Introduction
In the global medical and health field, the humanistic care provided by nurses has consistently been a significant issue attracting considerable attention [1]. With the aging global population and the increasing prevalence of chronic diseases, as well as rising expectations for the quality of medical services, the importance of nurses’ humanistic care has become increasingly pronounced [2, 3]. Furthermore, the World Health Organization emphasizes the necessity of considering patients’ feelings and reactions within the evaluation framework of the medical service system [4]. In recent years, numerous studies have focused on measuring and enhancing nurses’ humanistic care capabilities, encompassing research related to nursing education reform [5], optimization of work environments [6], and the construction of professional culture [7], among others, to address the global demand for high-quality medical care. However, in China, the humanistic care capabilities of nurses have yet to meet the standards required for high-quality nursing services, a challenge that is particularly evident in the current medical environment [8]. In resource-limited settings, medical technology often takes precedence over the expression of humanistic values, leading nurses to prioritize disease treatment in their daily work while potentially neglecting effective communication with patients and the provision of essential emotional support [9]. This situation contributes to a growing lack of empathy from patients towards nurses, resulting in increased patient worry and dissatisfaction [10]. Additionally, multiple studies have indicated that nurses’ overall scores in humanistic care abilities generally fall below acceptable standards, further corroborating the prevalence and severity of this issue [11, 12]. Therefore, it is particularly urgent to enhance nurses’ humanistic care capabilities, as this improvement will not only elevate the overall quality of nursing services but also effectively address patients’ emotional needs and psychological expectations. The “Outline of Healthy China 2030 Plan” issued by the Chinese government highlights the importance of continuously improving nurses’ medical humanistic care skills and fostering a harmonious nurse-patient relationship [13]. This plan sets forth overarching expectations for nursing staff’s caregiving abilities.
Nursing has long been associated with the concept of care since the time of Florence Nightingale. Care is considered a fundamental element of nursing science, an essential quality for individuals in the nursing profession, and vital for providing optimal patient care [14]. Through the practical application of caring behaviors, such as operations and interactions, nurses convey care and the feeling of “caring” [15]. In the practice of nursing, the essence of care becomes evident gradually, demonstrated through acts of compassion and encompassing not just a way of life, values, and beliefs, but also an action procedure that is put into practice [16]. Therefore, caring behavior stands as a defining characteristic of nursing.
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Caring behavior is a crucial aspect of nursing practice that plays a significant role in ensuring quality care for patients and fostering positive outcomes for both patients and nurses. Mosby’s Medical Dictionary defines caring behavior as actions that demonstrate concern for a patient’s well-being, such as providing comfort, attentive listening, honesty, and non-judgmental acceptance [17]. Essentially, caring behavior encompasses meeting both the physical and emotional needs of patients. The physical aspect involves tasks like providing therapy, training, and physical rehabilitation, while the emotional aspect involves treating patients with kindness, instilling confidence, and offering hope [18]. The dimensions of caring behavior include respect and connection, knowledge and skills, and support and reassurance [13]. By incorporating caring behavior into nursing practice, healthcare professionals can improve the quality of care, enhance patient health outcomes, promote feelings of safety and satisfaction, and ultimately elevate the overall delivery of medical services [19].
In hospitals, nurses constitute the majority of medical staff, and their caring behaviors are essential for improving the quality of medical care [20]. Consequently, current research is increasingly focused on analyzing the factors that affect nurses’ caring behaviors [21]. Prior studies have highlighted the significant roles of both educational background and nurse characteristics in shaping nurses’ caring behavior [18, 22]. Kibret [23] identified that cultivating a positive work environment and reducing workload can boost the manifestation of caring behaviors among nurses. Moreover, other research has pointed out that organizational support, psychological factors, occupational fatigue, and empathy are crucial factors that influence nurses’ caring behavior [24, 25]. Results from a multi-center cross-sectional study conducted in Egypt indicate that positive communication from supervisors can significantly mitigate the effects of patients’ mistreatment of nurses on nurses’ psychological detachment, thereby alleviating the negative consequences of this situation on nurses’ caring behaviors [26]. Moreover, a recent descriptive study involving nursing students confirmed that empathy acts as a mediating factor between emotional support and caring behaviors, with researchers suggesting that fostering empathy can effectively enhance the caring behaviors of nursing students [27].
The outpatient clinic is a crucial department in hospitals that offers a range of medical services. Outpatient nurses play a vital role in improving overall service quality [28]. However, working in outpatient clinics can pose unique challenges for nurses, including increased physical and emotional stress [29]. In China’s tertiary hospitals, outpatient clinics are facing high patient volumes, rapid turnover, complex patient conditions, and a noisy environment [30]. Research indicated that nurses in such high-stress environments were more susceptible to developing compassion fatigue over time [29]. Compassion fatigue refers to the negative emotions that arise from nurses’ regular exposure to patient suffering, stressful work environments, and constant selflessness, reflecting the adverse effects of the nursing profession [31]. Egyptian scholar El-Ashry [32] conducted a study among intensive care nurses, confirming a strong correlation between elevated pressure levels and compassion fatigue. The results of the research indicate a significant positive correlation between postcode stress and both occupational burnout and secondary traumatic stress, in addition to compassion fatigue. This finding underscores that the high levels of stress and emotional exhaustion experienced by nurses during cardiopulmonary resuscitation contribute to increased compassion fatigue and burnout [32]. Consequently, it is imperative to prioritize the mental health of nurses working in high-stress environments, such as critical care, as effective mental health management can mitigate the negative effects of stress and enhance the overall resilience and psychological well-being of nursing professionals. Despite the importance of this issue, there is a lack of research on compassion fatigue among Chinese outpatient nurses. Previous studies have shown that high levels of compassion fatigue can deplete nurses’ emotional reserves, leading to professional burnout and secondary traumatic stress [29]. This, in turn, can negatively impact nurses’ interactions and communication with patients, potentially reducing the quality of care provided [33]. While it is hypothesized that there is a negative relationship between nurses’ compassion fatigue and their caring behaviors, empirical validation of this relationship is currently lacking.
Organizational support is a critical environmental factor within an organization, particularly in relation to nurses’ perception of the hospital’s support for their work, prioritization of their interests, and recognition of their value [34]. Previous studies have highlighted the significant role of organizational support in reducing compassion fatigue among nurses [35]. Further research has shown a direct and negative correlation between the level of organizational support for nurses and the development of compassion fatigue [36]. Moreover, social exchange theory suggests that when employees feel supported and valued by their organization, they are more likely to reciprocate with caring behaviors [37]. This reciprocal exchange of benefits nurtures a positive relationship between the organization and its employees. Thus, perceived organizational support is closely linked to both compassion fatigue and caring behaviors.
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The Job Demands-Resources (JD-R) model classifies factors that promote positive work behaviors into job demands and resources [38]. In our rapidly changing society, there is a growing emphasis on resource factors. Among these, organizational support stands out as a vital work resource for nurses. Nurses rely on sufficient organizational support to boost their work engagement, with caring behavior often reflecting this engagement. Furthermore, compassion fatigue represents a potential challenge within personal resources [39]. Studies suggested a mutual relationship between job resources and personal resources in the JD-R model [40]. Consequently, compassion fatigue could significantly influence the link between organizational support and nurses’ caring behavior.
Previous studies have predominantly concentrated on various career-related phenomena among inpatient nurses, with relatively little attention directed towards the specific group of outpatient nurses. The issues of compassion fatigue encountered by outpatient nurses may possess unique characteristics due to significant differences in work environments, patient flow, and patient demographics. This study aims to address the gap in research regarding compassion fatigue within this specific healthcare group. Additionally, the mediating relationship between nurse compassion fatigue, perceived organizational support, and caring behavior has not been thoroughly investigated, particularly among outpatient nurses. Consequently, this study established organizational support as the independent variable, compassion fatigue as the mediating variable, and caring behavior as the dependent variable, while constructing and validating a mediating effect model. The study aspires not only to provide hospital and nursing managers with insights on effectively delivering organizational support to mitigate compassion fatigue and enhance the mental health of outpatient nurses, but also to comprehensively elucidate the intrinsic linkage mechanisms among the various variables. By understanding the relationships between relevant psychological and behavioral phenomena among Chinese outpatient nurses, this research will offer new intervention perspectives and strategies for improving caring behavior in outpatient nursing practice in China, ultimately providing empirical evidence to enhance patient experiences and elevate the quality of outpatient nursing services.
Theoretical basis
The JD-R model is a significant framework proposed by scholar Demerouti [41] for understanding employee happiness, work motivation, and performance in the workplace. This model categorizes job characteristics into two groups: job demands and job resources. Job demands refer to factors that require sustained physical or mental effort at work, such as work pressure and workload. In contrast, job resources encompass the physical, social, or organizational factors that facilitate the achievement of work goals, mitigate job demands, and promote personal growth and development, including work autonomy and social support. When job resources are sufficient, the negative effects of job demands on employees can be alleviated, thereby enhancing employees’ work engagement, happiness, and performance. In the JD-R model, organizational support is classified as a job resource. When outpatient nurses perceive organizational support—such as the provision of adequate training opportunities and reasonable staffing levels—this creates an environment that fosters the implementation of caring behaviors. A randomized controlled trial conducted by El-Gazar [42] demonstrated that a job crafting intervention grounded in JD-R theory can significantly enhance nurses’ job crafting behaviors and promote a harmonious work enthusiasm. Essentially, the positive resources provided by the organization can improve nurses’ work performance, attitudes, and behaviors. For ambulatory nurses, organizational support translates into an increased availability of resources to effectively address patients’ needs, thereby enhancing the likelihood of exhibiting caring behaviors. According to the JD-R model, organizational support serves as a vital work resource that can alleviate the pressures stemming from work demands. Chinese outpatient nurses face considerable work demands, including high-intensity patient reception and the management of complex conditions, which can easily result in compassion fatigue. However, when these nurses perceive organizational support—such as adequate break schedules, psychological counseling, and other resources—they are better positioned to cope with these work demands, ultimately diminishing the occurrence of compassion fatigue. The burnout dimension of compassion fatigue can lead to emotional depletion among outpatient nurses. Within the framework of the JD-R model, this phenomenon represents a job demand that significantly diminishes the psychological resources available to nurses. When nurses experience emotional exhaustion, they may lack the energy and emotional capacity required to deliver adequate care to their patients. According to the JD-R model, job stressors, akin to job demands, impact nurses’ job performance—including their caring behavior—by influencing their levels of burnout, which encompasses a component of compassion fatigue. Furthermore, organizational support, viewed as a job resource, can mediate the relationship between job stressors and burnout. Specifically, when an organization offers adequate support and mitigates outpatient nurses’ compassion fatigue, these nurses are more likely to exhibit caring behavior. Conversely, insufficient organizational support that exacerbates compassion fatigue can lead to a decrease in such caring behavior. Based on this theory, the study developed a research hypothesis model (Fig. 1) and proposed several hypotheses:
H1
Perceived organizational support has a direct positive impact on the caring behavior of outpatient nurses.
H2
H2: Perceived organizational support has a direct negative impact on outpatient nurses’ compassion fatigue.
H3
Compassion fatigue has a direct negative impact on the caring behavior of outpatient nurses.
H4
Compassion fatigue mediates the relationship between perceived organizational support and caring behavior by outpatient nurses.
Fig. 1
The theoretical model of this study
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Methods
Design and participants
This study adhered to the guidelines for cross-sectional studies as outlined by the Reporting of Observational Studies (STROBE) and was conducted between November 2023 and January 2024. A convenience sampling method was employed to distribute questionnaires to outpatient nurses across six tertiary general hospitals in Xi’an, China, that met the specified inclusion criteria. Among these six participating hospitals, four were affiliated with universities. The number of beds in these hospitals ranged from 2,580 to 5,037, while their annual outpatient visits varied from approximately 2.05 million to 3.93 million. The inclusion criteria comprised registered nurses with at least 1 year of experience in outpatient nursing, who provided informed consent and voluntarily agreed to take part in the study. Exclusion criteria encompassed outpatient nurses who were on leave for study or vacation during the survey period, as well as outpatient trainee nurses.
Based on the Kendall [43] sample size estimation method, the recommended sample size for descriptive research should be 10 to 20 times the number of variables. In this study, there were 10 variables from the sociodemographic questionnaire and 7 dimensions from 3 scales, totaling 17 variables. To account for potential missing and invalid questionnaires, the initial sample size was increased by 20%, leading to an estimated range of 204 to 408 cases. Ultimately, the study collected 432 questionnaires, discarded 19 incomplete responses, and obtained 413 valid questionnaires, resulting in an effective recovery rate of 95.6%.
Data collection
The questionnaire was distributed and collected using the online Questionnaire Star platform. A pre-test involving 20 outpatient nurses was conducted to refine the format and content of the questionnaire based on their feedback. Prior to distribution, consent and collaboration were obtained from the director of the outpatient department at the hospital being studied. The questionnaire link was then provided to eligible outpatient nurses with the director’s assistance. To ensure unbiased survey data, participants filled out the questionnaire anonymously after giving informed consent. The questionnaire homepage clearly outlined the filling techniques and research purpose to maintain consistency. Measures were taken to prevent individuals from submitting multiple responses by restricting each device to a single reply. All mandatory questions were preconfigured in the system, and only questionnaires with no logical errors were included in the final analysis.
Measures
Demographic information questionnaire
For the research content and purpose of this study, the researcher developed a questionnaire to collect demographic information from outpatient nurses. The questionnaire consisted of ten variables that reflected the demographic and sociological characteristics of outpatient nurses. These variables encompassed gender, age, length of service in nursing, educational level, professional title, marital status, number of children, average monthly income, employment type, and whether they had received training on humanistic care.
Perceived organizational support scale
The Perceived Organizational Support Scale (POS) was developed by Chinese scholar Chen, based on the research of Eisenberger, specifically for Chinese knowledge workers [44, 45]. Zuo later revised certain content and expressions of the original scale to better align with the unique characteristics of the nursing profession [46]. The POS comprises two dimensions: emotional support and instrumental support, totaling 13 items. Emotional support includes 10 items, while instrumental support includes 3 items. Each item was rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). POS scores ranged from 13 to 65, with higher scores indicating a stronger sense of support. The Cronbach’s α coefficient of the total scale in this study was 0.92, demonstrating high internal consistency and reliability.
Compassion fatigue scale
The Compassion Fatigue Short Scale (C-CFSS) in Chinese, originally developed by Adams [47]and translated by Sun [48], was used to evaluate compassion fatigue levels among medical staff. Previous studies have shown strong psychometric properties of the scale when applied to Chinese medical professionals [48]. The C-CFSS consists of 13 items across 2 dimensions: 5 items assess secondary trauma and 8 items evaluate job burnout. Each item is rated on a 10-point Likert scale from 1 (never) to 10 (always). Total scores on the C-CFSS range from 13 to 130, with higher scores indicating more severe compassion fatigue. Compassion fatigue levels are classified as low (< 4 points), medium (4 to < 7 points), and high (≥ 7 points) based on average item scores. The scale has demonstrated good reliability and validity, with Cronbach’s α coefficients of 0.90 for the total scale, 0.87 for the burnout subscale, and 0.83 for secondary trauma.
Caring behaviors Inventory
The study assessed the caring behavior of outpatient nurses using the Chinese version of the Caring Behaviors Inventory (C-CBI). This inventory, initially developed by Wolf [49] and later translated and revised by Da [50], consisted of 24 items categorized into three dimensions: respect and connection (10 items), support and assurance (9 items), and knowledge and skills (5 items). Each item was rated on a 6-point Likert scale ranging from 1 (never) to 6 (always). The total C-CBI score ranged from 24 to 144, with higher scores indicating better levels of caring behavior. The C-CBI scores were classified into three levels based on the average item score: low level (< 2 points), medium level (2 to < 5 points), and high level (≥ 5 points). The Cronbach’s α coefficient for the total scale was 0.96, and for the subscales, it was 0.90 for respect and connection, 0.90 for knowledge and skills, and 0.93 for support and assurance.
Ethical considerations
This study was approved by the Ethics Committee of the Second Affiliated Hospital of Air Force Medical University in Xi’an, Shaanxi Province, China, and was conducted in accordance with the ethical guidelines of the Declaration of Helsinki [51]. Prior to commencing the survey, approval was obtained from the director of the outpatient department at the selected hospital. Instructions for the questionnaire were clearly provided on the home page of each electronic questionnaire, outlining the main purpose, significance, and filling method of the study for the nurses. Additionally, a link to the informed consent form was made available on the home page. Nurses were required to select the “agree” option before proceeding to answer the questionnaire. The study employed an anonymous survey method, ensuring that no personally identifiable information was collected from the participating nurses. Nurses had the freedom to choose whether or not to participate in the questionnaire and could opt out at any stage during the survey. The completed questionnaire responses were accessible only to the research team members, and the exported data was encrypted to ensure security.
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Data analysis
Data analysis was performed using IBM SPSS software (version 25.0) and the SPSS PROCESS macro (version 3.3). Frequency (n) and percentage (%) were used to present count data, while medians and IQR were used for measurement data due to non-normality and unequal variances. The Mann-Whitney U test and Kruskal-Wallis H rank-sum test were used to analyze variations in caring behavior among outpatient nurses with different characteristics. Spearman correlation analysis was conducted to explore the relationship between nurses’ perceived organizational support, compassion fatigue, and caring behavior. The PROCESS macro (Model 4) [52] was applied to examine the mediating role of compassion fatigue in the relationship between perceived organizational support and caring behavior. The significance of the indirect effect was assessed using the bias-corrected percentile Bootstrap method with 5000 samples [52]. If the 95% confidence interval did not include 0, it indicated a statistically significant indirect effect. Covariates such as age, length of service in nursing, professional title, marital status, number of children, average monthly income, and employment type were included in the mediation model while standardizing the research variables. All statistical tests used two-sided tests, with a significance level set at P < 0.05 to determine significant differences.
Results
Participants’ demographic characteristics and their distribution by caring behavior scores
All 413 participants in this study were female. The largest proportion of outpatient nurses, accounting for 43.6%, were between the ages of 26 and 35. The number of nurses with 6–10 years of experience was similar to those with 16–20 years of experience. The majority of nurses in the study held undergraduate degrees (n = 365, 88.4%). A small percentage of nurses (7.7%) held the professional title of deputy director or above. A higher proportion of nurses were married (n = 311, 75.3%), and the majority had one or more children (n = 265, 64.2%). Only 18.4% of nurses reported an average monthly income of less than RMB 4,000 ($550.74). The majority of employment type was personal agent nurses (n = 359, 86.9%). Additionally, more than 50% of outpatient nurses had received humanistic care training. The detailed general demographic characteristics can be found in Table 1.
Table 1
Participants’ demographic characteristics and their distribution by caring behavior scores (N = 413)
Variables | N (%) | C-CBI score, M (P25, P75) | H/Z-value | P-value |
|---|---|---|---|---|
Age(years) | ||||
≤ 25 | 67(16.2) | 110.00(109.00,112.00) | 37.506a | <0.001 |
26∼35 | 180(43.6) | 120.00(96.00,133.00) | ||
36∼45 | 123(29.8) | 130.00(109.00,140.00) | ||
>45 | 43(10.4) | 133.00(123.00,139.00) | ||
Length of service in nursing(years) | ||||
≤ 5 | 123(29.8) | 110.00(103.00,114.00) | 49.991a | <0.001 |
6∼10 | 69(16.7) | 119.00(96.00,128.00) | ||
11∼15 | 104(25.2) | 125.00(109.00,141.00) | ||
16∼20 | 68(16.5) | 126.00(107.00,136.00) | ||
>20 | 49(11.9) | 134.00(120.00,142.00) | ||
Educational level | ||||
College or below | 40(9.7) | 112.00(110.00,126.00) | 5.778a | 0.055 |
Undergraduate | 365(88.4) | 119.00(103.00,136.00) | ||
Postgraduate or above | 8(1.9) | 133.00(133.00,140.00) | ||
Professional title | ||||
The nurse | 112(27.1) | 112.00(109.00,122.75) | 17.780a | <0.001 |
Nurse practitioner | 148(35.8) | 115.00(96.00,139.50) | ||
Nurse-in-charge | 121(29.3) | 128.00(107.00,136.00) | ||
Deputy director nurse or above | 32(7.7) | 123.00(120.00,140.75) | ||
Marital status | ||||
Unmarried | 102(24.7) | 110.00(109.00,114.00) | -6.061b | <0.001 |
Married | 311(75.3) | 125.00(107.00,139.00) | ||
Number of children | ||||
None | 148(35.8) | 110.00(103.00,117.75) | 27.096a | <0.001 |
One | 164(39.7) | 124.00(109.50,139.00) | ||
Two or more | 101(24.5) | 125.00(96.00,139.00) | ||
Average monthly income (RMB) | ||||
≤ 4000 | 76(18.4) | 111.00(102.25,114.00) | 27.637a | <0.001 |
4001∼6000 | 79(19.1) | 114.00(109.00,136.00) | ||
6001∼8000 | 142(34.4) | 114.00(101.25,133.00) | ||
8001∼10000 | 70(16.9) | 132.00(96.00,141.00) | ||
>10,000 | 46(11.1) | 133.00(120.00,139.00) | ||
Employment type | ||||
Formally employed nurse | 54(13.1) | 126.00(120.00,140.00) | -3.452b | 0.001 |
Personal agent nurse | 359(86.9) | 114.00(104.00,134.00) | ||
Had received humanistic caring training | ||||
Yes | 246(59.6) | 120.00(107.00,136.50) | -1.411b | 0.158 |
No | 167(40.4) | 114.00(103.00,124.00) |
Statistically significant differences were found in the caring behavior scores of 413 outpatient nurses across various demographic factors such as age, length of service in nursing, professional title, marital status, number of children, average monthly income, and employment type (P < 0.01) (refer to Table 1).
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Descriptive statistical analysis of variable scores
The median values of perceived organizational support, compassion fatigue, and caring behavior are 46.00, 51.00, and 116.00, respectively. The results of descriptive statistical analysis of the scores of these variables are presented in Table 2.
Table 2
Descriptive statistical analysis of variable scores (N = 413)
Variables | Items | Scoring range | Total score, Median (P25, P75) |
|---|---|---|---|
Perceived organizational support | 13 | 13 ∼ 65 | 46.00(40.00,52.00) |
Instrumental support | 3 | 3 ∼ 15 | 12.00(10.00,14.00) |
Emotional support | 10 | 10 ∼ 50 | 34.00(30.00,40.00) |
Compassion fatigue | 13 | 13 ∼ 130 | 51.00(32.50,59.00) |
Job burnout | 8 | 8 ∼ 80 | 31.00(19.00,38.00) |
Secondary trauma | 5 | 5 ∼ 50 | 17.00(13.00,21.00) |
Caring behavior | 24 | 24 ∼ 144 | 116.00(107.00,136.00) |
Respect and connection | 10 | 10 ∼ 60 | 44.00(38.00,53.00) |
Support and assurance | 9 | 9 ∼ 54 | 50.00(43.00,56.00) |
Knowledge and skills | 5 | 5 ∼ 30 | 25.00(22.00,29.00) |
Correlations of the study variables
The study’s correlation coefficients between variables are detailed in Table 3. The results of Spearman correlation analysis revealed a negative correlation between perceived organizational support and compassion fatigue (ρ=-0.547, P < 0.01), a positive correlation between perceived organizational support and caring behavior (ρ = 0.469, P < 0.01), and a negative correlation between compassion fatigue and caring behavior (ρ=-0.641, P < 0.01).
Table 3
Correlations of the study variables (N = 413)
Variables | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
|---|---|---|---|---|---|---|---|---|---|---|
1 | 1 | |||||||||
2 | 0.848** | 1 | ||||||||
3 | 0.978** | 0.737** | 1 | |||||||
4 | -0.547** | -0.414** | -0.562** | 1 | ||||||
5 | -0.577** | -0.400** | -0.604** | 0.960** | 1 | |||||
6 | -0.318** | -0.316** | -0.303** | 0.769** | 0.585** | 1 | ||||
7 | 0.469** | 0.364** | 0.470** | -0.641** | -0.685** | -0.288** | 1 | |||
8 | 0.465** | 0.360** | 0.467** | -0.611** | -0.649** | -0.289** | 0.931** | 1 | ||
9 | 0.416** | 0.322** | 0.415** | -0.619** | -0.657** | -0.283** | 0.952** | 0.821** | 1 | |
10 | 0.383** | 0.282** | 0.392** | -0.543** | -0.606** | -0.205** | 0.871** | 0.761** | 0.772** | 1 |
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Mediating effect of compassion fatigue between perceived organizational support and caring behavior
Bootstrapping analysis using the PROCESS macro (version 3.3) was conducted to examine the mediating role of compassion fatigue in the relationship between perceived organizational support and caring behavior while controlling for confounding variables. The analysis of confounding variables involved the Mann-Whitney U test and the Kruskal-Wallis H rank-sum test of variance, with demographic variables as independent variables and caring behavior as the dependent variable. Control variables in the model included age, length of service in nursing, professional title, marital status, number of children, average monthly income, and employment type (refer to Tables 1 and 4).
Table 4
The mediating model of compassion fatigue between perceived organizational support and caring behavior (N = 413)
Outcome variable | Predictor variable | R | R2 | F(df) | β | t |
|---|---|---|---|---|---|---|
Caring behavior | ||||||
Perceived organizational support | 0.498 | 0.248 | 16.672 | 0.363 | 8.125** | |
Age | 0.170 | 1.738 | ||||
Length of service in nursing | 0.163 | 2.504* | ||||
Professional title | -0.077 | -1.137 | ||||
Marital status | 0.360 | 2.264* | ||||
Number of kids | -0.269 | -3.140** | ||||
Average monthly income | -0.001 | -0.014 | ||||
Employment type | 0.098 | 0.570 | ||||
Compassion fatigue | ||||||
Perceived organizational support | 0.609 | 0.371 | 29.791 | -0.550 | -13.312** | |
Age | -0.081 | -0.896 | ||||
Length of service in nursing | -0.101 | -1.679 | ||||
Professional title | -0.012 | -1.199 | ||||
Marital status | -0.170 | -1.157 | ||||
Number of kids | 0.117 | 1.481 | ||||
Average monthly income | 0.035 | 0.737 | ||||
Employment type | 0.123 | 0.776 | ||||
Caring behavior | ||||||
Perceived organizational support | 0.602 | 0.362 | 25.451 | 0.131 | 2.655** | |
Compassion fatigue | -0.422 | -8.496** | ||||
Age | 0.136 | 1.505 | ||||
Length of service in nursing | 0.120 | 1.998* | ||||
Professional title | -0.082 | -1.317 | ||||
Marital status | 0.288 | 1.964 | ||||
Number of kids | -0.219 | -2.772** | ||||
Average monthly income | 0.014 | 0.296 | ||||
Employment type | 0.150 | 0.945 |
Table 4 displays the outcomes of testing a mediation effect using 5000 bootstrap samples. The findings revealed that perceived organizational support had a significant predictive impact on caring behavior. Even when compassion fatigue was taken into account, the direct predictive influence of perceived organizational support on caring behavior remained significant. The results also demonstrated that both perceived organizational support and compassion fatigue were significant predictors of caring behavior (β = 0.363, P < 0.01, and β = -0.422, P < 0.01, respectively). Notably, in the model that included compassion fatigue, the impact of perceived organizational support on caring behavior decreased (β = 0.131, P < 0.01). Additionally, perceived organizational support was found to significantly predict compassion fatigue (β = -0.550, P < 0.01). These findings suggest that compassion fatigue serves as a partial mediator in the relationship between perceived organizational support and caring behavior.
The study found that the 95% bootstrapped confidence interval of the direct effect of perceived organizational support on caring behavior and the mediating effect of compassion fatigue did not include 0 (95% Boot CI = [0.034, 0.228]; [0.172, 0.292], refer to Table 5). This suggests that perceived organizational support might predict caring behavior directly through the mediating effect of compassion fatigue. The relationship between these variables is illustrated in Fig. 2, where the direct effect was 0.131 and the mediating effect was 0.232. Notably, the mediating effect accounted for 63.9% of the total effect.
Table 5
Decomposition table of total effect, direct effect, and mediating effect (N = 413)
Effect | Boot SE | 95% Boot LLCI | 95% Boot ULCI | The relative effect (%) | |
|---|---|---|---|---|---|
Total effect | 0.363** | 0.045 | 0.275 | 0.451 | |
Direct effect | 0.131** | 0.049 | 0.034 | 0.228 | 36.1 |
Mediating effect | 0.232** | 0.031 | 0.172 | 0.292 | 63.9 |
Fig. 2
The mediating effect model of outpatient nurses’ compassion fatigue between perceived organizational support and caring behavior. Abbreviations: a, the effect of perceived organizational support on compassion fatigue; b, the effect of compassion fatigue on caring behavior; c, the total effect of perceived organizational support on caring behavior; c’, the direct effect of perceived organizational support on caring behavior; ab, the mediating effect of compassion fatigue
**P < 0.01
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Discussion
This study delves into the connections between perceived organizational support, compassion fatigue, and caring behavior in outpatient nurses. The research results support the theoretical hypotheses and provide valuable insights for improving nurses’ caring behavior. Specifically, the findings revealed a positive relationship between perceived organizational support and caring behavior, while compassion fatigue was negatively associated with both perceived organizational support and caring behavior. Moreover, the study demonstrates that compassion fatigue acts as a partial mediator between perceived organizational support and the caring behavior of outpatient nurses. These results suggest that outpatient nurses who perceive lower levels of organizational support are more likely to experience compassion fatigue, leading to a decline in their nursing behaviors. Importantly, this study is the first to investigate the mediating role of compassion fatigue in the relationship between perceived organizational support and caring behaviors among outpatient nurses from a resource-based perspective. As such, these findings contribute to the enrichment of the JD-R model.
The study revealed that the perceived organizational support score was lower compared to previous studies by Cheng [53] and Wang [54]. The differences in scores could be attributed to varying levels of economic development in different cities, with Xi’ an lagging behind Wuhan and Suzhou. This lack of economic progress can indirectly affect nurses’ perceived organizational support by influencing working conditions, income levels, career opportunities, and social status. Discrepancies in scores may also be influenced by differences in work departments, with clinical departments having more resources and full-time nurses compared to outpatient departments, where staff shortages and heavy workloads are common. The higher score for instrumental support than emotional support suggests that while necessary resources are provided, emotional connections and psychosocial needs are not adequately addressed [53]. Nurse managers should focus on not only providing material support but also showing genuine care and attention to enhance nurses’ sense of organizational support.
In this study, compassion fatigue scores were consistent with Zhang’s [55] study, slightly higher than Yi’s [56] study, but significantly lower than Li’s [57] study. This discrepancy could be attributed to variations in participant sources and the timing of the survey. Yi’s [56] study focused on nursing interns, who are mainly involved in learning and observation tasks rather than full nursing responsibilities, potentially leading to lower emotional involvement and job stress levels. On the other hand, outpatient nurses directly interact with patients and handle complex medical situations, increasing their susceptibility to compassion fatigue. Li [57] conducted research during an epidemic, highlighting that nurses faced heightened work pressure, increased emotional involvement, concerns about personal safety, lack of adequate rest and support, differences in psychological flexibility, and limited emergency skills and psychological training. The average score for job burnout was higher than that for secondary trauma, consistent with previous studies [56, 57]. While secondary trauma can also impact nurses’ mental health negatively, it is usually a one-time occurrence or episodic event. In contrast, the continuous high workload and stressful environment faced by outpatient nurses are ongoing stressors in their daily work, making them more prone to job burnout than secondary trauma. Research on compassion fatigue among nurses in China has been increasing in recent years, with a focus primarily on clinical departments and limited exploration in outpatient departments. This study provides valuable insights for future research in this area. The findings reveal that while there has been some improvement in compassion fatigue among outpatient nurses, 46.5% of nurses still experience moderate to severe levels of compassion fatigue. As a result, it is recommended that nursing managers prioritize organizing compassion fatigue management training to help nurses effectively identify and manage negative emotions. Additionally, providing psychological counseling services can aid in alleviating work-related stress. Implementing a shift system to more evenly distribute workloads may also prove beneficial. By taking these proactive measures, empathy fatigue among outpatient nurses can be gradually mitigated.
In this study, the score for caring behavior was higher than in Chen’s [13] study but lower than in Qiu’s [58] study, falling within a medium range overall. The differences in results may be attributed to the variation in participants’ sources and the varying levels of economic development in the surveyed regions. This study focused on outpatient nurses, who have more extensive nursing experience, deeper professional knowledge, and stronger empathy compared to nursing interns in Chen’s [13] study. The nurses examined in this study are from Xi’an, a city with high economic, social, and medical standards in China, while Qiu’s [58] research focused on nurses in Fuzhou. Fuzhou has seen significant advancements in recent years, surpassing Xi’an in economic, social, and medical sectors. Cities with high standards tend to have better medical resources and industry standards, promoting high-quality nursing services and nurturing a culture of care. “Support and assurance” scored the highest, “Knowledge and skills” the second highest, and “Respect and connection” the lowest, consistent with previous studies [13, 58]. Outpatient nurses, dealing with a high volume of mobile patients, may potentially overlook genuine patient needs, resulting in a deficiency in providing humanistic care. This study observed variations in caring behavior scores among outpatient nurses, influenced by factors such as age, length of service in nursing, professional title, marital status, number of children, average monthly income, and employment type. Outpatient nurses who are older, have more experience, and hold higher professional titles tend to exhibit a stronger sense of responsibility and more stable humanistic care qualities. These qualities are manifested in their proactive communication and patient service behaviors [58]. Research suggests that married nurses with children are able to balance multiple family roles, enabling them to better understand and address the physical and mental needs of patients [58]. Moreover, nurses with higher salaries often report greater happiness and job satisfaction, with satisfaction serving as a positive predictor of their humanistic care abilities. Additionally, formally employed nurses often demonstrate a strong sense of belonging and develop positive work attitudes, fostering the growth of their humanistic philosophy of care. In recent years, China has actively promoted high-quality nursing services, advocated for the strengthening of scientific research and practice related to humanistic care in nursing, and enhanced the caring capabilities of nurses. Medical institutions have responded positively and achieved favorable outcomes [13]. However, existing research on nurses’ caring behavior predominantly focuses on clinical departments [58, 59], with limited attention given to outpatient clinics. Outpatient clinics serve as the frontline for Chinese hospitals to deliver high-quality nursing services. Enhancing the caring behavior of outpatient nurses is crucial for advancing high-quality nursing services in hospitals. Therefore, nursing managers can enhance the professionalism and service awareness of outpatient nurses by organizing regular training sessions on patient care and communication skills. Implementing a reward system can also help boost nurses’ motivation to provide quality care to patients, ultimately improving caring behaviors among outpatient nurses.
The study findings confirmed the hypothesis that perceived organizational support is a key predictor of caring behavior among outpatient nurses, consistent with previous research by Tian [60]. Perceived organizational support refers to nurses’ perception of how much the hospital values and supports them, which can significantly impact their attitudes and behaviors, especially in patient care [60]. Social exchange theory suggests that nurses who feel well-supported by their organization are more likely to respond with higher job satisfaction, a stronger professional identity, and positive work behaviors [37]. Caring behaviors exhibited by nurses are indicative of their dedication to their work and profession and can be considered positive work behaviors. Therefore, outpatient nurses who perceive strong organizational support are more likely to demonstrate caring behaviors. This underscores the importance for nursing managers to implement interventions that enhance caring behaviors by improving perceived organizational support. Previous studies have emphasized the role of leadership support, welfare benefits, and job support in shaping perceived organizational support [45]. In this study, organizational support was identified as a significant factor influencing the caring behavior of outpatient nurses, demonstrating a strong internal relationship with the nursing practice environment. El-Gazar’s study [61] explored the profound impact of the nursing practice environment on nurses’ work and partially validated the conclusions of the current study. Specifically, El-Gazar’s research indicated that nurses’ subjective perception of their work environment affects their “flow” experience, which in turn reduces hidden care rationing and the occurrence of adverse events. Therefore, the concept of organizational support proposed in this article can be further expanded to include related factors, such as a healthy nursing practice environment, to provide a more comprehensive analysis of how to promote caring behavior among outpatient nurses. Furthermore, a multi-center survey study by Atta [62] revealed the detrimental effects of an adverse working environment on nurses’ career stability. In our study, perceived organizational support emerged as a key factor in fostering caring behavior among outpatient nurses, which was also closely linked to their career stability. Specifically, robust organizational support can mitigate the negative impact of toxic workplace behavior on nurses’ career stability, thereby positively influencing their caring behavior. Additionally, Jia’s [63] research showed a strong link between career development and perceived organizational support. Hence, nursing managers should not only provide work support but also focus on promoting career growth and emotional support to boost perceived organizational support among outpatient nurses.
The study findings revealed a significant negative correlation between perceived organizational support and compassion fatigue, supporting H2 and consistent with previous research [35]. Tang’s study [64] emphasized the crucial role of adequate organizational support in creating a positive work environment. A positive work environment not only boosts nurses’ job satisfaction but also reduces emotional exhaustion, effectively preventing compassion fatigue, especially in high-stress settings. The conservation of resources theory also supported this outcome, showing that organizational support can lower nurses’ physical and mental resource depletion and job burnout, ultimately easing compassion fatigue [65]. El-Gazar’s research [61] indicates that factors contributing to a poor nursing practice environment can exacerbate the depletion of both physical and mental resources among nurses. Enhanced organizational support may improve the nursing practice environment, enabling nurses to experience a greater sense of flow at work, which could more effectively alleviate compassion fatigue. Consequently, El-Gazar’s findings underscore the significant role of organizational support in mitigating compassion fatigue. Furthermore, research by Atta [62] highlights that negative workplace behaviors can intensify pressure on nurses, rendering them more vulnerable to professional burnout. Thus, organizational support may play a crucial role in preventing these detrimental behaviors and fostering a more conducive work environment for nurses, which is intrinsically linked to the objective of alleviating compassion fatigue. Existing literature indicated that strong organizational support can meet nurses’ emotional needs and reduce work-related stress [66], further explaining the negative association between perceived organizational support and compassion fatigue. Therefore, nursing managers should actively leverage all organizational resources to establish a supportive work environment for nurses, ultimately alleviating compassion fatigue.
The negative correlation between compassion fatigue and caring behaviors supports H3, indicating that as outpatient nurses experience more severe compassion fatigue, their level of caring behaviors decreases. This finding is in line with Jeon’s [67] perspective. The Conservation of Resources theory suggests that compassion fatigue can deplete nurses’ psychological resources, leading to a decrease in work engagement and caring behavior [65]. Insufficient caring behavior from nurses may result in negative feedback from patients and leaders, further reducing their work enthusiasm and worsening compassion fatigue. There exists an interactive relationship between nurses’ caring behavior and compassion fatigue. Additionally, caring behavior is closely linked to nurses’ moral development. A cross-sectional study conducted by Amin [68] underscores the significant role of managing interprofessional collaboration systems and fostering moral resilience in enhancing nurses’ ethical care capabilities. Consequently, when nurses experience compassion fatigue, their caring behavior may be adversely affected, potentially leading to negative implications for their moral judgment and conduct, which are associated with nurses’ moral competence. Future research could further investigate strategies to mitigate compassion fatigue by enhancing nurses’ moral competence, thereby improving their caring behavior. Furthermore, negative behaviors in the workplace not only jeopardize nurses’ career stability but may also influence their caring behavior and levels of compassion fatigue [62]. For instance, nurses who encounter mobbing may be more vulnerable to compassion fatigue, which can detrimentally impact their performance in providing care. Marshall [69] also highlights compassion fatigue as a reflection of nurses’ desire to improve their professional skills and caregiving abilities. However, prolonged exposure to compassion fatigue can have adverse effects on nurses’ physical and mental well-being, potentially causing job burnout and a decline in caring behavior. Based on these research findings, it is recommended that nursing managers prioritize the physical and mental well-being of outpatient nurses and address any negative emotions they may be experiencing. Providing adequate humanistic care to nurses can make them feel valued and supported, helping them better cope with psychological stress and ultimately enhance their caring behavior.
The study found that compassion fatigue partially mediates the relationship between outpatient nurses’ perceived organizational support and caring behaviors, confirming Hypothesis H4. This means that compassion fatigue not only has a negative association with caring behavior but also reduces the impact of perceived organizational support on caring behavior among outpatient nurses. Drawing from the JD-R model [41], resources include both work and personal resources, which collectively influence positive work behavior. Perceived organizational support, as a job resource, influences compassion fatigue, a negative personal psychological resource, leading to a decrease in nurses’ caring behavior. In the study conducted by El-Gazar [61], a healthy nursing practice environment is shown to facilitate the flow of nurses at work and mitigate the hidden rationing of care as well as adverse events. This finding supports the perspective of our study, which posits that adequate organizational support resources can foster a healthy nursing practice environment, thereby alleviating compassion fatigue among outpatient nurses and ultimately enhancing their caring behavior. Conversely, Atta’s study [62] indicates that negative behaviors in the workplace can adversely affect nurses’ career consolidation. While this differs from the focus of our research, it underscores the significance of external factors on various aspects related to nurses’ careers. Similarly, Amin’s study [68] examined the influence of moral resilience and interprofessional cooperation on nurses’ moral competencies. Although this topic diverges from the central theme of our study, both studies highlight the impact of various factors on nurses’ professional performance. Our research specifically investigates the effects of organizational support and compassion fatigue on the caring behavior of outpatient nurses. Collectively, these diverse research avenues contribute to a more comprehensive understanding of the factors influencing the careers of outpatient nurses. The heavy workload of outpatient nurses can deplete their psychological resources, affecting their caring behavior without sufficient organizational support or self-regulation skills [70]. Conversely, organizational support can help nurses manage work-related stress effectively [71]. The conservation of resources theory suggests that work resources have a spiral value-added effect, enabling nurses to acquire more resources and build resilience in coping with resource depletion [70]. This underscores the importance of having adequate working resources. Personal resources, influenced by job resources, significantly shape individuals’ caring behaviors, enriching the understanding of the JD-R model. Therefore, nursing managers should acknowledge the significance of outpatient nurses’ work and personal resources. By effectively leveraging the positive motivational impact of organizational support resources, they can mitigate the negative effects of compassion fatigue on nurses and ultimately enhance their capacity for providing caring behavior.
Implication for nursing management
This study explores the mediating role of compassion fatigue in the relationship between perceived organizational support and caring behaviors among outpatient nurses, emphasizing the importance of addressing both work and personal resources. The findings suggest that nursing managers can impact nurses’ caring behaviors by improving perceived organizational support and understanding the mediating effect of compassion fatigue. The study offers a novel perspective on enhancing caring behaviors among outpatient nurses, establishing a theoretical and practical groundwork for further research on improving caring behaviors in high-pressure nursing environments. Nursing managers can enhance perceived organizational support by providing vocational training, education opportunities, a safe working environment, necessary resources, and reducing work burdens. Additionally, they should address compassion fatigue by promoting humanistic care, encouraging open communication, providing psychological counseling, managing work schedules effectively, and fostering mutual support among nurses.
Limitations
This study is subject to several limitations. Firstly, the use of convenience sampling and data collection from only six tertiary hospitals in Xi’an may limit the generalizability of the study results. Future research should consider expanding the sample scope by including hospitals from various regions and levels to further validate the findings. Secondly, all participants in this study were female nurses. It is suggested that future studies include a higher proportion of male nurses to ensure more comprehensive results. Thirdly, the data in this study was gathered through self-reports by nurses, potentially introducing bias. To enhance the study, future research should consider collecting data from various groups, such as nurse leaders, patients, and physicians. Lastly, the study utilized a cross-sectional design, limiting its ability to establish causal relationships among predictor variables. To address this limitation, future longitudinal and qualitative studies should be conducted to delve deeper into the effects of perceived organizational support and compassion fatigue on the caring behaviors of outpatient nurses.
Conclusions
The research findings have important implications for nursing management. Firstly, there is a need to improve the current levels of perceived organizational support, compassion fatigue, and caring behaviors among Chinese outpatient nurses, which requires attention from local nursing managers. Secondly, the study confirms a significant relationship between outpatient nurses’ perceived organizational support, compassion fatigue, and caring behavior. Importantly, the findings indicate that compassion fatigue acts as a partial mediator in the relationship between perceived organizational support and the caring behavior of outpatient nurses. Nursing managers should focus on how perceived organizational support and compassion fatigue impact the caring behaviors of outpatient nurses, by effectively managing work and personal resources, using organizational support to alleviate compassion fatigue, and helping nurses enhance their caring behaviors. In nursing management practice, managers can help reduce negative emotions and psychological resource depletion among nurses by providing sufficient work resources and emotional support, leading to improved caring behavior and ultimately enhancing the quality of hospital nursing services.
Acknowledgements
We thank all of participants who give their time for this survey.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the Declaration of Helsinki and was reviewed and approved by the Ethics Committee of the Second Affiliated Hospital of Air Force Medical University in Xi’an, Shaanxi Province, China. Participation in the research was voluntary and the risks involved were extremely low. To ensure the privacy of the subjects, the questionnaire was anonymous. The study adhered to national legal and institutional requirements, and informed consent was obtained from all participants.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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