Relationship between empathy and burnout as well as potential affecting and mediating factors from the perspective of clinical nurses: a systematic review

Nursing care is a complex and demanding profession. Nurses are mostly responsible for caring for patients and alleviating their suffering in a challenging and stressful environment [1]. One consequence of continuous stress is burnout, which is described as an inability to cope with emotional stress at work or a sense of failure and exhaustion due to the overuse of energy and resources [2, 3]. Burnout is a psychological syndrome that frequently occurs among individuals who do ‘people-work’. Burnout is associated with increased feelings of emotional exhaustion, the development of negative attitudes, and a tendency to evaluate oneself negatively [4]. According to Maslach’s theory, burnout can be divided into three dimensions: emotional exhaustion, depersonalisation, and reduced personal accomplishment [4]. Emotional exhaustion refers to high emotional demands that deplete personal resources; depersonalisation refers to the attempt to distance oneself emotionally from patients and colleagues; and reduced personal accomplishment refers to a negative view of oneself and a decrease in self-esteem [4]. Burnout is characterised by a high level of emotional exhaustion, a pronounced sense of depersonalisation, and a low level of personal accomplishments [5]. Burnout may adversely affect the psychological well-being of nurses, nursing staff retention, and the quality of patient care [6‐8]. The Maslach Burnout Inventory (MBI) is considered the ‘gold standard’ for measuring burnout and has been widely used in most empirical research [9].

On the contrary, empathy is the ability to understand and share other persons’ feelings and communicate their understandings [10, 11]. Empathy is considered an essential skill in the process of communicating with patients within patient-centered care [12, 13]. According to Rogers, empathy is the ability of the clinician to feel the patient’s private world as if it were his or her own, without losing the quality of ‘as if’ [14]. In 2007, Rogers identified three dimensions of empathy, including cognitive, emotional, and behavioural [15]. The emotional and cognitive dimensions refer to the clinician’s ability to experience and share the feelings of others and to be able to objectively and rationally identify and understand the feelings of others. The behavioural dimension usually refers to the clinician’s ability to communicate their understanding of another person’s perspective. Researchers also suggested a fourth dimension of empathy, which is morality [16]. Morality refers to the intrinsic altruistic motivation to feel empathy for others. In addition, Davis suggested four different components of empathy [17]. Two of the components are at the cognitive dimension of empathy, including fantasy and perspective-taking. The other two components of empathy are at the emotional dimension, including empathic concern and personal distress. Empathy is beneficial for building a good nurse-patient relationship, thus resulting in increased patient confidence, better patient compliance with treatment, improved clinical outcomes, and increased patient satisfaction [18‐25]. Different from burnout, there is no ‘gold standard’ for measuring empathy [26]. Instead, a variety of tools were used to evaluate the empathy score, including the Jefferson Scale of Physician Empathy (JSPE), Interpersonal Reactivity Index (IRI), and Scale of Empathy Competencies of Clinical Nurses (SECCN) [27, 28].

The relationship between empathy and burnout has been an area of increasing research interest. Although most studies demonstrated that empathy was negatively related to burnout, there is contradicting evidence [29]. It is therefore necessary to critically examine the relationship between the two and elucidate the reasons for the conflicting results. These investigations will further facilitate the development of interventions and policies aiming at helping nurses and healthcare organisations to improve management and prevent burnout.

Based on the articles related to empathy and burnout, The study aimed to thoroughly and methodically examine the literature evaluating the connection between burnout in clinical nurses and empathy as well as draw a relationship between them. The factors that influence the level of empathy and burnout during the last 11 years were also examined. There are conflicting views on the association between empathy and burnout and we sort to reason the contradicting results. This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline, which would present more transparent, complete, and accurate reporting of systematic evaluations [30].

Burnout syndrome is a prevalent problem among medical professionals, which would lead to severe consequences not only for the medical staff themselves but may also affect patient treatment outcomes. Due to the increasing responsibilities required to deliver proficient, humane, culturally sensitive, and moral care, burnout is more frequent among nurses than among other health professionals [47]. This review investigated the related literature and summarized the empathy and burnout levels among nurses, their relationships, and the possible affecting factors.

In general, the burnout ratio in China was relatively low. Three studies (Studies 8–10) carried out in China showed that the ratio of severe burnout was 5.7%, 5.4%, and 6.06% respectively. Similarly, results from a study (Study 6) conducted in Spainshowed that high levels of burnout only accounted for 3.7%. On the contrary, two studies carried out in the USA and Spain (Studies 2 and 3) indicated a high ratio of severe burnout that both accounted for one-third of the participants. These great differences in burnout levels may be partly due to differences among different regions. As suggested in other studies, the ratio of high-level burnout was relatively low in France and only accounted for 4.6% [48]. However, for Pakistani house officers and postgraduate trainees, high-level burnout rate amounted to 29.8% [49]. The different burnout levels among different regions may be attributed to the differences in healthcare systems as well as cultural differences in distinct countries. In this review, participants of the two studies (Studies 2 and 3) that reported high levels of burnout were enrolled in trauma centers and emergency care centers. Healthcare workers in both of these departments were more prone to exposure to higher occupational stress than other medical workers [50]. Thus, the different working environments may be a factor that causes high burnout levels.

Many additional factors considered to be related to burnout were included such as age, working experience, shift schedule, and levels of work. Apart from these demographic and work-related characteristics of the participants, empathy was one of the most studied factors that was considered to be related to burnout. The empathic ability of health professionals not only provides high-quality care to patients but can also help to reduce burnout of medical workers [40, 51]. When comparing the general relations between empathy and burnout, the included studies showed a consistently negative correlation. However, when considering the different components of empathy and burnout, the relationships were more complicated. In this review, three studies (Studies 5, 7, and 8) indicated that empathy was positively associated with emotional exhaustion. It is conceivable that an empathetic nurse feels distress and sorrow from patients in their daily work, which might lead to emotional exhaustion. However, they could also feel happy when patients recovered. Therefore, we considered that empathy would not always lead to emotional exhaustion, and their relations need to be investigated further. Studies 7, 11, and 14 indicated that burnout was consistently positively correlated with personal distress, and negatively correlated with perspective-taking and empathic concern. Personal distress is a negative emotion of oneself due to witnessing pain or distress. Understanding the pain of the patient, communicating with them, and offering assistance while acknowledging that their situation is different from one’s own is a crucial component of empathy that allows one to experience the highest levels of compassion satisfaction [52]. Perspective-taking and empathic concern can therefore lead to the desire to help those in distress. However when the level of perspective-taking is low and is accompanied by a high level of personal distress, burnout emerges. This is supported by other literature reporting that emotional sharing with poor self-regulation can cause personal distress, thus leading to decreased empathic concern [53]. Due to these, we concluded that relating empathy and burnout based on their different components is rational. Distinct dimensions of empathy or burnout would be differentially related and thus could illustrate a more specific association between these factors.

Besides the direct relationship between empathy and burnout, seven studies suggested that some factors were also involved in mediating their relationships. Study 7 suggested inference of patients’ mental states was a mediating factor between empathy and burnout. This study considered empathy and burnout at different dimensions and led to complicated results. Perspective-taking was considered to increase the inference of patients’ mental states thus leading to a higher level of personal accomplishment. However, as suggested above, personal distress is a negative consequence of empathy, which is negatively related to social functioning [54]. This study also indicated that increased personal distress was associated with less inference of mental states, leading to negative consequences like increased emotional exhaustion. Based on these results, personal distress should not be included in the definition of empathy, and should not be considered in the intervention programs to improve empathic skills.

Three studies suggested mediating factors involved in empathy and burnout but did not alter their negative relationship. Study 8 suggested the nursing organisational climate as a mediator. It was found that empathy had a positive effect on nursing organisational climate and could protect nurses from burnout. Empathy facilitates to construct a relaxed and comfortable organisational climate [38]. Highly empathetic nurses can communicate well with colleagues and create amicable working relationships, which can provide nurses with positive emotions to achieve high personal accomplishment [55]. It can be concluded from this study that nursing managers can improve nurses’ work environment to reduce burnout. Study 10 indicated that coping style was an essential mediator between empathy and burnout. Highly empathetic nurses have more positive responses to stress and a stronger perception of psychological resilience and social support [56, 57]. Thus, when highly empathetic nurses encounter stressful events, they are more inclined to seek help from others and respond accordingly. Positive coping styles may help nurses alleviate stress, maintain a good psychological state, and calmly deal with problems. It has been found that nurses with positive coping skills were more prone to experience lower levels of depersonalisation, emotional exhaustion, and decreased personal accomplishment [58]. Study 13 showed that STS and WPS, as mediating factors, were significantly correlated with empathy and burnout. Studies have reported that medical staff with high empathy are more prone to STS, especially in the case of high workload and time pressure, because the existence of high empathy is more likely to lead to emotional infection [59, 60]. Therefore, when healthcare workers maintain high enthusiasm for their work, even when the level of empathy is low, the emotional exhaustion is low [61].

The last two studies illustrated that due to the mediating factors involved, the relationship may change between empathy and burnout. Study 11 suggested that when empathic feelings gave rise to pathogenic empathy-based guilt, they might be more vulnerable to developing burnout symptoms. Nurses constantly recruit their empathic abilities in their daily work. Given the close relationship between empathy and guilt, highly empathetic nurses are more likely to experience pathogenic empathy-based guilt, which means excessive and misplaced responsibility for their patients. This unrealistic responsibility may lead to the disruption of the lives of the nurses and also lead to unprofessional caring [41]. Thus, intervention programs targeting pathogenic empathy-based guilt may be particularly important to help reduce burnout. Study 9 indicated that highly empathetic medical staff can better understand the patients and may deepen their professional knowledge to cure their patients, thus enhancing their job commitment [39]. Job commitment provided medical staff with a better understanding of their own behavior when communicating with patients and dealing with colleagues, which significantly attenuated job burnout. However, empathy was suggested to negatively correlate with job satisfaction. Medical staff use empathy to face illness and death in their daily work. The overwhelmed feeling of powerlessness and helplessness may cause dissatisfaction with their work, finally leading to burnout [39].

The current developments concentrating on the relationships between empathy and burnout, as well as any potential influencing or mediating elements, were reviewed together in this review. Intervention programs aiming at reducing stress and burnout should consider these potential factors for better outcomes. It is worth noting that empathy and burnout should be considered based on their different dimensions to elucidate more accurate consequences.

There are several limitations to this study. Since the goal of this study was to examine research conducted within the last 11 years, only a small number of literature was incorporated in this review. Consequently, the perspective on empathy and burnout was not comprehensive. In addition, the sample size varied across different studies. Some studies enrolled a relatively small number of participants, which may lead to bias when interpreting the results.

This review investigated literature published in the last 11 years, illustrating the relationship between empathy and burnout, as well as their affecting and mediating factors. This review is the first to summarize that mediating factors involved in empathy and burnout could alter the relationship between empathy and burnout. These results provided valuable information to aid in designing intervention programs and further establishing approaches to reduce burnout in nurses. It can also be a solid foundation for further research in this field.