The impact of nursing work environment, emotional intelligence, and empathy fatigue on nurses' presenteeism: a structural equation model

The prevalence and complexity of presenteeism have drawn significant attention within the nursing field, establishing it as a critical focus in both academic research and healthcare management [16, 70]. Presenteeism refers to employees continuing to work despite physical or psychological health issues, rather than taking time off [37, 52]. This issue is particularly pronounced in the nursing profession, where studies indicate that nurses exhibit significantly higher presenteeism rates compared to other occupational groups, such as managerial professionals—with reported rates up to three to four times greater [56, 69]. Moreover, due to differences in culture, healthcare systems, nurse-to-patient ratios, and workplace policies across countries lead to significant variations in nurse presenteeism rates [42, 44, 50, 58]. For example, in Sweden, the highly unionized healthcare system provides nurses with greater autonomy, resulting in a presenteeism rate of 54% [38]. In contrast, in Saudi Arabia, factors such as job insecurity and punitive measures discourage nurses from taking leave, leading to a higher presenteeism rate of up to 70.6% [3].

Unlike traditional absenteeism, presenteeism is more difficult to detect and manage [40]. Although nurses remain physically present at work, their compromised health can mask serious underlying issues and systemic occupational risks, leading to wide-ranging negative consequences for individuals, patients, and healthcare organizations [60]. Firstly, presenteeism results in significant productivity losses, placing a considerable financial burden on healthcare institutions. A study in the United States estimated that nurses lose approximately $37.3 billion annually in productivity due to presenteeism [35]. Secondly, it is strongly linked to burnout and stress, which can further exacerbate presenteeism, creating a vicious cycle [61, 74]. Moreover, presenteeism poses a serious threat to patient safety, as it is associated with poor outcomes such as missed care, patient falls, disease transmission, epidemic spread, medication errors, and inefficiency [20, 35, 57, 71]. Alarmingly, research has shown that presenteeism correlates with an increased risk of patient mortality, presenting a critical challenge to the quality of care and patient safety [44].

Although numerous studies have explored the issue of presenteeism, most have focused on general occupational groups, such as corporate employees and teachers [31]. Existing research on nurse presenteeism has primarily focused on organizational factors, such as staffing levels and workload, while exploration of the mediating mechanisms underlying nurse presenteeism behavior remains insufficient. [1, 46]. Therefore, it is crucial to further explore the nurse presenteeism rate and its influencing factors.

The nursing work environment has been identified as a significant predictor of presenteeism, exhibiting a negative correlation [22]. The concept of the nursing work environment refers to the combination of physical, organizational, and social factors that affect nurses' ability to perform their duties effectively. These factors include staffing levels, leadership quality, workplace culture, and resource availability. A U.S. survey revealed that work-related stress, poor leadership, limited opportunities for professional development, and work-life imbalance are strongly associated with presenteeism[2]. The American Association of Critical-Care Nurses (AACN) has long emphasized the importance of a healthy work environment in enabling nurses to provide optimal care, as it enhances job satisfaction and reduces burnout [64]. In a healthy work environment, nurses experience lower levels of burnout and turnover, greater job satisfaction, and reduced presenteeism [18, 33]. As the frontline providers of patient care, nurses are essential to maintaining patient safety and care quality [9, 41]. However, the unique nature of nursing, which involves human-centered tasks with low substitutability, high demands, limited autonomy, and significant pressure, coupled with the ethical responsibilities of the profession, makes nurses less likely to take sick leave, even when unwell [68]. Therefore, studying the relationship between the nursing work environment and presenteeism helps provide a multidimensional perspective to understand the predictors of nurse presenteeism.

Emotional intelligence refers to the ability to recognize, understand, regulate, and effectively utilize both one's own emotions and those of others [7]. According to the Job Demands-Resources (JD-R) model, work environment factors can be classified into two categories: job demands (e.g., workload, stress) and job resources (e.g., emotional intelligence, peer support). When job demands exceed available resources, negative outcomes such as burnout and presenteeism may occur. A healthy nursing work environment, characterized by safety, empowerment, and job satisfaction, directly enhances nurses' ability to manage emotions by offering emotional support and fostering effective communication [48]. Moreover, reasonable workloads and stress management strategies provided in such environments help nurses cope with emotional pressure and improve their emotional intelligence. Emotional intelligence, as a key job resource [21, 24], plays a vital role in nursing practice [54]. It is essential for enhancing nursing efficiency and acts as a protective factor against psychosocial risks [62]. Emotional intelligence improves both physical and mental health, boosts job satisfaction and engagement, reduces burnout, and lowers presenteeism rates. Research indicates that individuals with higher emotional intelligence are more adept at recognizing, understanding, and managing their emotions, thereby mitigating the negative impact of stress on health [80]. Additionally, these individuals exhibit stronger coping strategies and adaptability and tend to maintain work engagement rather than opting for presenteeism, thereby avoiding the consequences of presenteeism.

Empathy fatigue is an emotional depletion experienced by caregivers, social workers, and other helping professionals due to prolonged exposure to the pain and stress of others [11]. The increasing complexity of healthcare, the intense interpersonal interactions required in nurses' daily tasks [45], excessive psychological demands, and workplace stress can exacerbate emotional exhaustion, particularly in settings with insufficient resources or weak support systems, leading to a higher incidence of empathy fatigue [43]. Unhealthy work environments not only deprive nurses of necessary rest and recovery time but also increase their emotional burden in dealing with patient suffering. When combined with cumulative burnout, empathy fatigue intensifies [14]. However, due to a sense of responsibility and commitment to their patients, nurses often continue working instead of taking time off to rest. This behavior, characterized by working while ill or emotionally depleted, raises the incidence of presenteeism, ultimately affecting nurse performance and patient safety. Overall, an empowering work environment can alleviate compassion fatigue by providing decision-making autonomy and emotional support, helping nurses manage emotional stress more effectively [30]. This, in turn, reduces stress-related presenteeism caused by compassion fatigue, ultimately impacting the quality of care and patient safety. Therefore, addressing compassion fatigue is essential for reducing presenteeism and improving the overall quality of care."

Emotional intelligence plays a critical role in mitigating compassion fatigue. A study conducted in Uganda on psychotherapists revealed that the four key components of emotional intelligence—social awareness, self-awareness, self-management, and social skills—are negatively correlated with levels of compassion fatigue [28]. This suggests that healthcare professionals with higher emotional intelligence are better equipped to manage their emotions, maintain emotional stability, and exhibit psychological resilience when faced with patients' suffering, thereby preventing emotional overinvestment and reducing the occurrence of compassion fatigue [51]. Emotional intelligence enables nurses to more effectively identify and regulate their emotions in response to emotional stress, decreasing the incidence of emotional exhaustion and enhancing their adaptability in high-pressure environments. As a result, they are better able to employ positive coping strategies to manage work-related stress. In this way, emotional intelligence serves as a buffer, significantly reducing compassion fatigue caused by emotional depletion, thus protecting the mental health and work performance of nurses.

In conclusion, although an increasing number of people recognize that emotional intelligence and empathy fatigue are important factors influencing nurse presenteeism, research on their mediating role between the nursing work environment and presenteeism remains limited. Therefore, this study will explore the relationship between nursing work environment, emotional intelligence, empathy fatigue and nurses' presenteeism rates. We propose the conceptual framework (see Fig. 1) and hypotheses for this study: (1) the nursing work environment is negatively associated with nurses' presenteeism; (2) emotional intelligence mediates the relationship between the nursing work environment and nurses' presenteeism; (3) compassion fatigue mediates the relationship between the nursing work environment and nurses' presenteeism; and (4) emotional intelligence and compassion fatigue jointly mediate the link between the nursing work environment and nurses' presenteeism.

This study constructed a structural equation model to examine the relationship between the nursing work environment and nurse presenteeism, as well as the roles of emotional intelligence and compassion fatigue. The findings indicate that the nursing work environment, nurses' emotional intelligence, and compassion fatigue are all significantly related to nurse presenteeism. Mediation analysis revealed that both emotional intelligence and compassion fatigue serve as significant mediators in the relationship between the nursing work environment and presenteeism.

In this study, the presenteeism score of nurses in Henan Province was 19.49 ± 5.910, significantly lower than those of nurses in Croatia (21.3 ± 4.5) and Turkey (26.46 ± 52.39), but higher than the scores reported for nurses in Sichuan Province and Beijing, China. These differences may be attributed to variations in work stress, health support systems, and cultural factors across countries and regions. For instance, Turkey has a relatively low nurse-to-patient ratio, and the nursing profession endures long-term high-intensity work pressure with limited professional support mechanisms, making nurses more vulnerable to presenteeism in high-stress work environments [6]. In contrast, eastern regions of China, such as Beijing, benefit from more abundant medical resources, leading to reduced professional stress and improved work environments for nurses. However, in central regions like Henan Province, although the healthcare system has developed in recent years, challenges remain in enhancing nurse staffing and improving work environments, which may contribute to the relatively higher presenteeism scores observed [66].

This study identified a significant negative correlation between nursing work environment scores and nurse presenteeism scores, supporting Hypothesis 1. This finding aligns with previous research conducted in other populations. Studies have highlighted that participation in decision-making is a key factor influencing nurses' work motivation [4]. Additionally, psychosocial work factors—such as job stress, perceived workload, burnout, job satisfaction, and health status—have been shown to predict nursing quality [65]. Authentic nurse leadership has been found to reduce turnover, enhance psychological resilience, and improve nurses' overall well-being. Collectively, these healthy work environment factors can significantly lower nurse presenteeism rates. Research also indicates that common reasons for presenteeism among healthcare providers include the desire not to burden colleagues, a strong sense of responsibility toward patients, and the need to avoid future increased workloads due to presenteeism [26]. These findings underscore the importance of adequate healthcare resources, standardized nursing practices, and a manageable perceived workload in preventing presenteeism. To address this issue, hospitals should establish nursing committees that involve nurses in discussions regarding the formulation of nursing policies and process improvements. Furthermore, workloads should be appropriately distributed based on nurses' work intensity, skill levels, and scheduling preferences to avoid excessive concentration of tasks. Finally, offering more career development opportunities, such as promotion pathways and mentorship programs, can enhance the nursing work environment and reduce presenteeism.

This study demonstrates that the nursing work environment is positively associated with nurses' emotional intelligence and negatively associated with presenteeism. An improved nursing work environment enhances emotional intelligence in nurses, which, in turn, contributes to a reduction in presenteeism rates, hypothesis 2 was tested [22]. This finding aligns with previous research, which identifies emotional intelligence as a key factor in improving nursing quality and work efficiency, effectively reducing presenteeism [55]. A safe and efficient nursing work environment fosters supportive management, effective resource allocation, and greater professional autonomy and development opportunities, which, in turn, enhance nurses' self-management abilities [15]. In such optimized environments, nurses have easy access to the emotional support and resources essential for their roles, enabling them to manage complex tasks and improve emotional regulation skills, ultimately fostering the comprehensive development of emotional intelligence [34]. It is well established that nurses face numerous stressors at work, including personal challenges, long hours of standing, workplace violence, bullying, the demanding nature of their tasks, patient care responsibilities, and interactions with patients in need [13, 47]. These challenges require strong emotional management, stress-coping strategies, and interpersonal communication skills. Nurses with high emotional intelligence are better equipped to manage psychological stress, serving as a buffer against burnout and mental health issues caused by emotional strain, thereby reducing presenteeism [62]. As a result, the work environment indirectly influences nurses' mental health and job performance by enhancing emotional intelligence, a mechanism that helps reduce presenteeism [29]. The research findings suggest that hospitals should enhance the work environment for nurses by providing adequate resources, manageable workloads, and effective team communication mechanisms. Furthermore, emotional intelligence training should be integrated into nurses' continuing education programs through diverse formats, including online learning and workshops. This strategy ensures that nurses continuously develop their emotional intelligence at various stages of their careers. Nursing department leaders should promote regular assessments of nurses' emotional awareness, emotional management, and emotional communication skills. By quantifying this data, nurses can obtain a clear understanding of their current emotional intelligence levels and identify areas for improvement. Previous studies have also highlighted emotional intelligence as a critical psychological resource for long-term success, supporting its inclusion in nursing education programs to build a solid foundation for future nursing professionals [8, 19].

The results of the study confirmed that empathy fatigue was a mediating variable between the nursing work environment and nurses' presenteeism, indicating that a better work environment leads to lower levels of compassion fatigue, which in turn reduces presenteeism [12, 39], validating Hypothesis 3. This finding aligns with previous research. Nurses face significant challenges in modern healthcare, including increasing occupational stress [49]. Nursing requires sustained empathy in dealing with patients’ pain and anxiety, but prolonged emotional engagement can negatively impact nurses themselves [75]. Behnke’s study suggests that when nurses care for trauma survivors, their own traumatic memories may be reactivated, causing emotional discomfort [5]. Without adequate support or resources in the work environment, this emotional burden is more likely to develop into compassion fatigue, which can lead to secondary traumatic stress. In such instances, nurses may experience fatigue, weakened immunity, pain, anxiety, depression, difficulty concentrating, emotional exhaustion, and frustration, all of which can impair sleep quality (Y. [78]). When nurses' emotional investment, job satisfaction, psychological resilience, and work engagement are undermined by compassion fatigue [53], their presenteeism tends to increase [17]. A well-structured psychosocial work environment, characterized by thoughtful work organization and task content, can have a positive impact on nurses' health and well-being [76]. According to emotional regulation theory [27], hospitals and nursing institutions should offer psychological counseling and emotional management training, such as mindfulness meditation, mindfulness-based stress reduction (MBSR), and emotional regulation techniques like cognitive restructuring. These interventions help nurses recognize and manage their emotional responses, thereby mitigating the long-term impacts of emotional labor. Additionally, hospitals should allocate nursing resources based on patient volume and care complexity to ensure manageable workloads. Increasing the number of nursing staff or support personnel can further distribute the workload, reducing stress and minimizing the risk of compassion fatigue.

This study identified a chain mediation effect involving emotional intelligence and compassion fatigue in the relationship between the nursing work environment and nurse presenteeism, hypothesis 4 was tested. This finding highlights the significant impact of the nursing work environment on nurses' psychological well-being and professional behavior and deepens our understanding of how emotional intelligence mitigates the challenges associated with nursing work. Optimizing the work environment not only reduces work-related stress and presenteeism directly but also enhances nurses' emotional intelligence [10], enabling them to better manage and regulate emotional stress at work [73]. Emotional intelligence, as an important individual resource, helps nurses deal with complex emotional labor and also enhances their psychological resilience in the face of professional emotional challenges [13, 36]. This mechanism underscores the crucial role of emotional intelligence in professions with high emotional demands. Furthermore, there is a significant association between emotional intelligence and compassion fatigue. Increased emotional intelligence effectively reduces the incidence of compassion fatigue and serves as a buffer when compassion fatigue arises [59]. This dual mechanism—where an improved work environment boosts emotional intelligence, which in turn reduces compassion fatigue, and subsequently, compassion fatigue affects presenteeism—illuminates the dynamic interactions among the nursing work environment, emotional intelligence, compassion fatigue, and presenteeism. Consequently, the identification of this chain mediation effect provides valuable insights for nursing management. Future research should focus on developing comprehensive intervention strategies to address emotional labor and compassion fatigue, aiming to improve nurse presenteeism and ultimately enhance the quality of nursing services and patient satisfaction.

The study possesses some limitations. First, as a cross-sectional study, it only examines the relationship between variables at one point in time, which limits our ability to determine causality or how these relationships might change over time. Future research should use longitudinal or experimental designs to explore these dynamics more thoroughly. Second, the study focused on nurses in a specific region, which may limit the generalizability of the findings. A broader study including different regions and healthcare settings is needed to confirm the results more widely. Finally, the study relied on self-reported data, which can introduce bias. Future research should consider using objective measures or third-party assessments to provide more accurate and reliable data.

This study examined the nursing work environment, nurses' emotional intelligence, empathy fatigue, and presenteeism. A chain mediation model was developed to investigate the mechanisms through which the nursing work environment influences presenteeism among nurses. The results revealed that emotional intelligence and empathy fatigue served as mediators in the relationship between the nursing work environment and presenteeism. These findings offer theoretical support and practical guidance for research and interventions focused on reducing presenteeism among nurses, which is crucial for enhancing their well-being and improving the quality of care.