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Journal of Research in Nursing logoLink to Journal of Research in Nursing
. 2023 Jul 1;28(6-7):485–495. doi: 10.1177/17449871231177164

The mediating role of empathy in the impact of compassion fatigue on burnout among nurses

Nihal Topçu 1, Mahmut Akbolat 2, Mustafa Amarat 3,✉
PMCID: PMC10741259  PMID: 38144971

Abstract

Background:

The burnout levels of nurses, who have an important place in the delivery of health services, are increasing day by day. As the burnout levels of nurses increase, there may be undesirable situations such as compassion fatigue specific to them, their patients and their institutions.

Purpose:

The aim of this study is to determine the effect of compassion fatigue seen in nurses on burnout and the mediating role of empathy in this effect.

Methods:

The research was conducted on nurses working in three public hospitals operating in Sakarya, Turkey, between 2 January and 16 April 2019. Since the research was conducted in more than one hospital, the minimum number of participants was determined for each hospital using the stratified sampling method in the first stage. In the second stage, the participants were selected by convenience sampling method. Descriptive statistics, linear regression and process macro regression analysis were used to analyse the data.

Results:

The results showed the effect of nurses’ compassion fatigue on burnout and empathy (β = 0.673). In addition, empathy has a mediating role in the effect of compassion fatigue on burnout (β = 0.251).

Conclusions/implications for practice:

Reducing the burnout levels of nurses, who have a very important place in the delivery of health services, is important for both themselves and patients. It is recommended that the results of this study, which may contribute to the development of the awareness of nurse managers, should be made with the ability to understand the symptoms of compassion fatigue and burnout, teaching coping methods and providing support by experts when necessary.

Keywords: burnout, compassion fatigue, empathy

Background

Nursing is a health-related profession that plays an active role in the protection, development and maintenance of public health (Tuna and Sahin, 2021). Members of this profession have recently experienced burnout due to many factors. Nurses experiencing burnout may cause undesirable results in organisational functioning and patient care. This situation makes the issue even more critical (Başar and Basım, 2016). Many studies have been conducted in the literature on nurses’ burnout. Başar (2020) conducted a literature review on the factors that cause burnout in nurses; divides them into two groups individual and contextual factors. Individual factors include nurses’ characteristics and experiences (Shah et al., 2021; Thomas et al., 2019). On the other hand, contextual factors vary between the place where they work and their managers. These consist of occupational, environmental and organisational conditions (Ghavidel et al., 2019; Haizlip et al., 2020). Both individual and contextual factors increase the burnout levels of nurses. Nurses are experiencing burnout experience negativities at the individual and organisational level. Individual consequences may include physical ailments and illnesses, dissatisfaction with life and work (Kelly, 2020; Rudman et al., 2020). Among the organisational outcomes are patient dissatisfaction (Carthon et al., 2021), decrease in service quality (White et al., 2020), decrease in performance (Dyrbye et al., 2019), intention to leave, and non-fulfilment of duties and responsibilities (Guo et al., 2019). As a result, burnout in nurses negatively affects health presentation. Although there are empirical studies in the literature about nurses’ burnout, it is seen that there are not enough studies on nurses’ compassion fatigue.

Compassion fatigue can be defined in the literature as the burden of witnessing the traumas and pain experienced by the patients they care for. In short, it can be expressed as ‘cost of caring’ (Henson, 2020). This is a very important situation for nurses (Hsiao, 2023). Several studies investigate the factors affecting nurses’ compassion fatigue and burnout, and the results of cross-sectional surveys conducted by many authors (Zhang et al., 2018). Compassionate care can be considered a care model that accelerates the patient’s recovery, positively affects the patient physiologically and increases patient satisfaction and the basis of nursing practices. On the other hand, compassion fatigue causes nurses to wear out mentally, physically and spiritually and may prevent the continuation of empathy (Peters, 2018).

The concept of empathy is a skill that represents an individual’s understanding of the feelings and thoughts of other individuals. It is considered one of the important skills for healthcare professionals (Duarte et al., 2016). Nurses constitute a professional group that supports people when they face their spiritual, emotional and physical suffering, shows courage, healing and compassion and cares about individuals (Zhang et al., 2018). For this reason, nursing practises develop in the context of a compassionate, empathetic relationship between patient and nurse. The necessary empathetic relationship can also contribute to compassion fatigue if conscious steps are not taken to avoid and reduce this situation (Lombardo and Eyre, 2011). Therefore, nurses witnessing the pain experienced by patients and empathising by being compassionate (Alan, 2018), and the stress they experience while trying to meet the needs of patients and their families can cause compassion fatigue. Recent studies also support this view, and compassion fatigue and burnout levels are found to be high in nursing (Mottaghi et al., 2020). Compassion fatigue does not only affect nurses’ job satisfaction, physical and emotional health, but it also affects the workplace by reducing productivity (Lombardo and Eyre, 2011).

Although studies on compassion fatigue and burnout shed light on the literature, it is not known what other variables affect these two variables. In this study, empathy was preferred as the mediator variable of these two variables. This is because nurses’ characteristics include helping patients and understanding their feelings. The empathic approach requires understanding the feelings of the other person. Nurses who use empathy skills effectively and know themselves can achieve practical empathy. When the nurse’s empathy and empathy skills are improved in inpatient communication, the quality of the health service offered (Dizer and İyigün, 2009) and patient satisfaction increase, and the medical error rate is minimised (Williams et al., 2014). However, empathy is at the centre of feelings of guilt, leading to pathogenic guilt beliefs when excessive and misguided (Duarte and Pinto-Gouveia, 2017). There are limited studies on excessive responsibility for the well-being of others and how they relate to professional quality of life. Recent studies have found a relationship between empathy and compassion fatigue (Cao and Chen, 2021; Duarte and Pinto-Gouveia, 2017; Mottaghi et al., 2020) and between empathy and burnout (Ren et al., 2020). In the light of this information, this research was planned to determine the mediating role of empathy in the effect of compassion fatigue on burnout in nurses. The research hypotheses were formed for the research purpose.

  • H1: Nurses’ compassion fatigue positively affects empathy.

  • H2: Compassion fatigue positively affects burnout.

  • H3: Empathy positively affects burnout.

  • H4: Empathy has a positively mediating role in the effect of compassion fatigue on burnout.

Methods

Design

This study as a cross-sectional, correlational, descriptive study of nurses’ compassion fatigue, burnout and empathy.

Setting

The research was carried out on nurses working in Sakarya/Turkey. Between 2 January 2019 and 16 April 2019, 995 nurses were working in the relevant hospitals when the research was conducted.

Participants

Participants in the study were selected in two stages. Since the research was conducted in more than one hospital, the minimum number of participants was determined for each hospital using the stratified sampling method in the first stage. In the second stage, the participants were selected by convenience sampling from among the nurses who worked for at least 3 years and stated that they were willing to participate in the research. Table 1 shows the total number of nurses by hospitals, the minimum number of nurses to be reached and the number of nurses participating in the research.

Table 1.

Information on the research population and sample.

Hospital Total number of nurses Sample to be reached Reached sample
Hospital 1 740 207 316 (42%)
Hospital 2 180 50 86 (48%)
Hospital 3 75 21 39 (52%)
Total 995 278 441 (44%)
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Participants’ demographics

Of the nurses participating in the research, 78.8% are women, and 21.2% are men. The majority of the participants, 62.6%, completed their undergraduate education. While the age of the participants was generally balanced, the rate of employees over 45 years old (5.4%) was lower than the others. The duration of service consisted of those who completed 3 years of service as a criterion in selecting participants. Here, the participant ratio is at most 35.6% and consists of those working for 3–5 years. Finally, the intensive care nurses constitute 22.9% of the nurses’ units (see Table 2).

Table 2.

Demographic profile.

n %
Gender Female 342 78.8
Male 92 21.2
Marital status Married 208 57.8
Single 152 42.2
Education High school 39 8.8
Associate degree 100 22.7
Bachelor 276 62.6
Graduate 26 5.9
Age <25 77 17.5
25–29 118 26.8
30–34 70 15.9
35–39 72 16.3
40–44 80 18.1
⩾45 24 5.4
Service duration <5 157 35.6
5–9 78 17.7
10–14 67 15.2
15–19 61 13.8
⩾20 78 17.7
Unit Intensive care 101 22.9
Urgent 95 21.5
Operating room 42 9.5
Surgical 71 16.1
Internal 89 20.2
Other 43 9.8
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Measurements

In the research, three different scales and a questionnaire consisting of the socio-demographic characteristics of the participants were used as a data collection tool. Brief information about the data collection tool used in the study is given below. All scales are designed in a 5-point Likert structure. Researchers who can use Turkish translations of the two scales, except for Compassion Fatigue, both in Turkish and English academically, adapted the scales to Turkish by following the steps below. Firstly, the scales were translated into Turkish. Secondly, the translations were analysed by experts in the field of health sciences and necessary changes were made. Thirdly, Turkish scale expressions were translated back into English and checked. In the last stage, it was concluded that both the original scales and the translated scales were similar.

Socio-demographic characteristics

The features consisting of five questions consist of gender, educational status, age, length of service and the units in which the participants work.

Compassion Fatigue Scale

Compassion Fatigue Scale was developed by Pommier (2010) and adapted into Turkish by Akdeniz and Deniz (2016). The scale consists of dimensions and 24 expressions and six subsections; Kindness (6, 8, 16 and 24), Indifference (2, 12, 14 and 18 phrases), Common Humanity (11, 15, 17 and 20), Separation (3, 5, 10 and 22), Mindfulness (4, 9, 13 and 21) and Disengagement (1, 7, 19 and 23). The expressions constituting the Indifference, Separation and Disengagement dimensions of the scale are negative; the dimensions of Common Humanity, Mindfulness and Kindness awareness consists of positive expressions. The scores of the dimensions that make up the positive statements were calculated by reversing the study. Accordingly, as the score obtained from the scale increases, the level of compassion fatigue of the participant’s increases.

Spanish Burnout Inventory

The Spanish Burnout Inventory, taken from Gil-Monte and Olivares Faúndez (2011), aims to reveal the individual’s desire to achieve goals in the workplace. Scale has 20 expressions and four sub-sections: Enthusiasm towards the job (1, 5, 10, 15, 19), Psychological exhaustion (8, 12, 17 and 18), which expresses the emergence of emotional and physical exhaustion because it requires dealing with people who create or cause problems, Indolence (2, 3, 6, 7, 11,14), which indicates the indifference of the institution towards its customers and the presence of cynicism) and Guilt (4, 9, 13, 16, 20), which expresses the emergence of feelings of guilt about negative attitudes and behaviours developed at work, especially towards people with whom has business relations. When the scale is compared with the Maslach burnout scale, it has similar features to enthusiasm towards the job, personal achievement, psychological exhaustion, emotional exhaustion, Indolence depersonalisation dimensions. Since the expressions in the Enthusiasm towards the job dimension are positively formulated, low scores indicate high levels of burnout, and high scores in other dimensions indicate high levels of burnout.

Toronto Empathy Scale

Toronto Empathy Scale was developed by Spreng et al. (2009) and 8 of them were positive (1, 3, 5, 6, 8, 9, 13 and 16), and 8 of them were negative (2, 4, 7, 10, 11, 12, 14 and 15) consists of 16 expressions. Negative questions are reversed while performing operations on the scale. In the original, the values given to their expressions are summed up and accordingly measure their empathy status below or above average. Within the scope of this research, we conducted our analyses not on totals but on expression averages. It can be stated that individuals with a higher mean have higher empathy.

Validity and reliability of scales

In the study, exploratory factor analysis and reliability analyses were performed first. According to the exploratory factor analysis, each scale used was reliable. In addition, the sample adequacy test Kaiser-Meyer-Olkin (KMO) for each scale (Compassion Fatigue: 0.921; Burnout: 0.860 and Empathy: 0.956) was found to be close to perfect. Bartlett’s tests of all scales were found to be significant. The variance explained for the Compassion Fatigue Scale was 67.88%, for the Burnout scale 56.37% and for the Empathy scale 52.79%. It seems that the scales met all of the requirements.

After determining the usability of the scales according to the results of exploratory factor analysis, confirmatory factor analysis was used to test whether the goodness of fit was appropriate or not.

As in the original Compassion Fatigue Scale, the six-factor structure was confirmed in this study. Confirmatory factor analysis (CFA) findings, χ2 = 440.696, p = 0.001, χ2/df = 1.859, Tucker–Lewis Index (TLI) = 0.955, Comparative Fit Index (CFI) = 0.961, Goodness of Fit Index (GFI) = 0.920, Adjusted Goodness of Fit Index (AGFI) = 0.899, Root Mean Square Error of Approximation (RMSEA) = 0.044. Burnout scale, the four-factor structure was confirmed in this study. DFA findings, χ2 = 293.769, p = 0.001, χ2/df = 1.933, TLI = 0.940, CFI = 0.952, GFI = 0.938, AGFI = 0.915 and RMSEA = 0.046. Empathy scale, the single-factor structure was confirmed in this study. DFA findings, χ2 = 260.513, p = 0.001, χ2/df = 2.658, TLI = 0.950, CFI = 0.959, GFI = 0.930, AGFI = 0.903 and RMSEA = 0.061. According to these values, it was decided that the goodness of fit of the scales used in the study was appropriate.

Data collection

Before the data were collected, the nurses were asked to fill the informed consent form. In addition, the participants were informed about the permissions obtained regarding the research and its ethical compliance. By the permission obtained, the data in the study were collected by face-to-face survey method in 2019. Between these dates, the researchers visited all the hospitals in the universe every day and held interviews with the participants who volunteered for the study. The data collection process took about 3 months, as the participants had intense and challenging working conditions and shifts.

Data analysis

We analysed the data using SPSS (Statistical Package for the Social Sciences, Armonk) statistics V 22, AMOS (Analysis of Moment Structures, New York, USA) and the PROCESS Macro (New York, USA), a structural equation modelling framework used to test both direct and mediating effects. Hayes’ Model 4 was used to identify the mediating role of Empathy on the effect of compassion fatigue on burnout.

Ethical considerations

With the letter numbered E.301, legal permission was obtained from Sakarya Provincial Health Directorate to carry out the study in public health institutions. Approval was obtained from Sakarya University Ethics Committee regarding the compliance of the study with ethical rules (61923333/050.99/).

Results

The mean standard deviations showing the participants’ compassion fatigue, burnout and empathy levels and the correlation between these three variables are given in Table 3. As shown in the table, the participants’ compassion fatigue, burnout and empathy levels are low. However, there is a positive relationship between compassion fatigue, burnout and empathy.

Table 3.

Correlation, mean and standard deviation results for variables.

Mean SD 1 2
Compassion Fatigue 2.08 0.472 1
Burnout 2.51 0.502 0.507** 1
Empathy 2.41 0.466 0.681** 0.470**
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SD: standard deviation.

**

indicates 99% confidence interval.

In order to test the hypotheses put forward in the research model, first of all, the effect of compassion fatigue on burnout was analysed (Table 3). Accordingly, the model created to determine the compassion fatigue on burnout is statistically significant (F = 151,761; p = 0.000). Compassion fatigue on burnout has a positive effect (β = 0.539, p < 0.00). Then, the measurement of the effect of compassion fatigue on empathy was carried out. The established model has a significant (F = 378,638; p = 0.000) and positive effect (β = 0.673, p < 0.000). The model established to measure the effect on empathy and burnout is significant (F = 87,763; p = 0.000) and it affects positively (β = 0.251, p < 0.00).

Finally, compassion fatigue has a positive effect on burnout (β = 0.370, p < 0.00). It contributes positively to the development of this effect as a means of empathy (β = 0.169, p < 0.00). Accordingly, when the indirect effect arising from the mediating role of empathy is added, overall compassion fatigue on burnout is more strongly (β = 0.539, p < 0.00) affected (Table 4).

Table 4.

Direct and indirect effect results for compassion fatigue, burnout and empathy.

Direct effect β SD t p LLCI ULCI
Compassion Fatigue Burnout 0.370 0.059 6.318 0.000 0.453 0.625
Indirect effect
Compassion Fatigue Empathy Burnout 0.169 0.04 0.091 0.247
Total Effect 0.539 0.044 12.319 0.000 0.453 0.625
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SD: standard deviation; LLCI: lower limit confidence interval; ULCI: upper limit confidence interval.

Discussion

According to the results of the research, nurses’ mean scores on compassion fatigue, burnout and empathy scales were found to be low. Similar and different results are found in the literature. Firstly, compassion fatigue, which was detected at low levels in some studies (Chen et al., 2018), was found at moderate levels in some studies (Özdelikara and Babur, 2020) and high levels in others (Adanir, 2019). It is possible to express the reasons for these differences as the health system and date range of the researches.

Secondly, similar results to compassion fatigue are also found in the literature on burnout and empathy. There are studies showing that nurses experience low, moderate (Kolthoff and Hickman, 2017) and high levels (Ajoudani et al., 2019; Choi et al., 2019) of burnout. Similarly, there are empirical studies suggesting that there are different evaluations about empathy (Mottaghi et al., 2020; Özdelikara and Babur, 2020; Zarei et al., 2019). Different results were found from these pioneering studies encountered in the literature mainly because the research was not conducted on a specific nurse group. Studies in the literature mainly were carried out on nurses working in intensive care, oncology and palliative care. In this study, all nurses were included in the sample group without distinguishing. Therefore, it can be said that the difference in working conditions may be effective in achieving different results. Another reason for the different results may be that research was conducted before, during and after the COVID period.

There is a statistically significant positive correlation between burnout and empathy with compassion fatigue. Similarly, Duarte and Pinto-Gouveia (2017) found a relationship between empathy, burnout and compassion fatigue experienced by nurses.

Maytum et al. (2004), in their study on nurses working with children with chronic diseases, suggested a significant relationship between compassion fatigue and burnout. Similar empirical findings are also found in other studies on nurses in the literature (Adanir, 2019). Although not on nurses, studies on health workers (Weintraub et al., 2016) and hospice workers (Slocum-Gori et al., 2011) also found a positive relationship between compassion fatigue and burnout. In line with the results of the study and the literature, it can be stated that the nurses working on the front lines experience burnout and that compassion fatigue is among the important causes of burnout.

Özdelikara and Babur (2020) found a positive and significant relationship between compassion fatigue and empathy. Although the relationship is different according to the time and place where the research was carried out, empathy and compassion fatigue are related concepts. On the other hand, Abbaszadeh et al. (2017), in their study to reveal the relationship between compassion fatigue and burnout in nurses, claim that there is no significant relationship between compassion fatigue and burnout in nurses and present a different result. In general, although it is a study that expresses a contradictory opinion, there is a relationship between compassion fatigue and burnout in nurses. This result is supported by both this study and many studies in the literature.

The study results also confirm that nurses’ compassion fatigue affects their burnout levels. In line with these results, the H2 hypothesis was accepted. There are different studies with similar results (Henson, 2020; Jarrad and Hammad, 2020). The study results also confirm the proposition that compassion fatigue affects empathy. In line with these results, the H1 hypothesis was accepted. Mottaghi et al. (2020) reveals similar results to this study by revealing the mediator role of empathy in the effect of compassion fatigue on burnout. Although the research model is not used, Duarte and Pinto-Gouveia (2017) claim that higher levels of burnout and compassion fatigue are observed when an association based on empathy and guilt is made in their research.

Compassion fatigue in nurses increases burnout, and empathy has a positive enhancing effect on this effect. Which means we accepted the H3 hypothesis. Given their nature or job, nurses are particularly exposed to situations that constantly activate their empathic abilities. Given the relationship between compassion fatigue and empathy, nurses who are more likely to experience feelings of empathy are likely to feel excessive and undue responsibility for their patients. In addition, nurses are more likely to experience burnout syndrome due to their empathy, and over time they get more tired of showing compassion towards patients. H4 hypothesis was accepted. In other words, by increasing compassion fatigue in nurses, their empathy increases, which, in turn, increases burnout. When the empathic approach of nurses who constantly experience compassion fatigue is included, the burnout syndrome they experience increases. While this situation negatively affects the individual lives of nurses, on the one hand, it can cause undesirable results, such as the emergence of institutional inefficiency.

Limitations and recommendations

This research was carried out within certain limits. Within the scope of the research, it is possible to collect these limitations under two headings. Firstly, the study was conducted before the COVID-19 era. With the COVID period, the working hours of hospitals and especially the burdens on nurses differ. The second limitation is that the research was conducted with nurses who worked at the relevant hospitals in Sakarya for at least 3 years. In addition, only empathy and compassion fatigue were used as variables in the prediction of burnout. Apart from these variables, it is recommended that more research be done to determine the possible effects of other individual and organisational variables on burnout.

Conclusion

This study revealed that nurses’ compassion fatigue and empathetic abilities could impact burnout. Burnout levels of nurses experiencing compassion fatigue are increasing. In addition, the empathic abilities they use while performing their profession play a significant mediator role in this effect. In short, empathy increases the effect of compassion fatigue on burnout. Reducing nurses’ burnout, who have an essential place in delivering health services, is vital for themselves and their patients. By using the empirical information obtained from this and similar studies, nurse managers should be provided with the ability to understand the symptoms of compassion fatigue and burnout in nurses, teach methods to cope with these problems and receive professional support from experts when necessary. Finally, compassion fatigue can reach higher levels in processes such as the pandemic that affect the whole world, and in such cases, these situations of nurses should be measured and monitored.

Key points for policy, practice and/or research.

  • Nurse managers should understand compassion fatigue and raise awareness on this issue.

  • Compassion fatigue can be seen in nurses periodically, and this will increase their sense of burnout.

  • Informative trainings and seminars can be organised for nurses about compassion fatigue, burnout and empathy skills, and these can be repeated at regular intervals to keep interest in the subject alive.

  • More detailed research on compassion fatigue in nurses is recommended. In particular, it is not known how it will affect the quality of service delivery.

Biography

Nihal Topçu completed her master’s degree in health management. She continues to work in the fields of nursing and health management.

Mahmut Akbolat is a Professor in the Department of Health Management at Sakarya University. At the same time, he continues to work as the director of the Institute of Business Administration. He has more than 100 works in the field of health management.

Mustafa Amarat worked as a Research Assistant at Sakarya University Health Management Department between 2016 and 2022. He received his doctorate from Sakarya University in the field of health management. He is currently working as an associate professor in the Department of Health Management at Ordu University.

Footnotes

Author contributions: Mahmut Akbolat and Nihal Topçu were involved in the study design. Nihal Topçu was involved in data collection. Mustafa Amarat and Mahmut Akbolat were involved in data analysis. Mahmut Akbolat was involved in study supervision. Mustafa Amarat and Nihal Topçu were involved in manuscript writing. Mahmut Akbolat was involved in critical revisions for important intellectual content.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval: Before the data were collected, permission was obtained from the General Secretariat of Sakarya Public Hospitals Association, and a report on the compliance of the study with the ethical rules was obtained from Sakarya University Ethics Committee (61923333/050.99/).

ORCID iD: Mustafa Amarat Inline graphic https://orcid.org/0000-0001-8954-6314

Contributor Information

Nihal Topçu, Student, Department of Healthcare Management, Graduate School of Business, Sakarya University, Sakarya, Turkey.

Mahmut Akbolat, Professor, Department of Healthcare Management, Business Faculty, Sakarya University, Sakarya, Turkey.

Mustafa Amarat, Associate Professor, Department of Healthcare Management, Ordu University, Ordu, Turkey.

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