5, p = 0.001), and more than 10 years of experience (ß = -90.9, 95% CI: -175.9 to -5.8, p = 0.037). Additionally, nurses with more than 10 years of experience in the psychiatry department also reported considerably lower moral distress (ß = -139.0, 95% CI: -232.0 to -46.0, p = 0.004).
Mediation analysis for compassion fatigue on the association between clinician associative stigma scale and moral distress
Table 4: Using the Preacher & Hayes technique with bootstrap resampling, the mediation study results for Compassion Fatigue (CF) as the mediating variable on the relationship between the total MD as the independent variable and the total CASS as the dependent variable. With a β of 6.38 (95% CI: 5.51 to 7.29, p < 0.001), the Average Causal Mediation Effect of CF was significant, suggesting that CF is an important mediator of the association between CASS and MD scores. A β of 1.64 (95% CI: 0.64 to 2.68, p < 0.001) indicated that the Average Direct Effect of CASS on MD score, independent of CF, was likewise significant. When direct and indirect paths were combined, the Total Effect was significant (β = 8.03, 95% CI: 7.41 to 8.71, p < 0.001). The Proportion of Mediated Effect (0.80, 95% CI: 0.68 to 0.92, p < 0.001) showed that 80% of the total effect was mediated through CF.
Table 4
Mediation using Preacher & Hayes Method (bootstrap)
Effects | ß | 95% CI | p | |
|---|---|---|---|---|
Lower | Upper | |||
Average Causal Mediation Effect | 6.38 | 5.51 | 7.29 | < 0.001* |
Average Direct Effect | 1.64 | 0.64 | 2.68 | < 0.001* |
Total effect | 8.03 | 7.41 | 8.71 | < 0.001* |
Proportion of Mediated effect | 0.80 | 0.68 | 0.92 | < 0.001* |
Structural equation model mapping the relationships between CASS, CF, and MD
Figure 1: The three measurement models are displayed in the diagram. All path coefficients confirmed that the manifest variables loaded highly and significantly onto the latent constructs. loadings varied from 0.67 to 0.94, all P < 0.001. The fit of the SEM also appeared satisfactory as demonstrated by χ2/df = 2.84, CFI = 0.90, TLI = 0.90, RMSEA = 0.075, SRMR = 0.042. The middle part of this diagram represents the structural model that allows us to see the direct path of CASS to MD (path coefficient = 0.13) and the indirect path created through CF. It is important to mention that all path coefficients concerning the structural model had a significant p-value. An indirect effect was proved, and it was stated that CASS impacted MD with the path through CF (0.79 * 0.86) with an estimation value of 84% of the whole CASS effect on MD. Complete details of the path coefficients, including standardized and non-standardized estimates, standard errors, and p-values, are available in Supplementary Table S1.
Discussion
Results from our study provided initial insight into the interrelated relationship between Compassion fatigue, associative stigma, and moral distress; as far as we know, this is the first study that examines the relationship between these variables; moreover, we used structural equation modeling to provide a detailed explanation of this relationship. The structural model’s central feature highlights the direct effect of associative stigma (CASS) on moral distress (MD), alongside an indirect effect mediated by compassion fatigue (CF), which accounted for a substantial portion of the total effect of associative stigma on moral distress. These results highlight the intricate relationship between moral distress, associated stigma, and compassion fatigue.
Moreover, it sheds light on the critical role of compassion fatigue in the associative stigma and moral distress relationship. Specifically, most of the direct effect of stigma on moral distress is channeled through the emotional exhaustion associated with compassion fatigue, providing a thorough framework for understanding these elements in clinical settings. Additionally, results showed that psychiatric nurses experienced high levels of compassion fatigue in terms of distress in job burnout and secondary traumatic stress and frequently experienced stigma related to their work with individuals with serious mental illnesses. Moreover, this study shows that psychiatric nurses experienced high levels of moral distress.
Results showed that psychiatric nurses experienced high levels of compassion fatigue (CF), particularly in terms of distress in job burnout and secondary traumatic stress. These results align with global trends observed among psychiatric mental health nurses, where the prevalence of CF varied broadly. A recent meta-analysis of prevalence rates examining ProQOL-5 data from high and upper-middle-income countries highlights a wide spectrum of CF ranging from low to high [43].
In terms of educational level, the result indicated that nurses with a master’s degree had higher compassion fatigue than those with a bachelor’s degree. This could be attributed to the incomplete implementation of advanced practice registered nurses (APRNs), In Saudi Arabia, due to various regulatory, institutional, and cultural challenges [44]. This lack of effective APRN practice may explain higher levels of compassion fatigue among master’s degree nurses as they face unmet expectations of professional roles. Therefore, the hospital administration must address the high level of compassion fatigue among mental health nurses and mitigate appropriate intervention.
Concerning work experience, nurses with less than 5 years of working experience exhibited lower levels of compassion fatigue, and those with more than 10 years of experience in the psychiatry department had significantly lower compassion fatigue. This result aligns with previous research indicating that experienced nurses tend to have lower levels of secondary traumatic stress, which means that experience enhanced their resilience to compassion fatigue [45]. Several factors contribute to these findings; nurses with less experience may benefit from supportive work environments [46]. On the other hand, more experienced nurses may develop problem-solving skills and coping strategies, enabling them to strengthen their emotional resilience and be able to combat compassion fatigue [47].
Regarding the associative stigma level, our results showed a high and significant level of associative stigma among psychiatric nurses. Previous studies emphasized similar results among psychiatric nurses. For example, one study found that 91% of mental health professionals reported experiencing stigma [48]. Associative stigma is connected to adverse outcomes such as burnout, disengagement, and emotional exhaustion [36], which implies that associative stigma might diminish the compassion and effectiveness of mental health professionals.
The impact of associative stigma on nurses is profound, resulting in emotional distress and hesitation to disclose their profession due to concerns about judgment. Factors such as fears of contagion, blame, and negative stereotypes about mental health patients can adversely affect nurses’ professional identity and self-worth [49]. Although awareness of mental health has been improved in Saudi Arabia, deep-rooted societal perceptions of mental illness may persist, which can lead to prejudices toward mental health professionals. This may explain why mental health nurses reported increased levels of associative stigma, especially for those with old age.
Further, this study showed that male nurses experienced significantly lower stigma levels than female nurses. This result aligns with a study that reported that female nurses were more likely to experience significantly high associative stigma [50]. The positive attitude of female nurses could explain this, as they are more sympathetic toward patients with mental illness compared to male nurses [51]. While empathy is important for providing care, it may increase perceived association with the stigmatized patients. Also, in Arabic communities, females may be more sensitive to community prejudices and comments than males, which explains why female nurses experience high levels of associative stigma.
Furthermore, this study revealed intriguing results: nurses with a master’s degree had higher stigma levels than those with a bachelor’s degree. This is inconsistent with a study that found a bachelor’s degree in nursing was reported to have a higher stigma by association in Saudi [52]. Various international and national studies found that individuals with low educational levels hold strong stigmatizing views toward patients with mental illness. Although these studies were focused on patient-related stigma rather than associative stigma studies, the interrelation between the two could explain our findings. The potential explanation could be that nurses who are working in mental healthcare are perceived to “not require special skills, useless” and as a profession that is “done by anyone.” Therefore, nurses with high education may perceive their advanced qualifications as undervalued in the nursing field, potentially contributing to increased associative stigma.
Additionally, the results of this study revealed that nurses with less than 1 year of experience in the psychiatry department showed a high level of stigma, and those with over 1 year of experience reported significantly lower stigma levels. These results contrast with a study’s findings in Saudi Arabia, which indicated that mental health nurses with more than 5 to 10 years of experience had higher levels of stigma by association [52]. This discrepancy might be due to various mental health awareness activities that might help nurses recognize the importance of mental health care nursing and diminish feelings of stigmatization.
In reference to psychiatric nurses’ moral distress, results showed that they experienced moderate levels of moral distress. Notably, nurses with a master’s degree experienced higher levels of moral distress than those with a bachelor’s degree. Nurses with master’s degrees hold positions with more autonomy and responsibility, placing them in complex ethical dilemmas and decision-making challenges [53]. This greater responsibility may increase moral distress as they navigate difficult choices and work expectations. Further, nurses with bachelor’s degrees may encounter few ethical decision-making and face lower professional expectations, potentially leading to reduced moral discomfort.
Notably, nurses with more than 10 years of experience in the psychiatry department had significantly lower moral distress. It is possible that more experienced nurses develop effective coping strategies, emotional regulation, and resilience over time, which help them handle challenging working settings and social conflicts and make decisions more comfortably [54]. However, moral distress remained prevalent among psychiatric nurses, particularly for those facing issues such as unresolved conflicts, insufficient formal authority, and low staffing levels. Further, contributing factors to low moral distress include poor colleagues’ performance, time constraints, policy frameworks, legal obligations, violence, and patient safety demands, exacerbated distress among mental health nurses [12].
Strengths and limitations
One of our study’s significant strengths is its exploration of psychiatric nurses’ associative stigma and the mediating role of compassion fatigue in predicting moral distress. Additionally, our study enrolled a relatively large sample size and employed mediation analysis and structural equation modeling to test our hypotheses. However, one of this study’s limitations is its cross-sectional design and data collection from a single setting, which restricts generalizability. We recommend that future research utilize repeated measures designs, adopt other sampling techniques, and consider diverse geographical and clinical settings. Also, we recommend conducting a longitudinal study to explore the impact of compassion fatigue and moral distress on psychiatric nurses better to inform intervention strategies and long-term support.
Conclusion
In this study, psychiatric nurses are experiencing variant levels of moral distress, associative stigma, and compassion fatigue. Within the current demand for mental health care, the interrelated phenomena among these variables which is evident in this study can affect the psychiatric nurses’ mental health and clinical performance. Moreover, the study highlights the direct effect of associative stigma on moral distress, alongside an indirect effect mediated by compassion fatigue. The centrality of compassion fatigue in this relationship allows psychiatric nurses to recognize the detrimental impact associative stigma might have on moral distress. More awareness of this can lead to reimbursement of the dynamics and interventions to reduce emotional exhaustion and secondary traumatic stress. This study emphasizes the importance of supportive frameworks, indicating that moral distress could be addressed by reducing associating stigma and compassion fatigue, potentially leading to improved quality of care delivered by psychiatric nurses.
Implications
This study highlights the need for psychiatric and mental health institutions to regularly assess moral distress, compassion fatigue, and associative stigma among Psychiatric nurses. To address these concerns, institutions should design and implement educational initiatives that raise public awareness about psychiatric illness and the critical role of psychiatric health nurses, helping to reduce stigma. Continuing nursing education and training should also incorporate interventions that address compassion fatigue and moral distress, such as resilience-building programs, stress management workshops, and ethical decision-making training into nursing education. Emphasizing ethical education in psychiatric nursing can further strengthen nurses’ moral courage and decision-making skills, thereby reducing moral distress and promoting a supportive work environment.
Acknowledgements
The authors would like to thank all the nurses who participated in this study and Ms. Lama Alluhaidan, Dalal Almansour, Dlaeel Almnikher, Alhanoof Alkaybari, and Majd Alenzi for assisting in data collection.
Declarations
Ethics approval and consent to participate
The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of King Abdullah International Medical Research Center (KAIMRC) (No: 3094/23). Informed consent was obtained from all subjects involved in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
