The relationship between self-efficacy, learning burnout, willingness to fulfill the contract and empathy of rural-oriented tuition-waived medical students of China: a cross-sectional study

Abstract

Background

The empathy of rural-oriented tuition-waived medical students (RTMSs) is closely related to the construction of good doctor-patient relationship and the quality of rural medical and health services. The purpose of this study is not only to explore the relationship between self-efficacy, learning burnout, willingness to fulfill the contract and empathy, but also to explore the mediating role of self-efficacy between learning burnout and empathy, and between willingness to fulfill the contract and empathy.

Methods

Four hundred ninety-five rural-oriented tuition-waived medical students from 3 medical universities in Shandong Province were selected as research subjects, and General self-efficacy scale (GSES), Learning burnout of university student (LBUS), Willingness to fulfill the contract scale and Jefferson Scale of Physician Empathy-student version (JSPE-S) were used to investigate. SPSS 25.0 and AMOS 24.0 were used for statistical analysis and path analysis of the data.

Results

The willingness to fulfill the contract of rural-oriented tuition-waived medical students has a direct positive impact on self-efficacy (β = 0.11, P < 0.05) and empathy (β = 0.27, P < 0.001), and a significant direct negative impact on learning burnout (β = -0.25, P < 0.001). Learning burnout has a significant direct negative impact on self-efficacy (β = -0.34, P < 0.001), while self-efficacy has a significant direct positive impact on empathy (β = 0.22, P < 0.001). Learning burnout has no direct impact on empathy (β = -0.09, P = 0.109). Self-efficacy has a significant mediating effect between willingness to fulfill the contract and empathy (95% CI: 0.02–0.41), and also has a significant mediating effect between learning burnout and empathy [95% CI: -0.41- (-0.11)]. Learning burnout has no mediating effect between willingness to fulfill the contract and empathy (95% CI: -0.02–0.42).

Conclusion

This study found that learning burnout and willingness to fulfill the contract are important factors affecting rural-oriented tuition-waived medical students’ empathy, both of which can influence empathy through the mediating role of self-efficacy. This provides positive suggestions for medical colleges to improve the empathy of students, which is of great practical significance for continuously improving the service quality of general practitioners and ultimately realizing the development of high-quality rural medical and health undertakings. In addition, it also provides an important theoretical reference for the formulation of empathy intervention measures and broadens the direction of rural-oriented tuition-waived medical students’ research in the future.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-06637-6.

Introduction

Background

At present, China is in the stage of rapid urbanization, and the economic policy has obvious urban bias, and the "dual structure" of urban–rural division has gradually become prominent. In addition, local financial expenditure is biased towards cities, and they usually give priority to urban construction and development [1, 2]. As a result, large and medium-sized urban hospitals have concentrated a large number of high-tech medical equipment, constantly attracting more excellent doctors to enter urban hospitals, which has invisibly exacerbated the lack and backwardness of rural medical and health resources, and fallen into a vicious circle [3]. In 2014, the density of doctors in urban areas (3.54 per thousand people) was twice that of rural areas (1.51 per thousand people). As of 2020, the density of doctors in urban areas (4.25 per thousand people) is still twice that of rural areas (2.06 per thousand people) [4]. Therefore, the uneven distribution of medical and health resources between urban and rural areas has always plagued China and become a highly valued issue by the Chinese government. With the promotion of the rural revitalization strategy, rural medical service facilities have been improved, however, the lack of high-quality medical talent resources still restricts the development of China’s rural medical and health care industry. In order to alleviate this situation, the Chinese government began implementing the rural-oriented tuition-waived medical education (RTME) program for the first time in 2010. Rural-oriented tuition-waived medical students (RTMSs) must sign a directed employment agreement with the training school and the health administration department before entering the school, and promise to serve in rural medical and health institutions for six years after graduation. The project aims to enrich the rural medical and health service talent pool, so as to provide adequate and high-quality medical and health services to rural residents, and further alleviate the inequity in the distribution of medical services between urban and rural areas. At present, the research direction of RTMSs mainly focuses on the aspects of talents training, curriculum construction, primary medical care, directional training, professional thinking, and willingness to fulfill the contract, etc., but there is no research using structural equation (SEM) to study the influence of learning burnout and willingness to fulfill the contract on empathy and the mediating role of self-efficacy in RTMSs from the perspective of ethics [5].

Literature review

Empathy refers to the ability of an individual to understand and share feelings from the perspective of others [6], and is one of the basic qualities of doctors [7],which enables doctors to understand patients from the perspective of patients, feel the joy and sorrow of patients, and build a bridge of emotional connection between doctors and patients. The improvement of medical students’ empathy ability will help them improve the quality of their work in clinical work, gain the trust of patients [8], improve the satisfaction of medical services [9], and establish a good doctor-patient relationship [10]. In the future, RTMSs will serve rural residents whose education level, medical health cognition level, understanding and narrative ability of medical conditions are lower than those of urban residents [11–13]. To become a qualified medical worker, RTMSs not only need to treat the diseases of rural residents, but also need to listen to, care for, respect and understand the ailments and troubles of rural residents. To provide more intimate and targeted medical services, which are closely related to the empathy of RTMSs [14]. Therefore, researching on the empathy of RTMSs and its influencing factors will help medical colleges to train RTMSs’ empathy in a targeted manner, which is crucial to improving the quality of rural medical services.

Learning burnout refers to the phenomenon of energy exhaustion, enthusiasm exhaustion and negative attitude towards learning caused by long-term academic pressure in the learning process [15]. In China, the detection rate of learning burnout among college students is as high as 61.63% [16], and the detection rate of learning burnout among Chinese medical students is more prominent as high as 82% [17], which is caused by the complexity of medical professional knowledge and the long training cycle that make medical students face more learning and psychological pressure. At the same time, RTMSs can be employed after graduation, so there is no employment pressure. Compared with ordinary clinical medical students, they have worse learning enthusiasm and are more prone to learning burnout [18]. Studies have confirmed that learning burnout not only affects the academic performance of medical students, but also affects the physical and psychological health of medical students, such as dropping out, eating disorders, insomnia, depression and anxiety [19–22]. It may even lead to burnout in the later work of RTMSs, which in turn affects their care and understanding of patients, resulting in a decline in their empathy [15, 23]. Current studies have shown that empathy has a negative predictive and mitigating effect on learning burnout [24, 25], but there is still a gap in the research on the impact of learning burnout on empathy. Therefore, this study focused on the influence of RTMSs’ learning burnout during undergraduate study on the development of their empathy ability, because it is related to the improvement of future rural medical service quality and the construction of a good doctor-patient relationship.

The willingness to fulfill the contract refers to the subjective attitude and willingness of an individual to act in accordance with the agreement [12]. RTMSs are obligated to serve in rural hospitals for at least six years post-graduation as per their contracts. However, given that economic development, job prospects, and living standards in rural areas are significantly less favorable than in urban areas, they have become hesitant to fulfill their contractual obligations in rural areas. From 2010 to 2020, the propensity rate of RTMSs in China to fulfill the contract decreased from 90 to 65% [24]. Among the 1,673 RTMSs in three universities in Yunnan Province, only 21.43% chose to continue to work in rural areas after the six-year service period [25]. Relevant studies have shown that with the decline of RTMSs’ willingness to fulfill contracts, their empathy will also decline, and they will show strong learning burnout, resulting in their inability to truly understand patients’ needs and experiences in future work, and ultimately affecting their ability to better serve rural areas with professional medical knowledge [26–28]. From this, it can be seen that the willingness to fulfill the contract is one of the important factors that affects the learning burnout and empathy of RTMSs, so it is necessary to further analyze the relationship between RTMSs’ willingness to fulfill the contract and their learning burnout and empathy, so as to provide references for the expansion of rural medical talents and the improvement of their quality, so as to ensure that they can effectively maintain the medical health of rural residents.

Self-efficacy refers to an individual’s strong belief that he or she is capable of coping with various pressures and challenges [29]. Strong self-efficacy contributes to a more positive life, higher achievement, social skills and mental health [30–32]. When learning burnout occurs, medical students will have a negative attitude towards learning tasks, which will affect their cognition of their ability to cope with various problems and challenges, and ultimately lead to a decline in self-efficacy [33–35]. In addition, low self-efficacy among medical students can further hinder their ability to understand the feelings and needs of others, thereby reducing their empathy [36]. Therefore, it can be inferred that learning burnout is more likely to affect individual empathy through the mediating role of self-efficacy. RTMSs with a strong willingness to fulfill the contract are more inclined to actively honor their commitments and responsibilities [12]. Such proactive behavior would enhance their recognition of their own capabilities, motivating them to exert greater efforts in mastering theoretical knowledge and operational skills, and consequently, generating higher self-efficacy [37]. Simultaneously, RTMSs with high self-efficacy can better perceive the future working environment and are more disposed to devote time and energy to understanding patients’ feelings, thereby enhancing the quality of their diagnosis and treatment services and patient satisfaction, and further promoting the improvement of their empathy [38]. Therefore, we can conjecture that RTMSs willingness to fulfill the contract can affect empathy through the mediating effect of self-efficacy. Since previous studies on self-efficacy, learning burnout, willingness to fulfill the contract and empathy were limited to analyzing the correlation between the two variables, they did not pay attention to whether RTMSs self-efficacy played a mediating role between learning burnout and empathy, and between willingness to fulfill the contract and empathy. Therefore, we will study the relationship between self-efficacy, learning burnout, willingness to fulfill the contract and empathy of RTMSs and the mediating role of self-efficacy, which has positive significance for the improvement of RTMSs professional knowledge and the construction of grassroots medical and health care.

To sum up, this study aims to explore the relationship between self-efficacy, learning burnout, willingness to fulfill the contract and empathy of RTMSs, and further measure the mediating effect of self-efficacy on learning burnout and empathy, willingness to fulfill the contract and empathy, as shown in Fig. 1. On this basis, this study proposed the following hypotheses: (1) Learning burnout has a negative effect on empathy (H1); (2) Self-efficacy had a positive effect on empathy (H2); (3) Willingness to fulfill the contract has a positive effect on empathy(H3); (4) Learning burnout indirectly negatively affects empathy through the mediating role of self-efficacy (H4); (5) Willingness to fulfill the contract has an indirect positive effect on empathy through the mediating role of self-efficacy (H5); (6) Willingness to fulfill the contract has an indirect positive effect on empathy through the mediating role of learning burnout (H6).

Fig. 1.

A hypothetical conceptual model of the relationship between learning burnout, self-efficacy, willingness to fulfill the contract and empathy

Materials and methods

Participants

China’s Shandong Province began implementing the RTME program in 2017 and received the first RTMSs in 2022. In this study, samples were selected by multi-stage random sampling. (1) Firstly, according to the method of simple random sampling, 3 undergraduate medical universities in Shandong Province, which are responsible for cultivating RTMSs, were randomly selected as the sample points of this study. (2) Secondly, stratified random sampling method was used to divide the RTMSs of the three schools into three levels according to their grades, including senior (interns and trainees with clinical experience), middle (sophomores and juniors, and medical students who have learned medical theories), and lower (freshmen who have not yet been exposed to medical knowledge). The three schools have a total of 6 classes in the upper grades, 6 classes in the middle grades, and 3 classes in the lower grades. (3) Thirdly, the method of simple random sampling was used to randomly select 3 classes from each of the 6 classes in upper and middle grades, and the 3 classes in lower grades did not need to be sampled again. (4) Finally, using the method of cluster random sampling, all the students in three classes selected from each grade were taken as our research objects, and 521 rural-oriented tuition-waived medical students were randomly selected, of which 14 students were excluded according to the following exclusion criteria: (1) students who resolutely refused to participate in this survey; (2) The student who refuses to sign the performance contract; (3) Unenrolled or withdrawn students. A total of 507 students participated in the survey, and 495 valid questionnaires were collected, with an effective recovery rate of 97.63%.

After submitting an application for ethical review to the Ethics Committee of Jining Medical University, the expert group issues an ethical consent after reviewing the materials, and considers that the study does not involve medical intervention, and the data obtained from the results of the study cannot be linked to individuals, therefore, data collection can be carried out with the oral consent of the participants after they are informed of the anonymous nature of the study and the purpose of the study. This study collected questionnaire information, including the general sociological characteristics and scale of RTMSs, by means of paper questionnaires and on-site self-questionnaires. In order to ensure the quality of the research, the three universities arranged special personnel to be responsible for the issuance, recovery, verification and supervision of questionnaires.

Measures

The questionnaire designed in this study consists of five parts. The first part includes demographic characteristics survey (age, grade, gender, student origin) and academic characteristics survey (learning motivation, learning goals, contract service). The second to fifth parts are Jefferson Scale of Physician Empathy-student version (JSPE-S), Learning burnout of university student (LBUS), Willingness to fulfill the contract scale and General self-efficacy scale (GSES).

Jefferson scale of physician empathy-student version (JSPE-S)

Professor Mohammadreza Hojat developed the Jefferson Scale of Physician Empathy-student version (JSPE-S), which defines empathy in medical education and medical practice [39]. The Chinese version of Jefferson Scale of Physician Empathy-student Version (JSPE-S) was translated and revised by Tian Jiang et al., with a total of 20 items, and the overall Cronbach’s α was 0.861 [40]. The scale includes three dimensions: opinion selection (10 items), compassion (8 items), and empathy (2 items). The scale was scored using a 7-point Likert scale, ranging from 1 (completely disagree) to 7 (completely agree), with a total score ranging from 20 to 140, with the higher the score, the stronger the ability to empathize.

Learning burnout of university student (LBUS)

Learning burnout of university student (LBUS) was compiled by Rong Lian et al., with a total of 20 items, the overall Cronbach’s α was 0.865 [41], and the scale included three dimensions: Low mood (8 entries), inappropriate behavior (6 entries) and low sense of achievement (6 entries). The scale is scored using a 5-point Likert scale, which ranges from 1 (completely inconsistent) to 5 (completely consistent). The total score ranges from 20 to 100, with higher scores associated with higher levels of learning burnout.

Willingness to fulfill the contract scale

The willingness to fulfill the contract scale of RTMSs was modified by Xuewen Zhang based on the turnover intention Scale of Chinese medical personnel, and the overall Cronbach’s α was 0.699 [13]. The four items in the scale are " I want to leave the specialty of rural-oriented tuition-waived medicine and switch to other medical specialties ", "I often want to give up studying medical major"," In the future, I will leave the orientated rural hospital during the term of my contract ", and " In the future, I will leave the medical industry during the term of my contract". The scale was scored using a six-point Likert scale, ranging from 1(strongly agree) to 6(strongly disagree). The total score ranges from 4 to 24 points. The higher the score, the stronger the tendency to comply.

General self-efficacy scale (GSES)

General self-efficacy scale (GSES) compiled by Wang Caikang et al., Ralf Schwarzer et al., is often used to measure an individual’s self-efficacy level. The overall Cronbach’s α of this scale is 0.87, with only one dimension and 10 items [42]. A 4-point Likert scale was used to score on a 10–40 scale ranging from 1 (completely incorrect) to 4 (completely correct), with higher scores associated with greater overall self-efficacy.

Data analysis and conceptual model

The structural equation model (SEM) was chosen as the core research method in order to determine the correlation mode and exact mechanism of RTMSs learning burnout, willingness to fulfill the contract, self-efficacy and empathy. Structural equation model (SEM) is a multivariate statistical method to verify and analyze complex path relationships among multiple variables through mathematical models [43]. In this study, the conceptual model proposed (see Fig. 1) covers four latent variables: learning burnout, willingness to fulfill the contract, self-efficacy, and empathy. Each latent variable is operated on by at least two different observed variables as the minimum condition for model identification [44]. The analysis process is as follows: (1) Exploratory factor analysis (EFA) is used to conduct statistical analysis of variables to test the reliability and validity of the whole questionnaire; (2) Descriptive statistical analysis was used to describe and analyze the demographic and academic characteristics of 495 RTMSs; (3) The learning burnout, willingness to fulfill the contract, self-efficacy and empathy of RTMSs were quantitatively analyzed, and the results were expressed as mean and standard deviation (SD); (4) Pearson’s correlation coefficients was used to measure the paired correlation between latent variables, and the correlation coefficient was used to present the results; (5) On this basis, structural equation model (SEM) was used to further explore the relationship among learning burnout, willingness to fulfill the contract, self-efficacy and empathy, and confirmatory factor analysis (CFA) was conducted;(6) For the SEM model, the following fitting indexes are reported in this study: χ²/df, goodness-of-fit index (GFI), incremental fit index(IFI), comparative fit index (CFI), normed fit index (NFI), tucker–lewis index (TLI), and Approximate root mean square error of approximation (RMSEA) [42]. The indicators of good model fitting are χ²/df < 3, GFI > 0.90, CFI > 0.90, IFI > 0.90, NFI > 0.90, TLI > 0.90, and RMSEA < 0.08 [45, 46]. In this study, SPSS 25.0 version was used for descriptive statistics, AMOS 24.0 version was used to construct the hypothesis model, and maximum likelihood method was used to estimate the hypothesis model.

Reliability and validity

The results of exploratory factor analysis (EFA) showed that the KMO value of the questionnaire was 0.865, which was greater than 0.60, indicating that the possibility of data factor analysis was good. Bartlett’s sphericity test showed statistically significant difference (χ² = 4785.896, P < 0.001), and this dimension was suitable for validity test. Factors were extracted by principal component analysis, among which four components were the main components (initial eigenvalue > 1), and the cumulative variance contribution rate reached 63.115% (cumulative variance contribution rate > 60%), indicating that the questionnaire effect was acceptable and could fully reflect the original data. The load matrix obtained by the orthogonal rotation analysis of each factor load by the maximum coefficient of variation method shows that the factor composition is consistent with the hypothesis of the proposed model and has good structural validity. The most common reliability measurement method, the α reliability coefficient, that is, the internal consistency coefficient, was used to measure the reliability of the scales covered by the study, and the results were as follows: the Cronbach’s α values of Learning burnout of university student (LBUS),Willingness to fulfill the contract scale, General self-efficacy scale (GSES) and Jefferson Scale of Physician Empathy-student version (JSPE-S) were up to 0.756, 0.723, 0.786 and 0.913, respectively, indicating good reliability.

Common methods bias risk assessment

Compared with randomized controlled trials, cross-sectional studies are more susceptible to the risk of bias, and Harman single factor test was used in this study to test for common method bias. The results showed that there were 12 factors with eigenroots greater than 1, and the interpretation rate of the first factor was 18.45%, which was far below the critical standard of 40% [47], indicating that there was no serious common method bias problem in this study.

Results

General demographic and academic characteristics

Table 1 shows the general demographic and academic characteristics of 495 RTMSs surveyed. The age of RTMSs surveyed ranged from 18 to 26 years old, with an average age of (21.18 ± 1.082). The proportion of rural students (56.57%) is higher than that of urban students (43.43%), and only children account for 34.55%. Among them, 21.41% of the surveyed students reached the admission score of general undergraduate students in clinical medicine (non-funded); As for the reasons why the surveyed students choose to become RTMSs, 37.98% of the surveyed students are because of the guarantee of future employment, 31.11% of them are because they love medicine; 81.62% of the surveyed students want to take the postgraduate examination after graduation; 67.88% of the surveyed students believe that salary is the main factor affecting their future work intentions.

Table 1.

General characteristic of respondents

General characteristics	N	%
Sex
Male	226	45.66
Female	269	54.34
Student origin
Rural	280	56.57
Urban	215	43.43
Grade
Senior	189	38.18
Middle	194	39.19
Junior	112	22.63
Only child of parents
Yes	171	34.55
No	324	65.45
Reached the clinical medical college entrance examination score line
Yes	106	21.41
No	389	78.59
Reasons for applying for RTMSs
Love medicine	154	31.11
Love primary health care	23	4.65
Reduce the burden on the family	32	6.46
Future employment is guaranteed	188	37.98
Involuntary choice	67	13.54
Optional	31	6.26
Postgraduate entrance examination intention
Yes	404	81.62
No	91	18.38
Factors influencing future work willingness
Salary and treatment	336	67.88
Promotion space	24	4.85
Work content and atmosphere	71	14.34
Working environment condition	52	10.51
Other factors	12	2.42

Descriptive analysis of study variables

The total scores of learning burnout, willingness to fulfill the contract, self-efficacy and empathy were 55.27 ± 11.53, 18.41 ± 4.13, 26.35 ± 6.02, 111.54 ± 15.38, respectively. The detailed sub-dimension statistics of each indicator are shown in Table 2. Using the interquartile range method, the JSPE-S scale total score range of (0 ~ P25) is classified as the low group, (P25 ~ P75) as the medium group, and (P75 ~ P100) as the high group. In terms of scores, 118 (23.8%) RTMSs had low levels of empathy, 241 (48.7%) RTMSs had moderate levels, and 136 (27.5%) RTMSs had high levels of empathy.

Table 2.

Item scores of empathy, learning burnout, willingness to fulfill the contract and self-efficacy

Items	Mean ± SD
Willingness to fulfill the contract	18.41 ± 4.13
Learning burnout of university student (LBUS)	55.27 ± 11.53
Depressed mood factor	22.43 ± 5.82
Misbehavior factor	16.84 ± 4.28
Low achievement factor	16.00 ± 3.70
General self-efficacy scale (GSES)	26.35 ± 6.02
Jefferson Scale of Physician Empathy-student version (JSPE-S)	111.54 ± 15.38
Perspective selection factor	56.21 ± 8.01
Compassionate care factor	43.66 ± 6.63
Perspective-taking factor	11.67 ± 2.12

Correlations of study variables

In Table 3, Pearson’s correlation coefficients of 4 variables to be observed in RTMSs are presented. There was a significant positive correlation between willingness to fulfill the contract and self-efficacy and empathy, a significant negative correlation between learning burnout and empathy and self-efficacy, and a significant negative correlation between willingness to fulfill the contract and learning burnout.

Table 3.

Correlation coefficients of study variables

Items	Willingness to fulfill the contract	Learning burnout	Self-efficacy
Willingness to fulfill the contract
Learning burnout	−0.16a
Self-efficacy	0.13a	−0.33a
Empathy	0.26a	−0.21a	0.28a

^aAt level 0.01 (two-tailed), the correlation was significant

Testing of the constructed study model

In this study, a structural equation model (SEM) was established to connect, measure and evaluate the relationship between four variables (learning burnout, willingness to fulfill the contract, self-efficacy and empathy). The generalized least square method is used to fit the data into the theoretical model previously constructed, and the model is modified and improved according to the final fitting index. Finally, Fig. 2 shows the relationship between the path validity of the four variables used to construct the model. The results of confirmatory factor analysis (CFA) showed that χ²/df value was 2.52 (< 3.00), RMSEA is 0.06 (< 0.08), GFI was 0.93(> 0.90), CFI was 0.95 (> 0.90), IFI was 0.95 (> 0.90), TLI was 0.94 (> 0.90), NFI was 0.92 (> 0.90), and all the above results fit well. In summary, the model of learning burnout, willingness to fulfill the contract, self-efficacy and empathy of RTMSs fit well. Figure 2 and Table 4 show the mediating analysis path and effect values. Willingness to fulfill the contract had a direct positive impact on self-efficacy (β = 0.11, P < 0.05), willingness to fulfill the contract had a significant direct negative impact on learning burnout (β = −0.25, P < 0.001), and learning burnout had a significant direct negative impact on self-efficacy (β = −0.34, P < 0.001). Self-efficacy had a significant direct positive effect on empathy (β = 0.22, P < 0.001), willingness to fulfill the contract had a significant direct positive effect on empathy (β = 0.27, P < 0.001), and learning burnout had no direct effect on empathy (β = −0.09, P = 0.109). Table 5 presents the quantification results of three mediation paths between the four variables. In the mediating path between willingness to fulfill the contract and empathy, self-efficacy has a significant mediating effect (95% CI: 0.02–0.41), self-efficacy also had a significant mediating effect between learning burnout and empathy [95%CI:−0.41- (−0.11)], and learning burnout had no mediating effect between willingness to fulfill the contract and empathy (95%CI:−0.02–0.42).

Fig. 2.

Final model and standardized model path

Table 4.

Significance test of mediation test

Model pathways	Estimated	95%CI
Total effects
Self-efficacy←Willingness to fulfill the contract	0.20	0.10—0.31
Learning burnout←Willingness to fulfill the contract	−0.25	(−0.39)—(−0.13)
Self-efficacy←Learning burnout	−0.34	(−0.46)—(−0.20)
Empathy←Self-efficacy	0.22	0.10—0.35
Empathy←Learning burnout	−0.16	(−0.27)—(−0.05)
Empathy←Willingness to fulfill the contract	0.34	0.23—0.46
Direct effects
Self-efficacy←Willingness to fulfill the contract	0.11	0.01—0.23
Learning burnout←Willingness to fulfill the contract	−0.25	(−0.39)—(−0.13)
Self-efficacy←Learning burnout	−0.34	(−0.46)—(−0.20)
Empathy←Self-efficacy	0.22	0.10—0.35
Empathy←Learning burnout	−0.09	(−0.21)—0.32
Empathy←Willingness to fulfill the contract	0.27	0.16—0.40
Indirect effects
Self-efficacy←Willingness to fulfill the contract	0.08	0.04—0.17
Empathy←Learning burnout	−0.08	(−0.14)—(−0.04)
Empathy←Willingness to fulfill the contract	0.07	0.03—0.11

Table 5.

Significance test of each intermediary pathway

Model pathways	95% CI
Empathy←Self-efficacy←Willingness to fulfill the contract	0.02—0.41
Empathy←Learning burnout←Willingness to fulfill the contract	(−0.02)—0.42
Empathy←Self-efficacy←Learning burnout	(−0.41)—(−0.11)

Discussion

The medical and health service in rural areas is not only concerns the physical health of rural residents, but also affects the stability and development of the entire country and society. The original intention of the RTME program is to solve the problem of uneven development of medical and health care in urban and rural areas of China, and to provide high-quality medical talents for rural areas in China. The patient-centered biopsychosocial medical model requires not only the cultivation of medical knowledge and skills among medical students, but also the cultivation of their medical humanities literacy in medical education. Empathy is one of the most important psychological characteristics that medical personnel should possess, and having high empathy helps to generate high-quality medical behavior, build harmonious doctor-patient relationships, reduce doctor-patient disputes, and thus create a good medical environment [48]. It can be seen that the empathy of RTMSs will affect the quality of their service to rural medical work in the future. However, the total empathy score of 495 RTMSs in this study was 111.54 ± 15.38 points, which is similar or even lower than the empathy of non-funded undergraduate clinical medicine students at home and abroad [49–52]. For example, Wei Liu measured that the total empathy score of clinical medical students during their probationary period at Peking University People’s Hospital was 115.6 ± 1.40 points [53], the empathy score of 6009 clinical medical students in the American College of Osteopathic medicine was 116.54 ± 10.85 [39], and the empathy score of 281 medical students in Australia (112.3 ± 9.60) [54], all of which were higher than those of Chinese RTMSs.

In this study, the main focus was on investigating the impact of learning burnout, willingness to fulfill the contract, and self-efficacy on empathy among RTMSs, and measuring the mediating effect of self-efficacy between learning burnout and empathy, as well as between willingness to fulfill the contract and empathy. The results of the structural equation modeling (SEM) study are as follows: (1) Self-efficacy is positively correlated with empathy (H2); (2) Willingness to fulfill the contract is positively correlated with empathy (H3); (3) Learning burnout indirectly negatively affects empathy through the mediating effect of self-efficacy (H4); (4) Willingness to fulfill the contract indirectly and positively influences empathy through the mediating effect of self-efficacy (H5). However, we found that learning burnout has no direct impact on empathy (H1), and there is no significant mediating effect of learning burnout between willingness to fulfill the contract and empathy (H6).

The results of this study confirm H2, indicating a positive correlation between stronger self-efficacy and higher empathy. Students with high self-efficacy tend to be more positive, optimistic, and confident [55], and are better at observing and understanding others’ emotions, establishing good emotional bonds with others. This positive psychological state and good communication skills help improve students’ empathy, which is consistent with the research results of Yanzhen Zhang et al. on ordinary clinical medical students [38]. Self-efficacy influences the behavioral decisions and emotional journeys of RTMSs [56]. A higher sense of self-efficacy in these students fosters a more proactive approach to learning professional knowledge and skills, sustains their motivation, and boosts their confidence in future interactions with rural patients, enabling them to consider issues more objectively from the patients’ viewpoint [57].

The willingness to fulfill the contract refers to whether RTMSs are willing to go to rural areas to engage in medical work after state-funded training [58], which not only reflects personal integrity, but also relates to the reasonable allocation of medical resources in urban and rural China and the stable development of medical undertakings. The results of this study confirm H3, which means that the stronger the willingness of RTMSs to serve in rural medical and health institutions according to contract provisions after graduation, the higher their empathy. Xuewen Zhang’s research shows that the occupational identity and professional identity of RTMSs are positively correlated with their willingness to fulfill the contract [12, 58, 59], that is, RTMSs with strong willingness to fulfill the contract have clearer cognition and identification of their own profession and expertise. A higher sense of occupational identity and professional identity will encourage them to actively engage in rural medical and health work in the future, and be more proactive in paying attention to patients’ feelings, thereby improving their empathy [60]. For RTMSs, the willingness to fulfill the contract is not only their inner inclination towards future rural medical and health work, but also a behavioral inclination [61]. Therefore, the weak willingness of RTMSs to fulfill contracts may lead to negative emotions in their future work. The accumulation of such negative emotions will erode their ability to empathize with patients, thereby affecting the harmony of doctor-patient relationships, the improvement of medical quality, the stability of rural medical teams, and even the success or failure of RTME program.

The results of this study confirm that H4, learning burnout, indirectly and negatively affects empathy through the mediating effect of self-efficacy. Previous studies have shown a significant negative correlation between learning burnout and self-efficacy, and a significant positive correlation between self-efficacy and empathy. These results provide data and theoretical support for the establishment of H4 [38, 62]. The total score of RTMSs in this study was (55.27 ± 11.53), and the degree of learning burnout was significantly higher than that of ordinary clinical medical students (51.78 ± 11.01) [63]. RTMSs have already signed a contract for future employment in rural areas before entering school, and will not face the pressure of finding a job after graduation, which has caused the vast majority of RTMSs to lose interest and motivation in learning, that is, learning burnout. In the case of high levels of learning burnout, RTMSs are prone to negative, anxious, depressed, and easily irritable emotions, which not only affect the development of their mental health quality, but also make them doubt and negate the completion of their studies, resulting in a decrease in self-efficacy [64–66]. This makes them unable to actively face the difficulties and needs of patients in their work, that is, their empathy to perceive the pain of patients is frustrated [34].

The results of this study confirm H5, indicating that the willingness to fulfill the contract of RTMSs indirectly and positively affects empathy through the mediating effect of self-efficacy. Studies have shown that healthcare workers have developed a desire to resign or even engage in resignation behavior towards their current medical positions, which can lead to a decrease in their self-efficacy [67, 68]. The willingness to fulfill the contract of RTMSs reflects their identification with their medical studies and future medical careers. The stronger their willingness to fulfill the contract, the stronger their confidence in their ability to be competent for the job. Such positive psychological feeling prompts them to have a stronger sense of self-efficacy, which in turn prompts them to feel the emotions of patients more actively, solve the difficulties of patients in time, and establish a harmonious doctor-patient relationship with higher empathy [69]. Therefore, schools can enhance RTMSs willingness to work in rural areas in the future through professional education to improve their sense of self-efficacy, and further enhance their empathy, so as to better protect the health of rural villagers and contribute to the construction of rural medical and health undertakings.

In the structural equation model assumed in this study, we found that learning burnout has no direct impact on empathy, nor does it play a mediating role between willingness to fulfill the contract and empathy. This result cannot confirm H1 and H6. Regarding the relationship between empathy and learning burnout, Wenzhi Wu’s research has shown that empathy can affect learning burnout, but there is currently no research on the impact of learning burnout on empathy [45]. There may be other mediating variables such as stress, emotional intelligence, self-esteem, and occupational burnout that may affect the empathy of RTMSs in mediating the relationship between learning burnout and willingness to fulfill the contract and empathy [6, 70–72]. This may be a topic that we need to continue researching in the future.

Suggestions

Enhancing RTMSs’ willingness to fulfill the contract, reducing their learning burnout level and paying attention to the mediating role of their self-efficacy are effective ways to improve their empathy and thus enhance their rural primary health service ability. Accordingly, we propose the following countermeasures:

Cultivate the professional identity and occupational identity among RTMSs

A high level of professional identity and occupational identity can help RTMSs actively participate in the future rural medical and health work, so as to more actively understand and pay attention to the emotions, feelings and needs of patients, and thus have a high ability of empathy. Therefore, first of all, schools should not only develop targeted training plans for RTMSs to equip them with solid professional knowledge and practical skills, but also vigorously carry out extra-curricular activities, flipped classroom, social practice, etc., to enhance the interest of teaching process and students’ confidence and interest in professional learning, so as to enhance students’ professional identity. Secondly, schools should actively carry out medical humanities education courses, vocational identity education and rural primary medical practice activities to help RTMSs to have a deeper understanding of the characteristics and requirements of future careers, cultivate their enthusiasm for rural medical and health services, enhance their love for future careers, and improve their occupational identity.

Optimize teaching modes and methods

Schools and teachers play a very important role in developing empathy in RTMSs. While imparting knowledge, schools and teachers should pay attention to cultivating the empathic ability of RTMSs and encourage them to study medical ethics, doctor-patient communication, medical psychology and other courses in depth. By diversifying classroom teaching methods, such as group counseling, presentations, and role-playing, we can make learning more engaging, boost students’ interest in their courses, and enhance their motivation to learn, all while nurturing their empathy skills.

Strengthen the professional ethics education of RTMSs

RTMSs are the backbone of future rural medical work, and their professional ethics directly affect the quality of rural medical services in China, patient safety and rights, as well as social harmony and stability. Medical universities can strengthen the professional ethics education of RTMSs by setting up professional ethics courses, conducting case analysis and discussion in class, regularly carrying out lectures related to medical ethics, and encouraging students to actively participate in clinical practice activities, so as to further stimulate their enthusiasm in learning professional ethics.

Actively improving the self-efficacy level of RTMSs

Schools and teachers should encourage RTMSs to actively participate in various activities on campus, explore their interests and hobbies, and guide them to actively obtain various qualification certificates, so as to fully tap their potential and enhance their self-efficacy level. In addition, schools should also pay attention to the mental health of RTMSs, regularly conduct psychological assessments, and provide targeted psychological counseling for students with anxiety, depression, and other psychological problems based on the assessment results, helping them eliminate the influence of negative emotions and avoid a decrease in self-efficacy caused by the emergence of negative emotions.

Improve relevant incentive policies

During the development of the rural-oriented tuition-waived medical education (RTME) program, the National Health Commission of China issued a series of policies to encourage the application of RTMSs, such as waiving tuition and fees during school, granting living allowances, and having careers during work. However, after graduation, they will fall into a real conflict between fulfilling their contracts to work in the countryside or continuing their studies or bearing the consequences of breach of contract, which makes it a real problem whether they can retain RTMSs. At present, there are still shortcomings in China’s relevant incentive policies, mainly reflected in the restrictions on the ability improvement of RTMSs in the rural service process, low salary and benefits at the grassroots level in rural areas, and personal family factors [73]. Therefore, the country should optimize the promotion evaluation system, set up special funds to support graduates from financially disadvantaged areas, and provide resettlement allowances. At the same time, local governments should implement regulatory systems to ensure the implementation of relevant incentive policies, and truly solve the worries of employment placement, economic security, and contract renewal of RTMSs [74, 75].

In conclusion, we should take a more comprehensive view of how to improve the empathy of RTMSs. We should not only focus on enhancing their professional identity, occupational identity and self-efficacy, but also innovate teaching methods to integrate empathy cultivation with the curriculum. In addition, the improvement of the empathy ability of RTMSs is also inseparable from the policy support of the government department, and various incentive systems are used to encourage RTMSs to actively perform the agreement, laying a solid foundation for a good doctor-patient relationship.

Limitations and future directions

Although this study offers certain contributions and insights, it also has limitations. Firstly, this is a cross-sectional study, lacking in temporality and directionality, thus preventing the establishment of causal relationships. Future research should conduct longitudinal studies to validate our findings. Secondly, this study was limited to three medical universities in Shandong Province, which may have compromised the sample’s representativeness and led to biases, thereby limiting the conclusions. Therefore, these findings require further validation in multiple regions through prospective studies. Additionally, this study focused only on the self-efficacy and learning burnout of RTMSs as mediating variables in the relationship between their willingness to fulfill the contract and their empathy. Future research may explore additional mediating variables that could influence this relationship.

Abbreviations

RTMSs

Rural-oriented tuition-waived medical students

RTME

Rural-oriented tuition-waived medical education

GSES

General self-efficacy scale

LBUS

Learning burnout of university student

JSPE-S

Jefferson Scale of Physician Empathy-student version

SEM

Structural equation model

EFA

Exploratory factor analysis

SD

Standard deviation

CFA

Confirmatory factor analysis

GFI

Goodness-of-fit index

CFI

Comparative fit index

NFI

Normed fit index

TLI

Tucker–lewis index

RMSEA

Approximate root mean square error of approximation

Cronbach’s α

Cronbach’s Alpha coefficient

Authors' contributions

X.Z. conceptualized the idea. X.Z., G.H., C.F., Y.X., L.G. and Z.T. conducted data collection. G.H. and C.F. analyzed the data and wrote the first draft of the manuscript. X.Z. finalized and reviewed the final draft. All the authors read and approved the final manuscript.

Funding

This study was financially supported by the Shandong Province Education Science Planning Project Construction of Curriculum System based on Rural-oriented Tuition-waived Medical Students’ General Practice Post Competency Training (no.2020YB049) and Shandong Education Development Promotion Association’s "Construction and Empirical Research on the Evaluation System of General Medical Ability of Rural-oriented Tuition-waived Medical Students based on Trusted Professional Behaviors (EPAs)" (no. JCHKT2023362).

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Studies involving human subjects were reviewed and approved by the Medical Ethics Committee of Jining Medical University. The committee’s experts believed that the survey was anonymous, did not involve personal privacy and interventional therapy, so it can be conducted with verbal consent. Informed consent was obtained from all participants before any data was collected.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.