Background
Clinical nursing practice is important for nursing students to integrate their theoretical knowledge with practical skills, as well as help to enhance their professional competence and grow as nurses. However, clinical nursing faces various stressors such as complex events, negative feelings and emotions expressed by patients and their families, workload, personal conflicts, work shifts, and lack of work- and social-related psychological support [1]. These stressors take a serious toll on clinical nurses, decreasing their compassion satisfaction (CS) and inducing compassion fatigue [2, 3]. The work environments and atmospheres of nursing interns are similar to or even identical to professional nurses in clinical practice [4]. However, the compassion fatigue of nursing interns has received less attention [5].
Compassion fatigue has been originally described by Joinson [6] as the emotional, physical, and psychological exhaustion, which occurs as a result of prolonged exposure of healthcare providers to work stress. Based on his research on mental health issues in caregivers, Figley proposed the conceptual structure of compassion fatigue, primarily including burnout (BO) and secondary traumatic stress (STS), and developed the Compassion Fatigue Self Test to assess both [7]. BO is a psychological occupational syndrome characterized by emotional exhaustion, depersonalization (loss of compassion and concern), and reduced personal accomplishment [8, 9]. STS is stemmed from the exposure to traumatic experiences and stressful situations of others [10]. Even in stressful and traumatic situations, however, positive values and work experiences of caregivers must be evaluated [11]. In 2002, Stamm reflected on the limitations of the Compassion Fatigue Test, introduced the concept of compassion satisfaction (CS) with Figley, and further established the Compassion Satisfaction and Fatigue Test. The Professional Quality of Life Scale (ProQOL) is final the version [12]. The ProQOL has since been widely adopted for assessing compassion fatigue [10]. BO and STS increase the risk of compassion fatigue; CS is described as the pleasure gained from helping others through difficult times, which can mitigate the negative effects of BO or STS [3, 13].
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Nursing students showed varying degrees of compassion fatigue, mainly at moderate and above levels. Bouchard et al. used ProQOL-30 to conduct a cross-sectional survey of 118 students in Doctor of Nursing Practice at a large public university in the U.S.A. The findings revealed moderate levels of BO and STS, alongside moderately high levels of CS among these students [14]. Mathias et al. employed the ProQOL-30 to assess 67 undergraduate nursing students at the University of KwaZulu-Natal in South Africa, revealing average levels of compassion fatigue [15]. A more extensive cross-sectional survey conducted by Cao et al. in China, involving 972 nursing college students, yielded concerning results: 98.7% and 56.4% of participants exhibited moderate-to-severe BO and STS, respectively, while 33.4% reported moderate-to-low levels of CS [5]. Another study focusing on 260 nursing students practicing in Chinese tertiary hospitals found that 82.7% experienced varying degrees of compassion fatigue [16]. Contrastingly, a large-scale cross-sectional survey by Yi et al. (2022), which employed the compassion fatigue short scale to assess 2,256 junior college nursing interns, indicated that only 19.5% were at risk of compassion fatigue [17]. These disparities in prevalence may be attributed to various factors, including differences in cultural environments, assessment tools, and educational levels. Therefore, the prevalence of compassion fatigue among nursing interns needs to be further determined. Compassion fatigue not only negatively affects nurses’ well-being, job satisfaction, and willingness to stay in this job, but also influences patients’ prognosis and satisfaction with healthcare [18, 19]. So, it is of great significance to actively explore the influencing factors to prevent compassion fatigue among nursing interns.
The compassion fatigue of nursing interns is primarily influenced by demographic factors, internship-related factors, and psychological factors. ①In demographic factors, age, school year, and personality traits are related to BO, while educational level is related to STS and CS. Younger nursing students have more emotional exhaustion [20]. It has also been noted that the more advanced the school year, the higher degree of exhaustion and depersonalization among nursing students [21]. Undergraduate nursing students have significantly higher STS and notably lower CS than nursing students with associate degrees [5]. ②As for internship-related factors, a longitudinal study in China showed that compassion fatigue of nursing interns continued to increase with the length of practice [22]. In addition, liking the work atmosphere positively predicted CS and negatively predicted BO. Reasonable scheduling was a positive predictor of CS. Excessive working hours and not being recognized by the lead teacher were common risk factors for BO and STS. However, this study failed to further quantitatively analyzed or elaborated on work hours and scheduling practices [23]. ③From the aspect of psychological factors, cognitive empathy, resilience, and adaptive coping are not only important factors that can protect nursing students against compassion fatigue but also important contributors to CS; less compassionate care and more passive coping are important risk factors of compassion fatigue [5, 24]. Nursing students with resilient personalities are less affected by BO [25]. There is a moderate negative correlation between compassion fatigue and professional identity [17]. Nursing students with a lower willingness to leave the job tend to have higher levels of CS [26]. Furthermore, mindful self-care practices were associated with reduced BO risk [27, 28]. Family support contributes to CS [5, 22], and manager support significantly and negatively predicts BO and compassion fatigue [29].
In summary, despite some meaningful explorations on the occurrence of compassion fatigue in nursing students and the associated affecting factors, most of the studies have focused on school students, and few have involved nursing students in clinical internships; moreover, the effects of some internship environment-related factors (such as frequency of night shifts, working hours, stress of internships, and different professional titles of clinical nursing teachers) on the compassion fatigue of nursing interns are not yet clear. Limited studies have been reported on compassion fatigue in nursing interns [5], and this is still in the early stages in China. Therefore, it is important to assess the prevalence and related factors of compassion fatigue among nursing interns.
According to the ProQOL model, personal characteristics, work-related factors, and multiple psychosocial factors influence the negative (BO and STS) or positive (CS) aspects of caregivers [13]. Given the association between compassion fatigue and psychological stress, the System-Based Model of Stress proposed by Jiang [30] holds that the stress response is the result of the interaction of multiple factors, such as stressful events, personality traits, and cognitive appraisal. Guided by the above models and existing literature, we raise the hypothesis that demographic characteristics, internship-related factors, and psychological factors may be related to compassion fatigue. The demographic factors include age, gender, and educational level; the internship-related factors (stressful events) include department, professional title of clinical nursing teachers, number of night shifts monthly, daily working hours, and internship time; the psychological factors include personality traits, cognitive appraisal (choice of nursing profession, perceived stress), empathy, and psychological resilience. Therefore, the present study aims to assess the prevalence of compassion fatigue among nursing interns in China, and to examine their relationships with above variables. The hypothetical model is presented in Fig. 1. Therefore, the objectives of this study were to (1) examine the prevalence of compassion fatigue among Chinese nursing interns; (2) explore the relationship between compassion fatigue and demographic, internship-related, and psychological variables. The findings of this study may provide a theoretical basis for future intervention studies.
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Fig. 1
Hypothetical model of compassion fatigue
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Method
Design
This is a cross-sectional study.
Sample size
This study was a cross-sectional survey. The study population consisted of a total of 435 nursing students interning in 2 tertiary-level public hospitals in Shanghai in 2024. According to previous literature [5], the standard deviation of CS, BO, and STS of nursing students were 5.93, 3.69, and 5.97, respectively, with a permissible error of 1 point (α = 0.05) and a population size of 435. The maximum sample size to be surveyed was calculated as 106 using the PASS 11 software. Considering a 10% non-response rate, 118 participants were required for this study.
Participants
A total of 221 nursing interns from 2 tertiary-level public hospitals in Shanghai were selected from March to April 2024 by convenience sampling method. The inclusion criteria were: (1) nursing interns who are currently practicing in the hospitals; (2) nursing interns have normal cognitive ability, and can understand the content of the questionnaire. On the other hand, those who did not want to fill in the questionnaire for various reasons were excluded.
Instruments
General information questionnaire
A general information questionnaire was used to investigate the demographic and internship environment-related factors of nursing interns. The questionnaire was self-designed, including items involving age, sex, department, professional title of clinical nursing teachers, choice of nursing profession, number of night shifts monthly, daily working hours [total work hours per week divided by the number of work days per week according to Chinese labor law (≤ 8 h or > 8 h)], and internship time.
Compassion fatigue
The ProQOL scale [13] was used to assess compassion fatigue in nursing interns. The scale was translated into Chinese by Chen et al. [31] in 2013, including 3 dimensions of CS (entries 3, 6, 12, 16, 18, 20, 22, 24, 27, and 30), BO (entries 1, 4, 8, 10, 15, 17, 19, 21, 26, and 29), and STS (entries 2, 5, 7, 9, 11, 13, 14, 23, 25, and 28), with 10 entries for each dimension and 30 entries in total. The ProQOL scale adopted the Likert 5-point scale, with 1–5 points representing the frequency of occurrence from “no” to “always”. Some of the entries were scored in the reverse direction. Each of the three dimensions is scored separately, with a range of 10–50 points for each dimension. The critical values for CS, BO and STS were < 37, > 27 and > 17, respectively. Compassion fatigue occurs when any of the three dimensions of compassion fatigue exceeds a critical value. The number of dimensions with scores exceeding the critical value was 1, 2, or 3 indicating mild, moderate, or severe level of compassion fatigue, respectively. The total Cronbach’s α coefficient for this Chinese version of the scale was 0.91, and the Cronbach’s α coefficients of 3 dimensions were 0.87, 0.73, and 0.84, respectively [31]. This scale has been widely used to assess compassion fatigue in Chinese caregivers. Xie et al. [32] used this scale to conduct a cross-sectional survey of compassion fatigue among Chinese emergency nurses, and the results showed that the prevalence of compassion fatigue in this population was 75.9%.
Psychological resilience
The Connor-Davidson Resilience Scale (CD-RISC), developed by Connor and Davidson in 2003 [33], was used to measure an individual’s level of psychological resilience in response to stress. The CD-RISC was divided into 3 dimensions: toughness, strength, and optimism, with a total of 25 items; each item was scored on a 0–4 scale using a 5-point Likert scale, with 0–4 points representing “never” to “always”, 100 points in total. Higher scores indicated better psychological resilience. Yu et al. Chineseized the scale according to the Chinese cultural context, and the Cronbach’s α coefficient for the Chinese version of the CD-RISC was 0.89 [34].
Empathy
The empathy of nursing interns was assessed using the Jefferson Scales of Empathy that was developed by Hojat et al. [35] and translated and revised by An et al. [36]. The scale contained 3 dimensions: perspective taking, compassionate care, and transpersonal thinking, with a total of 20 entries. Each entry was scored on a 7-point Likert scale; 1 to 7 points indicated “totally disagree” to “totally agree”, with 20 to 140 points in total. Higher scores indicated higher levels of empathy among nurses. The Cronbach’s α coefficient, retest coefficient, and split-half coefficient of the scale were 0.750, 0.659, and 0.771, respectively [36].
Perceived stress
The Chinese Perceived Stress Scale (CPSS) was used to assess the psychological stress of nursing interns. This scale was compiled by Cohen [37] in 1983 and Chineseized by Yang et al. [38] in 2003. This scale had 14 items with a Likert scale of 5 points ranging from 0 (never) to 4 (very often), and the total score ranged from 0 to 56 points. Higher scores indicated a greater degree of stress felt by the individual. The Cronbach’s α coefficient of the scale was 0. 78 [38].
Personality traits
The complete version of the Eysenck Personality Questionnaire (EPQ) has been verified in the Chinese population with acceptable reliability and validity, and the extroversion/introversion subscale of the EPQ is used to assess individual personality traits [39]. This scale comprises 21 items and requires participants to provide a yes (1) or no (0) answer. The standard score T (T = 50 + 10 × (x − m)/SD) can be converted from norms to analyze the personality characteristics of the participant according to the total score (rough score) obtained on this scale. T-scores below 43.3 indicate introversion, introverted isolation, and inattention; T-scores above 56.7 indicate extroversion, optimism, and sociability; T-scores between 43.3 and 56.7 are intermediate and balanced, indicating that there are introverted and extroverted traits in the personality type, but neither of these traits is predominant.
Ethical considerations
This study was reviewed and approved by the Ethical Review Committee for Human Trials of Shanghai General Hospital (No. 2024108).
Data collection
The purpose and the filling method of the questionnaire, as well as the precautions, were explained on-site by two trained investigators using the same language to the nursing interns who met the inclusion criteria. Then these two investigators distributed the questionnaire to the nursing interns after explanation. The completeness of the questionnaires was assessed on-site after the questionnaires were recovered. A total of 240 questionnaires were distributed, and 221 valid questionnaires were finally completed, with an effective recovery rate of 92.1%.
Data analysis
The Statistical Package for Social Sciences (SPSS) for Windows Version 21.0 (IBM Corporation, New York, USA) was used for data processing and analysis. Descriptive statistics were used to present demographic characteristics, internship-related factors, psychological factors, as well as the prevalence of CS, BO, and STS. Measurement data were expressed as mean and standard deviation (SD); frequency and component ratios [n (%)] were used for the statistical description of count data, with Levene’s test to assess homogeneity of variance, independent sample t-test, one-way analyses of variance (ANOVA), and Pearson correlation analyses were used to compare the differences and examine the relationships between demographic characteristics, internship-related factors, psychological factors, and CS, BO, and STS. Finally, three multiple linear regression models were performed to identify significant variables associated with CS, BO, and STS among demographic factors, internship-related factors, and psychological factors. Variables used in the models were chosen based on clinical expertise and a p-value of < 0.2 on univariate tests to account for potential confounders [40]. Age, internship time, psychological resilience, empathy, and perceived stress were continuous variables, while gender, department, professional title of clinical nursing teachers, choice of nursing profession, number of night shifts monthly, daily working hours, and personality traits were categorical variables. We evaluated the linear relationship between continuous and ordered multi-categorical variables and the dependent variable by plotting scatter plots. Multicollinearity was assessed by using the Pearson correlation coefficient statistic and examining the variance inflation factor on a multiple regression model with the same dependent and independent variables. Regression diagnostic tests using residuals confirmed the normality, homoscedasticity, and independence assumptions. The fit of the models was assessed by the R-square. A two-sided p < 0.05 was indicative of a statistically significant difference.
Results
Demographic characteristics
The nursing interns aged from 18 to 24 (21.87 ± 1.50) years. Most of them were female (91.4%), and all were unmarried undergraduate nursing interns, with a mean internship time of 7.63 (SD = 1.26) months. The internship departments mainly included the medicine department, surgery department, pediatrics and obstetrics department, and emergency room and intensive care unit. Among these nursing interns, 50.23% of their clinical nursing teachers had intermediate or senior professional titles, 34.39% chose nursing profession as a transfer profession, 13.57% had more than 7 times night shifts per month, 44.34% worked for more than 8 h per day, and 48.87% had an intermediate personality type (Table 1). The mean psychological resilience score was 63.58 ± 15.27, the mean empathy score was 79.77 ± 6.08, and the mean perceived stress score was 26.16 ± 9.18.
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Table 1
Demographic characteristics of nursing interns (n = 221)
Compassion satisfaction | Burnout | Secondary traumatic stress | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
Variable | N | % | Mean ± SD | F/t | P | Mean ± SD | F/t | P | Mean ± SD | F/t | P |
Age(year) | 21.79 ± 0.87 | ||||||||||
Sex | |||||||||||
Male | 19 | 8.6 | 26.21 ± 5.67 | -2.81 | 0.010 | 30.26 ± 6.68 | 1.118 | 0.277 | 27.21 ± 9.14 | -0.734 | 0.464 |
Female | 202 | 91.4 | 29.99 ± 6.65 | 28.51 ± 4.39 | 28.53 ± 7.35 | ||||||
Department | |||||||||||
Medical department | 41 | 18.55 | 29.07 ± 6.32 | 1.807 | 0.129 | 28.00 ± 4.21 | 1.377 | 0.243 | 27.15 ± 7.26 | 2.396 | 0.051 |
Surgical deparment | 64 | 28.96 | 30.31 ± 6.30 | 28.45 ± 4.58 | 27.48 ± 7.90 | ||||||
Pediatrics and obstetrics department | 32 | 14.48 | 31.19 ± 8.25 | 27.81 ± 3.21 | 31.97 ± 6.19 | ||||||
Emergency room and intensive care unit | 34 | 15.38 | 30.74 ± 6.36 | 28.91 ± 5.20 | 28.56 ± 8.59 | ||||||
Other departments | 50 | 22.62 | 28.00 ± 4.86 | 29.86 ± 5.29 | 28.30 ± 6.71 | ||||||
Professional title of clinical nursing teachers | |||||||||||
Junior title | 110 | 49.77 | 29.52 ± 6.43 | -0.538 | 0.591 | 28.68 ± 4.95 | 0.053 | 0.958 | 26.42 ± 6.90 | -4.086 | < 0.001 |
Intermediate or senior title | 111 | 50.23 | 29.98 ± 6.38 | 28.65 ± 4.33 | 30.41 ± 7.59 | ||||||
Choice of nursing profession | |||||||||||
Personal choice | 145 | 65.61 | 30.34 ± 6.54 | 1.918 | 0.056 | 28.35 ± 4.40 | -1.391 | 0.166 | 28.62 ± 8.08 | 0.546 | 0.586 |
Professional transfer | 76 | 34.39 | 28.62 ± 5.98 | 29.26 ± 5.03 | 28.04 ± 6.30 | ||||||
Number of night shifts monthly | |||||||||||
0 ~ 3 times | 40 | 18.10 | 29.83 ± 7.50 | 0.011 | 0.989 | 28.15 ± 5.78 | 0.694 | 0.500 | 23.28 ± 6.52 | 16.885 | < 0.001 |
4 ~ 7 times | 151 | 68.33 | 29.76 ± 6.23 | 28.64 ± 4.27 | 28.92 ± 7.35 | ||||||
> 7times | 30 | 13.57 | 29.60 ± 5.79 | 29.47 ± 4.79 | 32.77 ± 5.83 | ||||||
Daily working hours | |||||||||||
≤ 8 h | 123 | 55.66 | 30.46 ± 6.81 | -1.844 | 0.067 | 27.67 ± 4.42 | 3.654 | < 0.001 | 27.10 ± 7.86 | 3.041 | 0.003 |
>8 h | 98 | 44.34 | 28.87 ± 5.75 | 29.91 ± 4.63 | 30.08 ± 6.72 | ||||||
Type of personality | |||||||||||
Introverted | 55 | 24.89 | 30.00 ± 6.12 | 0.103 | 0.902 | 29.16 ± 4.72 | 0.578 | 0.562 | 30.24 ± 7.07 | 2.453 | 0.088 |
Extraverted | 58 | 26.24 | 29.88 ± 6.61 | 28.78 ± 4.69 | 27.22 ± 8.33 | ||||||
Intermediate type | 108 | 48.87 | 29.56 ± 6.39 | 28.35 ± 4.58 | 28.14 ± 7.15 | ||||||
Prevalence of compassion fatigue, CS, BO, and STS
The mean scores of CS, BO, and STS of nursing interns were 29.75 ± 6.39, 28.72 ± 4.78, and 28.51 ± 7.51, respectively. Additionally, the percentages of mild, moderate, and severe compassion fatigue among nursing interns were 10.4%, 46.6%, and 43.0%, respectively.
Univariate analyses of factors associated with CS, BO, and STS
As shown by independent samples t-test and ANOVA results, male nursing interns had lower CS, higher BO among those who worked > 8 h per day, and higher STS among those whose clinical nursing teachers had intermediate or senior professional titles, more night shifts, and worked > 8 h per day (Table 1). In bivariate analysis, CS was positively correlated with psychological resilience (r = 0.330, p < 0.001) and empathy (r = 0.134, p = 0.047). BO was negatively correlated with psychological resilience (r = -0.172, p = 0.010) and empathy (r = -0.398, p < 0.001), and positively correlated with perceived stress (r = 0.177, p = 0.009). Finally, STS was negatively correlated with age (r = -0.173, p = 0.010) and internship time (r = -0.259, p < 0.001) (Table 2).
Table 2
Correlation between compassion satisfaction, burnout, secondary traumatic stress and age, internship time, psychological resilience, empathy, and perceived stress (n = 221)
Compassion satisfaction | Burnout | Secondary traumatic stress | ||
|---|---|---|---|---|
Age (years) | r | -0.019 | -0.122 | -0.173 |
p | 0.777 | 0.070 | 0.010 | |
Internship time(months) | r | 0.003 | 0.051 | -0.259 |
p | 0.960 | 0.451 | < 0.001 | |
Psychological resilience | r | 0.330 | -0.172 | -0.094 |
p | < 0.001 | 0.010 | 0.162 | |
Empathy | r | 0.134 | -0.398 | 0.044 |
p | 0.047 | < 0.001 | 0.514 | |
Perceived stress | r | 0.028 | 0.177 | 0.012 |
p | 0.676 | 0.009 | 0.855 | |
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Regression analyses examining covariates of CS, BO, and STS
In the CS model, male was a risk factor for CS and psychological resilience was a protective factor for CS. In the BO model, age and empathy were negatively correlated with BO, whereas daily working hours was a positive predictor of BO. The independent factors affecting STS were age, internship time, department, professional title of clinical nursing teachers, number of night shifts monthly, and daily working hours (Table 3).
Table 3
Multiple linear regression statistical analysis of compassion satisfaction, burnout, and secondary traumatic stress among nursing interns (n = 221)
B | SE | βeta | t | p | ||
|---|---|---|---|---|---|---|
Compassion satisfaction | (Constant) | 6.119 | 6.334 | 0.966 | 0.335 | |
Sex (ref: Male) | 3.920 | 1.486 | 0.172 | 2.638 | 0.009 | |
Department (ref: Medical department) | ||||||
Surgical deparment | 1.411 | 1.193 | 0.100 | 1.183 | 0.238 | |
Pediatrics and obstetrics department | 1.682 | 1.402 | 0.093 | 1.199 | 0.232 | |
Emergency room and intensive care unit | 1.762 | 1.393 | 0.100 | 1.265 | 0.207 | |
Other departments | -0.445 | 1.284 | -0.029 | -0.347 | 0.729 | |
Choice of nursing profession (ref: Personal choice) | -0.580 | 0.900 | -0.043 | -0.645 | 0.520 | |
Daily working hours(ref: ≤8 h) | -0.591 | 0.858 | -0.046 | -0.688 | 0.492 | |
Empathy | 0.089 | 0.068 | 0.085 | 1.299 | 0.195 | |
Psychological resilience | 0.127 | 0.028 | 0.303 | 4.616 | < 0.001 | |
Burnout | (Constant) | 76.063 | 7.977 | 9.535 | < 0.001 | |
Age (years) | -0.782 | 0.312 | -0.147 | -2.511 | 0.013 | |
Daily working hours(ref: ≤8 h) | 2.176 | 0.600 | 0.234 | 3.626 | < 0.001 | |
Perceived stress | 0.045 | 0.032 | 0.089 | 1.413 | 0.159 | |
Empathy | -0.328 | 0.045 | -0.429 | -7.309 | < 0.001 | |
Psychological resilience | -0.032 | 0.018 | -0.104 | -1.761 | 0.080 | |
Secondary traumatic stress | (Constant) | 68.780 | 12.557 | 5.477 | < 0.001 | |
Age (years) | -1.380 | 0.545 | -0.160 | -2.533 | 0.012 | |
Internship time(months) | -1.042 | 0.366 | -0.175 | -2.844 | 0.005 | |
Department (ref: Medical department) | ||||||
Surgical deparment | 0.393 | 1.373 | 0.024 | 0.287 | 0.775 | |
Pediatrics and obstetrics department | 3.622 | 1.593 | 0.170 | 2.274 | 0.024 | |
Emergency room and intensive care unit | 2.143 | 1.572 | 0.103 | 1.364 | 0.174 | |
Other departments | 0.858 | 1.445 | 0.048 | 0.594 | 0.553 | |
Professional title of clinical nursing teachers (ref: Junior title) | 2.767 | 0.925 | 0.185 | 2.991 | 0.003 | |
Number of night shifts monthly(ref: 0 ~ 3 times) | ||||||
4 ~ 7 times | 4.292 | 1.232 | 0.267 | 3.484 | 0.001 | |
>7times | 5.911 | 1.745 | 0.270 | 3.387 | 0.001 | |
Daily working hours(ref: ≤8 h) | 1.947 | 0.955 | 0.129 | 2.040 | 0.043 | |
Type of personality(ref: Introverted) | ||||||
Extraverted | -1.684 | 1.321 | -0.099 | -1.275 | 0.204 | |
Intermediate type | -1.354 | 1.120 | -0.090 | -1.209 | 0.228 | |
Psychological resilience | -0.021 | 0.031 | -0.043 | -0.694 | 0.488 |
Discussion
This study assessed compassion fatigue in 221 Chinese undergraduate nursing trainees using the ProQOL, which contains the CS, BO, and STS dimensions.
In this study, the compassion fatigue of 221 Chinese undergraduate nursing interns were assessed using ProQOL, which consists of three dimensions: CS, BO, and STS. The results showed that the scores of CS, BO, and STS of nursing interns were 29.86 ± 6.38, 28.72 ± 4.78, and 28.42 ± 7.51, respectively. Compared to a previous study on Chinese nursing students [5], our findings indicated similar levels of BO, whereas lower CS and STS scores. Additionally, nursing interns in this study had similar STS and BO scores but lower CS scores compared to midwifery students at a north-west UK university in a study by Elaine et al. [41]. This difference may be attributed to different work areas, workload, unit culture, and nurse characteristics of the study subjects [3]. Additionally, nursing interns with moderate and severe compassion fatigue in this study had a proportion of 46.6% and 43.0%, respectively. This suggested that there was a high degree of compassion fatigue among Chinese undergraduate nursing interns. How to help nursing interns cope with compassion fatigue should be taken into account by healthcare organizations.
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For the first time, this study found that male nursing interns had lower levels of CS. Consistently, a previous study [42] has also shown that male pediatric nurses exhibit lower levels of CS than females. This may be due to that males that participate in nursing in China account for an extremely low percentage compared with those in the developed countries, and most of them choose this nursing profession against their will; moreover, public prejudice, low professional status, and low salary may also contribute to decreasing their CS [43, 44]. However, male nurses in oncology and intensive care units have been shown to have higher levels of CS than female nurses [44, 45]. The reason may be that patients in these departments are more critically ill or have access to their families, and the working environment may be more friendly to male nurses who are not good at communication. Therefore, arranging departments and positions should be based on different physiological and psychological characteristics of male and female nursing interns, which may help to increase the CS of male nursing interns.
Additionally, the results of this study revealed that nursing interns with higher psychological resilience had higher CS levels. Supportably, previous research [5] has shown that psychological resilience is a potent predictor of CS. Psychological resilience reflects an adaptive process when encountering adversity. Individuals with higher psychological resilience are more capable of solving problems; psychological resilience can improve their psychosocial functioning and professional performance, including facing stressful clinical experiences [5, 24]. The psychological resilience score of the nursing interns in this study was 63.58 ± 15.27, which is still far from the ceiling. This suggested that enhancing the psychological resilience of nursing interns may be an important way to improve their CS.
This study showed that empathy is a protective factor for BO among nursing interns, and the study by Almudena et al. [46] also showed that empathy is associated with BO among nursing students confirming the results of this study. This is because nursing interns’ empathy helps individuals to understand and appreciate others’ thoughts, situations, and feelings [47], which helps to deal with conflicts between nurses and patients, making them more inclined to adjust their mindset and respond positively to events such as work stress, and reducing BO. Therefore, it is crucial to set up an empathy competence training program to establish psychological adjustment strategies for nursing interns to increase and maintain empathy.
The results of this study showed that daily working hours > 8 h was a common risk factor for BO and STS. Consistently, a large-sample multicenter empirical study on Chinese tertiary hospitals has also shown that nurses’ average daily working hours > 8 h is a risk factor for BO [3]. Another study has reported that working hours more than 40 h per week is associated with BO [48]. Heavy workload is a strong predictor of chaplains’ BO [49].This was similar to the results of this study. The analysis may be due to that nursing interns working more than 8 h a day are overburdened by their occupation. Under this situation, they are prone to work-family imbalance, endocrine disorders, sleep disorders or other physiological dysfunctions, and negative emotions (e.g., anxiety); these disorders can greatly affect their work motivation and mental health status, reduce their psychological capital, and lower their career satisfaction [50]. In addition, nursing in Chinese tertiary hospitals have a high workload, that is, nurses are often required to deal with acute and critical illnesses and difficult cases and provide high-quality specialty care, which may lead to their emotional exhaustion and lack of personal fulfillment [3, 51]. What’s more, nursing interns who work longer hours may spend more time with patients and dwell on their negative emotions, leading to BO and STS. Therefore, flexible scheduling, rationalization of workload, and shortening of daily working hours can help alleviate BO and STS among nursing interns.
The results of this study showed that older nursing interns had lower BO and STS, and internship time was a negative predictor of STS. Previous research has also shown that younger nursing students are prone to emotional exhaustion and BO [52], which is similar to the results of this study. This may be because older and longer practicum students have more knowledge and experience in clinical nursing tasks and skills. It has also been shown that older and more experienced students are not only less likely to use avoidance strategies but also more confident and capable of seeking and obtaining the necessary support. However, younger nursing students have lower self-efficacy due to their inexperience and lack of self-confidence, and the stresses that arise from caring for patients tend to be more intense for them [52, 53]. Therefore, younger nursing interns have more severe BO and STS than older individuals. However, another study has shown that the degree of compassion fatigue of nursing interns continues to worsen with the prolongation of the internship [22]. This is different from the results of the present study. The explanation may be that the nursing students in the previous study were during the outbreak prevention and control of New Coronary Pneumonia in China, their perception of public health emergencies and emergency response ability were still at an intermediate level, and they were prone to psychological stress reactions such as anxiety and panic, and long-term negative emotions, which exacerbated their compassion fatigue [16]. It is also possible that the subjects of the present study were in the middle and late stages of the internship, and no research on students in the early stage of the internship was carried out. Nursing interns at the early stage of the internship may be included in the future to carry out a longitudinal study in order to further validate the results of the present study.
According to the results of linear regression analysis results in this study, nursing interns in pediatrics and obstetrics had higher scores of STS, which has not been reported in previous studies. Previous studies have also shown higher scores of compassion fatigue, BO, and STS among pediatric nurses [54], which is partially the same as the results of this study. However, another study [10] has shown that nurses in the intensive care unit have higher compassion fatigue, which differed from the results of this study. This may be attributed to the fact that pediatric patients are a special group of patients who require higher skills in the nursing specialty, which is the weak point of nursing interns. Therefore, this may expose the nursing interns to more STS. Additionally, nursing interns who have bonded with laboring women in the course of providing labor and delivery care services are susceptible to STS as empathy and indirect exposure to trauma may occur as a result of witnessing the pain of labor and delivery. The study suggests that compassion fatigue should be a priority among nursing interns practicing in pediatrics and obstetrics.
Several studies have shown that night shifts are a risk factor for STS in nurses [55, 56]. However, little attention has been paid to the effect of night shift frequency on STS in nursing interns. The present study found that the number of night shifts monthly was an independent risk factor for STS in nursing interns. The more number of night shifts per month, the higher the STS score. The working hours of night shifts are opposite to the human biological clock; moreover, there are fewer staff members and more tasks to be undertaken, and there may be rapid changes in patients’ conditions and the seriousness of their illnesses. These not only negatively affect nurses’ sleep disorders, nutritional status, and appearance changes [57], but also negatively affect nursing interns because nursing interns have little clinical experience. Therefore, considering these challenges of night shift work, diversified scheduling strategies should be considered, such as following biorhythmic scheduling and implementing a centralized night shift system and a night shift incentive system; this strategy may reduce the risk of biological clock disorders and mitigate work-life conflicts; moreover, trying to arrange patient care on day shifts can reduce the nursing workload on night shifts, thus effectively alleviating STS among nurse interns.
In addition, we, for the first time, found that nursing interns whose clinical nursing teachers’ professional titles of intermediate or senior had higher STS cores. This may be because clinical nursing teachers with higher titles are required to take on more complex tasks and are exposed to more difficult and critically ill patient care than nurses with junior titles; therefore, nursing interns following these teachers with higher titles tend to be susceptible to more severe negative emotions from patients and their families, which results in higher STS scores. However, this idea is only speculative at this time, and further studies are needed to provide better conclusions regarding the relationship between the title of clinical nursing teachers and STS.
In the correlation analysis, perceived stress was positive, and psychological resilience was negatively related to BO among nursing interns. Previous study has also shown that stress is related to BO among nursing students [58]. However, perceived stress and psychological resilience showed no significance in the multifactorial analysis. This may be because there is a mediating variable between internship stress and BO, which affects the relationship between the two. Secondly, it may be that the sample size is too small and the sampling method may lead to bias; the relationship between internship stress, psychological resilience, and BO can be clarified by conducting a large-scale study in the future.
The relationship between the personality traits of nursing interns and compassion fatigue has received little attention. Existing studies have shown that some personality traits such as pleasant, cautious, and open-mindedness are positively associated with CS; neurotic personality traits is negatively associated with CS but positively associated with BO and compassion fatigue, and extroverted personality traits are associated with BO [51, 59, 60]. In this study, nursing interns with extroverted and intermediate personality traits had higher CS and lower BO and STS compared to those with introverted personalities trait, but the difference did not reach a significant level though both univariate and multivariate analyses. It may be related to the fact that the extroversion/introversion personality traits of nursing interns are also influenced by other personality traits such as volition and emotion, as well as by the sample size. Therefore, personality traits could be further subdivided in the future in order to explore the relationship between more types of personality traits and compassion fatigue.
Nursing interns who voluntarily chose the nursing profession have a certain interest and knowledge of the nursing profession and believe that the nursing program is the right choice, which contributes to learning enthusiasm and high levels of professional commitment [61] and professional identity [62], thereby reducing compassion fatigue [17]. Results from a previous study [16] also showed that nursing interns who voluntarily chose a nursing program had higher CS, lower BO, and lower STS than those who involuntarily chose a nursing program. The CS and BO of nursing interns who willingly choose nursing profession in this study were higher than those with profession transfers, but the difference was not significant and the findings differed from the conclusions of previous studies. The reason for this analysis may be influenced by the small sample size. Therefore, the effect of willingness to choose a nursing specialty on compassion fatigue needs to be further studied in the future.
Limitations
This study was focused on nursing interns in the middle and late stages of their internships and nursing interns in the early stages of their internships were not included. Hence, the extrapolation of the findings may be limited. Secondly, this study was a cross-sectional study and failed to explain the causal relationship between compassion fatigue and the influencing factors. In the future, nursing interns in the early stages of their internship could be included and a longitudinal study could be used to further validate the results of this study.
Conclusion
The results of this study showed that compassion fatigue among nursing interns was mainly at moderate and severe levels and can be influenced by various factors. Nursing interns who were male and had lower levels of psychological resilience had lower levels of CS. Nursing interns with lower levels of empathy had higher levels of BO; internship time, number of night shifts, and professional title of clinical nursing teachers influenced STS in nursing interns, and working hours per day is a common and independent influencing factor of BO and STS. Nursing educators should focus on nursing interns who are male, who have shorter internships time and whose clinical nursing teachers have higher titles; their compassion fatigue can be reduced by setting up appropriate courses through nursing interns’ psychological resilience and empathic ability. Meanwhile, reasonably arranging the frequency of night shifts and working hours of nursing interns can also be helpful.
Recommendations
This study suggests that compassion fatigue in nursing interns should receive more attention and relevant factors can be selected for future intervention based on the results of this study. In addition, since this study is a cross-sectional survey, the results drawn from this study shall be further validated in the future by longitudinal studies, qualitative studies, or the use of other more concise assessment tools such as the ProQOL-12 [63]. Also, the social support of nursing interns was not investigated in this study, and the relationship between the level of support from family members, friends, managers, and others on compassion fatigue in nursing interns needs to be further investigated in the future.
Acknowledgements
The authors are extremely grateful to all the nursing interns who participated in this study.
Declarations
Ethics approval and consent to participate
This study was reviewed and approved by the Ethical Review Committee for Human Trials of Shanghai General Hospital (No. 2024108). All participants were approached by a research nurse and provided a detailed explanation of the study’s purpose and procedures. Informed consent was received from all participants prior to their inclusion in this study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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