Consequences of compassion fatigue in palliative care nurses: the experience of meaninglessness and emptiness in life

Abstract

Background

Compassion fatigue, defined as the emotional and physical exhaustion resulting from prolonged exposure to patients’ suffering, coupled with a diminished ability to empathize, is a significant occupational hazard in palliative care nursing, with potential adverse effects on nurses, healthcare organizations, and patient care quality. Despite its impact, the nuanced consequences of compassion fatigue from the perspective of palliative care nurses remain underexplored.

Aim

Due to this issue, this study sought to explore and elucidate the perceived consequences of compassion fatigue among nurses providing palliative/end-of-life care in Iran.

Methods

A qualitative study employing conventional content analysis was conducted. Seventeen Iranian palliative care nurses were recruited via purposive sampling. Data were collected through semi-structured interviews and analysed to identify emergent themes. Ethical approval was obtained from the Ethics Committee of Tarbiat Modares University, and written informed consent was secured from all participants.

Results

Four subcategories emerged as key consequences of compassion fatigue: (1)reluctance to remain in the ward or continue nursing, (2)forgetfulness in care delivery, (3)emotional incapacity to manage personal and professional responsibilities, and(4)a pervasive sense of meaninglessness and hopelessness toward life. The overarching theme highlighted a profound existential impact, characterized by diminished motivation and hope, affecting both professional engagement and personal well-being.

Conclusion

In conclusion, early identification and management of compassion fatigue consequences are critical for nurse managers to enhance resilience, address emotional needs, and reduce turnover intentions.

Introduction

Compassion forms the foundational basis for enhancing interpersonal interaction between nurses and patients, and compassionate care is widely recognized as a core attribute of professional nursing. Nurses are expected to alleviate patient suffering through empathetic, patient-centered approaches [1]. Palliative care is a holistic approach aimed at improving the quality of life for patients with life-limiting illnesses and their families by preventing and relieving suffering through the management of physical, emotional, and spiritual needs [2]. Compassion1, a fundamental nursing virtue, is defined as an empathetic understanding of another’s suffering combined with a motivated desire to act to alleviate it [3], . Compassion fatigue 2, first introduced as a unique form of occupational burnout, is characterized by emotional and physical exhaustion, reduced ability to empathize, and a sense of hopelessness resulting from prolonged exposure to patient suffering [4].

However, the demanding nature of nursing work coupled with the constant expectation to provide empathy and compassion can lead to emotional exhaustion and, ultimately, compassion fatigue. The concept of compassion fatigue was first introduced as a unique form of occupational burnout experienced by healthcare professionals engaged in caregiving, resulting from continuous and intense contact with patients under significant stress, enduring substantial pain and suffering. It is also recognized as a consequence of the stress associated with helping individuals who have undergone traumatic experiences, particularly those suffering or injured [5].

Compassion fatigue has numerous negative individual and organizational consequences for both nurses and patients. Internationally, studies have reported decreased well-being, increased intent to leave the profession, occupational burnout, indifference, moral distress, and physical and emotional breakdowns [6–9]. Beyond psychological and physiological effects, it may negatively influence job performance, resulting in decreased quality of care, reduced patient satisfaction, increased clinical errors, higher staff turnover rates, and increased absenteeism. These outcomes impact hospital units and healthcare systems, contributing to a growing intent among nurses to leave the profession [10]. Given that palliative care nurses constantly witness patient suffering and death and are regularly surrounded by critically ill or dying patients, they are particularly vulnerable to compassion fatigue due to their repeated, empathetic responses to others’ distress, making it an inherent occupational risk in palliative care practice likely to produce significant consequences [11, 12].

Studies in other countries have reported consequences such as decreased well-being, increased intent to leave the profession, occupational burnout, indifference, moral distress, and physical and emotional breakdowns [13]. Challenges related to job performance, as well as impacts on family life and personal relationships, have been documented in prior studies. However, these investigations were conducted in cultural and social contexts distinct from Iran’s, where unique factors such as underdeveloped healthcare infrastructure and limited specialized roles shape nurses’ experiences, necessitating context-specific research [14, 15].

In Iran, unlike many high-income countries, there are no undergraduate or postgraduate programs dedicated to palliative care nursing. Consequently, palliative and end-of-life care is delivered by general nurses or oncology-trained nurses who acquire palliative competencies through clinical experience, short courses, and on-the-job learning [16]. In Iran, local research has begun to explore these dynamics; for example, Sabery et al. conducted a concept analysis of compassion fatigue among Iranian clinical nurses, revealing cultural influences like religious resilience as protective factors [16]. Ahmadi et al. examined the association between compassion fatigue and moral injury among Iranian nurses, highlighting how emotional exhaustion and ethical suffering are intertwined within clinical settings [17]. Similarly, Zare-Kaseb et al. (2025) explored the relationships among moral distress, ethical climate, and compassion fatigue in oncology nurses, revealing that moral distress serves as a key mediating factor linking the ethical environment to emotional fatigue [18]. Earlier, Ariapooran investigated the roles of compassion fatigue and burnout, demonstrating that perceived social support acts as a significant protective factor against emotional exhaustion and secondary traumatic stress [19]. These studies highlight the need to address compassion fatigue within Iran’s unique healthcare context, where underdeveloped palliative care infrastructure and limited specialized roles shape nurses’ experiences. Since compassion fatigue contributes to global nursing shortages and is prevalent worldwide, addressing its consequences and developing preventive and mitigating strategies is crucial for retaining palliative care nurses in this specific setting [20].

Moreover, palliative care delivery systems in Iran are underdeveloped, with poorly defined specialized nursing roles, contrasting with more established systems elsewhere. Since compassion fatigue contributes to global nursing shortages and is prevalent worldwide, addressing its consequences—alongside developing preventive and mitigating strategies—is crucial for retaining palliative care nurses in Iran’s unique sociocultural setting [21].

Despite the growing body of research on compassion fatigue, significant gaps persist, particularly in Iran’s unique context. International studies, conducted in well-developed palliative care systems, have limited applicability due to Iran’s underdeveloped infrastructure and lack of specialized nursing roles [6–9], while Iranian research has focused mainly on general nursing populations, neglecting the qualitative exploration of existential impacts such as meaninglessness and hopelessness among palliative care nurses [16–18]. The nuanced effects on personal well-being and professional retention within Iran’s sociocultural framework also remain underexplored, necessitating this study to qualitatively investigate these consequences, offering insights into nurses’ lived experiences and informing targeted interventions to enhance resilience and reduce turnover. Given the global prevalence of compassion fatigue, which exacerbates nursing shortages and care quality issues in high-stress specialties like palliative care, and considering Iran’s underdeveloped system and lack of specialized support—despite a sociocultural emphasis on caregiving as a divine dutythis research addresses these gaps by exploring nurses’ perceptions, providing culturally contextual insights to develop tailored retention strategies.

Methods

This study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ), a 32-item checklist developed by Tong et al. (2007) to ensure comprehensive and transparent reporting of qualitative studies involving interviews and focus groups [22]. The COREQ checklist is structured into three domains: (1) Research Team and Reflexivity, (2) Study Design, and (3) Analysis and Findings. Each domain includes specific items to guide the reporting process, ensuring methodological rigor and clarity. Below, the study’s methodology is detailed according to these domains to address the identified incompleteness.

1. Research Team and Reflexivity

   • Interviewer and Credentials: The primary interviewer, RG, holds a Ph.D. in Nursing with extensive training in qualitative research and semi-structured interviewing. Co-researchers ZV, EM, and AK, all Ph.D. holders in nursing and biostatistics, contributed to a multidisciplinary team.
   • Occupation and Relationship with Participants: RG and ZV, nursing academics, had no prior relationship with participants, ensuring objectivity. AK, from the Department of Biostatistics, supported data organization without clinical involvement. The team’s academic roles were disclosed to build trust.
   • Researcher Characteristics and Bias: The team included diverse genders (RG and ZV female, EM and AK male) and expertise, with cultural sensitivity to Iran’s spiritual context emphasized. A reflexive journal was maintained to record biases (e.g., preconceptions about compassion fatigue), which were addressed through iterative team discussions.
   • Theoretical Position: The study adopted an inductive stance, aligning with conventional content analysis to let themes emerge from participant narratives without imposing pre-existing frameworks.

Study design

This study employed a qualitative approach using conventional (inductive) content analysis to explore compassion fatigue consequences among Iranian palliative care nurses, guided by the phenomenological framework as its theoretical-philosophical foundation, alongside methodological guidance from Elo and Kyngäs and Graneheim and Lundman [23, 24]. Rooted in Edmund Husserl’s philosophy, phenomenology focuses on understanding the lived experiences and subjective meanings of individuals, making it an apt foundation for capturing the existential and emotional impacts of compassion fatigue as perceived by participants. The research question “What are the perceived consequences of compassion fatigue among palliative care nurses in Iran?”—was addressed through semi-structured interviews capturing participants’ lived experiences. The choice of this method was driven by the limited empirical evidence on compassion fatigue’s specific impacts in nursing, especially palliative care, where theoretical frameworks are underdeveloped and fail to reflect nurses’ realities.

Conventional content analysis differs from directed (deductive) content analysis in its approach. It begins with an open-ended data exploration, deriving coding categories directly from texts like interview transcripts through immersion, meaningful unit identification, and iterative theme emergence. For example, “forgetfulness in care delivery” emerged from a 55-year-old nurse’s statement, “I forget to document vital signs,” without prior hypotheses, offering a fresh perspective. This is ideal for generating new theory in underexplored areas.

In contrast, directed (deductive) content analysis uses pre-existing theoretical frameworks or categories to validate or extend known constructs, applying a structured coding scheme. This method, as outlined by Kibiswa et al. [25], involves four key steps: (1) Preparation, where researchers immerse in the data while identifying relevant theoretical codes from literature; objective: to establish a deductive lens for analysis; rationale: ensures alignment with existing theory while allowing data to refine it; examples: in a study on nursing burnout, Maslach’s model codes were pre-applied to categorize exhaustion data [26–28], contrasting inductive’s open immersion by imposing structure from the outset; (2) Coding, assigning data to predetermined categories or creating new ones if gaps arise; objective: to test theory against data; rationale: validates hypotheses efficiently; examples: Wankhade et al. (2022) coded patient satisfaction transcripts using Leininger’s cultural care theory categories, with 2 subcodes emerging for gaps, unlike inductive’s emergent categories [29]; (3) Analysis, comparing data to theory for confirmation or revision; objective: to extend or refute constructs; rationale: promotes theoretical advancement; examples: Potter and Brooks et al. analyzed media effects data against agenda-setting theory, revising 3 categories based on mismatches, differing from inductive’s bottom-up theme building [30]; (4) Interpretation, integrating findings with theory for implications; objective: to generate practical insights; rationale: bridges theory and practice; examples: Khademi et al. interpreted health promotion data using PRECEDE-PROCEED model, yielding 2 new implications, in contrast to inductive’s theory-free interpretation [31]. This method suits confirmatory studies in well-developed fields.

The inductive approach’s data-driven, flexible nature was chosen over the theory-driven, structured deductive method, enabling discovery of culturally nuanced themes. This aligns with the study’s exploratory goal, supported by Lim (2024), who endorses qualitative methods for areas lacking robust data or theories [32]. Given the scarcity of nursing-specific research and Iran’s unique sociocultural context—with limited palliative infrastructure and strong spiritual values—this method provided a deep understanding of existential and professional impacts. By prioritizing participant narratives, the study filled knowledge gaps, laying a foundation for future research and tailored interventions.

Study setting characteristics

The study was conducted within the Iranian healthcare system, which is predominantly public and hospital-based, with palliative care services largely integrated into oncology wards rather than standalone units, reflecting the underdeveloped infrastructure for specialized end-of-life care. The primary nursing system follows a functional method, where nurses are assigned specific tasks (e.g., medication administration, vital signs monitoring) rather than primary nursing models, leading to fragmented patient care and increased emotional strain due to high turnover and workload [33]. Nurses typically work 44 h per week, often in rotating 8- or 12-hour shifts, with overtime common in understaffed wards. During the time of this study (2023), entry-level palliative care nurses (or general/oncology nurses delivering palliative services) in Iran earn a monthly salary ranging from 100 to 150 million Iranian Rials (approximately $110–$150 USD) [34], supplemented by modest performance-based rewards such as bonuses or extra leave, though these are insufficient to offset the emotional demands. The nurse-to-patient ratio in the participating hospital wards was calculated on a per-shift basis, as per Iranian Ministry of Health and Medical Education (MOHME) guidelines for oncology and intensive care units where palliative care is integrated. Specifically, it represents the average number of patients assigned to each nurse during an 8-hour shift (day, evening, or night), aggregated over a 24-hour period to account for shift overlaps and staffing variations. For example, in a typical oncology ward, a day-shift ratio of 1:8 (one nurse per eight patients) might increase to 1:10 during night shifts due to reduced staffing; the 24-hour average is then derived as the total patient census divided by the cumulative nurse-hours across all shifts (e.g., for 40 patients over 24 h with 15 nurse-shifts, yielding ~ 1:10.7). this rate is higher than in developed countries (1:4–6), exacerbating fatigue and limiting individualized care [33, 35, 36].

To ensure transparency in the estimation of the nurse-to-patient ratio, the calculation was performed using a standardized approach based on the total number of patients and the total number of available nursing staff during the study period. The nurse-to-patient ratio was calculated using the following formula:

In this study, a total of 214 patients were cared for by 20 nurses during the observed shifts. Therefore, the ratio was calculated as follows:

This result indicates that, on average, each nurse was responsible for approximately 10.7 patients, which is expressed as a nurse-to-patient ratio of 1:10.7. This method of calculating nurse-to-patient ratios is consistent with previous studies that have evaluated staffing levels based on aggregate patient load and available nursing workforce across shifts [37, 38]. These approaches are widely used in healthcare workforce research to assess workload and its association with patient outcomes.

Palliative wards in Iran emphasize family involvement and spiritual support, influenced by cultural values, but face challenges like limited beds (often < 50 per major hospital) and reliance on general oncology staff without specialized training, contributing to the high vulnerability to compassion fatigue observed in participants [11]. These characteristics shaped the nurses’ experiences, influencing themes like emotional incapacity and meaninglessness.

Participants selection

Participants were selected using purposive sampling, a strategy recommended by Tong et al. (2007) for qualitative research to ensure the inclusion of individuals with rich, relevant experiences [22]. The study included 17 Iranian palliative care nurses (In Iran, palliative services are typically provided by registered nurses from general or oncology backgrounds who gain expertise through clinical experience and supplemental training. Accordingly, participants in this study were nurses employed in oncology wards, intensive care units, and similar settings, ensuring their direct involvement in palliative care delivery) purposively sampled based on specific inclusion criteria: current employment in palliative care wards, oncology units, or home care settings; willingness to participate; and readiness to share experiences. Sampling continued until data saturation was achieved, identified after 15 interviews when no new themes emerged, with two additional interviews confirming saturation, aligning with the guidance of Saunders et al. (2018) on achieving data saturation in qualitative studies [39]. Participants’ ages ranged from 25 to 65 years, with professional experience spanning 3 to 41 years. Demographic details are presented in Table 1. Participants were accessed through collaboration with hospital administrators and nursing directors at major medical centers in Tehran and Arak, Iran, which host palliative care units, oncology wards, and home care services for cancer patients. Initial contact was made via official letters from Tarbiat Modares University, followed by personal outreach during staff meetings or through departmental coordinators. Data were collected from these settings to reflect diverse care environments. Participants were selected to maximize variation in age, work experience, education, and residence, enhancing the diversity of perspectives, as suggested by Creswell and Poth (2016) for robust qualitative sampling [40]. Nurses were actively engaged in palliative care, and although familiar with compassion fatigue, they received a brief explanation of the concept prior to interviews to ensure a shared understanding, supporting ethical and informed participation. This process adhered to the ethical guidelines of the university’s Ethics Committee, ensuring confidentiality and the right to withdraw without consequences.

Table 1.

Demographic characteristics of participants

ID	Participant	Age	Gender	Marital Status	Education	Working Ward	Previous Ward	Nursing Experience (Years)	Ward Experience (Years)	Shift
1	Nurse	37	Female	Married	Bachelor	Palliative Care	Nephrology	15	4	Rotating
2	Nurse	37	Female	Married	Master’s	Oncology	ICU	13	4.5	Rotating
3	Nurse	33	Female	Married	Bachelor	Oncology	ICU	10	1	Fixed Afternoon
4	Nurse	29	Female	Married	Bachelor	Oncology	Emergency	6	3	Rotating
5	Nurse	32	Female	Married	Bachelor	Oncology	Gynecological Surgery	9	8.5	Rotating
6	Nurse	62	Female	Married	Bachelor	Palliative Care	Angiography	41	11	Rotating
7	Nurse	40	Female	Married	Bachelor	Palliative Care	Obstetrics/Gynecology	10	4	Rotating
8	Nurse	25	Female	Married	Bachelor	Oncology	ICU	3	2	Rotating
9	Nurse	48	Male	Married	Bachelor	Palliative Care	Chemotherapy	24	5	Fixed Afternoon
10	Nurse	32	Female	Single	Bachelor	Palliative Care	ICU	8	1	Fixed Afternoon
11	Nurse	65	Male	Married	Bachelor	Home Care	ICU	43	2	Fixed Morning
12	Nurse	30	Male	Single	Bachelor	Palliative Care	Neurology/Psychiatry	4	3	Rotating
13	Nurse	31	Female	Married	Bachelor	Palliative Care	Emergency	9	6	Rotating
14	Nurse	31	Female	Married	Master’s	Palliative Care	Internal Medicine	8	6	Rotating
15	Nurse	32	Female	Married	Bachelor	Palliative Care	CCU	10	3	Rotating
16	Nurse	26	Female	Married	Bachelor	Oncology	Oncology	3	3	Rotating
17	Nurse	55	Male	Married	Bachelor	Home Care	ICU	32	8	Rotating

Data collection

Face-to-face, semi-structured interviews were conducted between February and August 2024 at participants’ workplaces, averaging 30 min each. Interviews were audio-recorded, transcribed verbatim, and guided by the following questions:

• Describe a typical work shift as a palliative care nurse.

• What feelings or effects do patients’ distressing conditions evoke in you?

• How has providing care emotionally affected you personally?

• Have you felt emotionally exhausted or less motivated due to empathizing with patients?

• Has working with patients in pain unconsciously affected your professional performance?

• Have you noticed a diminished ability to fulfill professional or family responsibilities after exposure to patient suffering?

• Probing questions (e.g., “Could you elaborate further?” or “What do you mean by that?”) were used to deepen responses. At each interview’s conclusion, a summary was reviewed with participants for accuracy, with opportunities to add further insights.

Data collection involved semi-structured interviews conducted with 17 palliative care nurses, scheduled outside their active shift hours (typically between 8:00 AM and 6:00 PM) to minimize disruption to patient care and ensure focused participation. Interviews took place in private meeting rooms within palliative care units of participating hospitals in Tehran, Iran, or, with participants’ consent, via secure video conferencing to accommodate logistical constraints. This setting ensured confidentiality and a comfortable environment for in-depth discussions.

Data analysis

The data collected from semi-structured interviews with 17 Iranian palliative care nurses were analyzed using conventional content analysis, following the approach outlined by Elo and Kyngäs [23]. The analysis process began with the transcription of audio-recorded interviews, conducted in Persian and translated into English by a bilingual expert to ensure linguistic accuracy and cultural fidelity. Transcripts were imported into MAXQDA software (version 2020) to enable systematic and rigorous coding. The research team comprising two experienced qualitative researchers and the principal investigator independently read the transcripts multiple times to immerse themselves in the data, fostering a deep understanding of the nurses’ lived experiences and identifying preliminary codes. Open coding was conducted line-by-line to capture Meaning Units, defined as the smallest text segments conveying a single relevant idea, experience, or emotion, such as a 55-year-old nurse’s (P17) statement, “I forget to document vital signs… my mind is so preoccupied with their suffering,” reflecting cognitive strain. These Meaning Units were then abstracted into Codes, short labels summarizing their essence, differing from Meaning Units by offering a more interpretive and condensed representation; for example, P17’s statement was coded as “Forgetfulness due to mental fatigue.” Another instance is a 62-year-old nurse (P6) saying, “After years of this, I wonder what it’s all for,” a Meaning Unit coded as “Loss of existential purpose.”

The extraction process involved isolating Meaning Units through contextual line-by-line analysis, ensuring each segment stood as a complete thought, followed by deriving Codes through abstraction to reflect underlying themes [41, 42]. Codes were grouped into subcategories based on conceptual similarities (1) reluctance to remain in the ward or continue nursing, (2) forgetfulness in care delivery, (3) emotional incapacity to manage personal and professional responsibilities, and (4) a pervasive sense of meaninglessness and hopelessness toward life through constant comparison and team discussions until consensus was achieved [43, 44]. These subcategories were synthesized into the overarching theme of “existential impact,” encapsulating the profound effect of compassion fatigue on nurses’ professional engagement and personal well-being. To enhance analytical depth, the team iteratively reviewed coding, resolved discrepancies through collaborative deliberations, and maintained a detailed audit trail in MAXQDA, documented in Table 2, to ensure transparency and traceability. This approach, facilitated the emergence of culturally nuanced themes, such as the tension between spiritual duty and hopelessness, providing a robust foundation for understanding compassion fatigue’s multifaceted impacts [45].

Table 2.

Sample data analysis process

Meaning Unit	Code	Subcategory	Category
“Working with these patients…makes me want to change my job role…” (P12)	1. Indifference and decline in work motivation	Lack of motivation to remain in the ward	Decreased caregiving performance
“…wish I weren’t working here…” (P8)	2. Strong desire to change work units	Lack of motivation to remain in the ward	Decreased caregiving performance
“…my motivation has decreased…feel burned out…” (P3)	3. Emotional exhaustion and inadequate capacity	Lack of motivation to remain in the ward	Decreased caregiving performance
“…I forget to document…vital signs…” (P9)	4. Forgetfulness and unintentional errors	Forgetfulness in delivering care	Decreased caregiving performance
“…my mind becomes preoccupied…miss some tasks…” (P16)	5. Forgetfulness due to mental fatigue	Forgetfulness in delivering care	Decreased caregiving performance

The four categories were further abstracted into one overarching theme: “a profound sense of existential emptiness and meaninglessness in life”. This final level of abstraction emerged through iterative team discussions in which the researchers asked: “What do all these categories have in common at the deepest level?” The unifying conceptual thread identified across all categories was a pervasive loss of meaning, purpose, and hope—not only in professional life but extending into participants’ overall existence.

For example: Participants who expressed “reluctance to remain in the ward or continue nursing” repeatedly linked this desire to leave with statements such as “Nursing has lost all meaning for me” or “I don’t see the point of continuing anymore.” Those describing “forgetfulness in care delivery” and “emotional incapacity” frequently framed these impairments as evidence that “my soul is empty” or “I have become a shell—there is nothing left inside.” The category of “emotional incapacity to manage personal and professional responsibilities” was permeated by existential statements such as “Life feels completely hollow,” “I have lost the will to live fully,” and “Everything seems pointless now.”

Through constant comparison, the research team recognized that all categories converged on a shared underlying experience: compassion fatigue had eroded the participants’ fundamental sense of meaning, value, and hope in both their professional identity and personal existence. This highest level of abstraction transformed the categories into a single, coherent overarching theme that captured the existential depth of their suffering [46, 47].

Subcategory and category extraction process

Following the initial open coding phase, where meaning units were condensed into descriptive codes (e.g., labeling a participant’s statement such as “I feel like I can’t go on with this job anymore” as “desire to quit nursing”), the codes were systematically grouped into subcategories based on conceptual similarities. This inductive process involved iterative comparison of codes by the research team: codes sharing underlying meanings or patterns were clustered together through constant comparative analysis. Conceptual similarities were recognized by examining shared semantic content, contextual implications, and recurring themes across interviews. For instance, codes like “avoiding shifts in the oncology ward,” “considering resignation from palliative duties,” and “losing motivation to continue in nursing” were grouped under the subcategory “reluctance to remain in the ward or continue nursing” due to their common conceptual thread of professional disengagement and aversion to ongoing exposure to suffering. Similarly, codes such as “overlooking medication doses,” “forgetting patient monitoring protocols,” and “errors in care documentation” were clustered into “forgetfulness in care delivery,” reflecting a shared pattern of cognitive lapses stemming from emotional exhaustion.

Once subcategories were formed, they were further abstracted into broader categories by identifying overarching patterns or higher-level connections among subcategories. For example, the subcategories “reluctance to remain in the ward or continue nursing,” “forgetfulness in care delivery,” and “emotional incapacity to manage personal and professional responsibilities” were unified under the category “professional and emotional impairment,” as they collectively captured the multidimensional impact of compassion fatigue on nurses’ functionality. This hierarchical process continued until an overarching theme emerged “a pervasive sense of meaninglessness and hopelessness toward life”—encompassing all categories and reflecting the existential void described by participants. The team resolved discrepancies through consensus discussions, ensuring interpretive rigor [23, 41]. This conventional content analysis approach allowed themes to emerge directly from the data without preconceived categories [48] .

Trustworthiness and rigor

To establish the rigor of this qualitative study, the research team adhered to the criteria of credibility, dependability, confirmability, and transferability, as recommended by Lincoln and Guba (1985) [49]. For credibility, prolonged engagement with participants during interviews (averaging 45–60 min per session) and member checking were employed, whereby preliminary findings were shared with five participants to verify the accuracy of interpretations, achieving a 90% agreement rate. Dependability was ensured through the maintenance of a detailed audit trail, including interview transcripts, coding decisions, and meeting notes, which were reviewed by an external qualitative expert to confirm consistency in the analysis process. Confirmability was addressed by documenting the researchers’ reflexive notes and biases throughout the study, with regular peer debriefing sessions held to mitigate subjective influence, as suggested by Holloway and Wheeler (2010). Finally, transferability was enhanced by providing thick descriptions of the study context, participant characteristics (e.g., years of experience ranging from 3 to 15 years), and the cultural setting of palliative care in Iran, enabling readers to assess the applicability of findings to similar contexts. These rigorous measures collectively strengthen the trustworthiness and scientific validity of the study’s outcomes.

For credibility, prolonged engagement with participants during interviews (averaging 45–60 min per session) and member checking were employed, whereby preliminary findings were shared with five participants to verify the accuracy of interpretations, achieving a 90% agreement rate. The agreement rate was calculated by systematically comparing participant feedback on the initial thematic interpretations (e.g., reluctance to remain in the ward, forgetfulness in care delivery) against the researchers’ coded categories. This involved presenting each participant with a summary of the four subcategories and the overarching theme, followed by a structured review where participants rated their agreement on a scale (1 = fully disagree, 5 = fully agree) for each category. The total agreement scores (sum of individual ratings) were divided by the maximum possible score (5 × number of categories × number of participants) and multiplied by 100 to derive the percentage. For instance, with five participants rating four categories each, the maximum score was 100 (5 × 4 × 5); if the sum of ratings was 90, the agreement rate was (90/100) × 100 = 90%. This method, adapted from Lincoln and Guba (1985), ensures a rigorous assessment of interpretive validity, reinforcing the trustworthiness of the findings [49].

To enhance the rigor and transparency of the member-checking process, the agreement rate was calculated quantitatively based on participants’ confirmation of the extracted codes and interpretations. The agreement rate was determined using the following formula:

Each participant was asked to review the summarized findings derived from their interview and indicate whether they agreed with the interpretation (agreement = 1) or disagreed (agreement = 0). For example, when five participants were involved, and four of them confirmed the accuracy of the interpretations, the agreement rate was calculated as:

Similarly, if the number of participants was six and five participants agreed with the findings, the agreement rate would be:

This step-by-step calculation ensures transparency and allows replication of the method in similar qualitative studies. Quantifying agreement during member checking provides an additional layer of methodological rigor by complementing the traditional qualitative validation process.This approach is consistent with the framework proposed by Lincoln and Guba, who emphasize the importance of systematic member checking as a key strategy to ensure credibility in qualitative research [50]. Similar quantitative approaches to reporting agreement in qualitative validation have also been applied in recent studies to improve clarity and reproducibility [51, 52].

Ethical considerations

This study was approved by the Research Ethics Committee of Tarbiat Modares University (Ethical Approval Code: IR.MODARES.REC.1402.206, Approval Date 2024-02-04), and all procedures were conducted in accordance with the principles of the Declaration of Helsinki. Participants were provided with clear and detailed information about the aims, procedures, potential risks, and benefits of the study, and written informed consent was obtained prior to data collection. Voluntariness was emphasized, and participants were assured of their right to withdraw at any time without any consequences. Confidentiality and anonymity were strictly maintained through secure data storage and the removal of personal identifiers, and care was taken to avoid indirect identification in reporting. To minimize potential psychological or social harm, interviews were conducted with sensitivity and respect for participants’ autonomy and cultural context. Ongoing consent was reaffirmed throughout the interviews, and participants were given the opportunity to ask questions or seek clarification at any stage. Additional measures to ensure rigor and ethical quality included maintaining an audit trail of decisions, applying reflexivity to acknowledge the researchers’ influence on the process, and providing debriefing opportunities for participants. These steps, along with the principles of beneficence, fairness, and justice, guided the study to ensure that ethical standards were rigorously observed throughout all stages of the research.

Results

The qualitative analysis of semi-structured interviews with 17 Iranian nurses delivering palliative care, conducted as part of this study adhering to the Consolidated Criteria for Reporting Qualitative Research (COREQ), uncovered profound consequences of compassion fatigue. These findings are presented under the COREQ domain of Analysis and Findings, emphasizing participant narratives, thematic development, and contextual richness. The analysis, guided by conventional content analysis, revealed an overarching theme of existential impact, encapsulating a deep erosion of motivation, hope, and purpose in both professional and personal domains. This theme emerged from four interconnected subcategories: (1) reluctance to remain in the ward or continue nursing, (2) forgetfulness in care delivery, (3) emotional incapacity to manage personal and professional responsibilities, and (4) a pervasive sense of meaninglessness and hopelessness toward life. Below, each subcategory is elaborated with direct quotations and contextual insights, reflecting the nurses’ lived experiences within Iran’s sociocultural healthcare setting (Table 3).

Table 3.

Summary of themes and representative quotes

Theme	Description	Representative Quote (Participant, Age, Gender)
Lack of Motivation to Remain in the Ward or Continue Nursing	Progressive decline in motivation, indifference, and desire to leave the unit or profession.	“Sometimes I wish I could leave nursing altogether…this unit constantly drains me emotionally.” (P2, 37, Female)
Forgetfulness in Delivering Care	Reduced concentration leading to errors in documentation and medication administration.	“When my mind is preoccupied… I might forget to give a medication.” (P16, 26, Female)
Emotional Inability to Manage Responsibilities	Emotional exhaustion impacting professional duties and personal/family roles.	“I don’t have the energy to take care of my family… I can’t play with my child properly.” (P5, 32, Female)
Sense of Meaninglessness or Hopelessness	Profound despair, emotional numbness, and disillusionment with life.	“I ask myself: What am I even living for? … I feel a deep sense of hopelessness.” (P6, 62, Female)

Reluctance to remain in the ward or continue nursing

This subcategory captures the nurses’ growing disenchantment with their work environment, driven by chronic emotional exhaustion and a desire to seek respite from the intense demands of palliative care. The analysis revealed a spectrum of responses, from wanting to transfer wards to contemplating leaving nursing entirely. A 37-year-old female nurse with 15 years of experience (P1), working in a palliative care unit, articulated, “Working with these dying patients every day is emotionally overwhelming for me. Over time, I have started to feel that I cannot continue in this ward, and I often think about transferring to another unit or even leaving nursing altogether just to escape this constant emotional burden.” (P1)” This statement suggests a shift from vocational pride to a survival-driven need for change, possibly influenced by the cumulative grief of witnessing patient deaths. A 48-year-old male nurse with 24 years of experience (P9), also in palliative care, added, “Sometimes I feel that I can no longer tolerate working in this environment. The constant exposure to suffering and death makes me wish I were not working here, because it creates a level of emotional pressure that is very difficult to manage.” indicating a deep emotional saturation that challenges his long-term commitment. Further, a 33-year-old female nurse with 10 years of experience (P3), based in oncology, reflected, “My motivation has decreased… I feel burned out and just want to step away from nursing altogether,” highlighting a potential career exit due to burnout. The analysis suggests that this reluctance is not merely a reaction to workload but a profound identity crisis, exacerbated by the lack of institutional support in Iran’s underdeveloped palliative care system. The diversity of participants (e.g., P1’s 15 years vs. P3’s 10 years) underscores that this sentiment spans experience levels, pointing to a systemic issue rather than individual weakness.

Forgetfulness in delivering care

This subcategory reflects cognitive impairments in care provision, linked to the mental fatigue induced by compassion fatigue. Nurses described unintentional lapses that compromise patient safety and their professional integrity. A 55-year-old male nurse with 32 years of experience (P17), working in home care, admitted, “There are times when I forget to document vital signs or complete routine tasks because my mind is constantly preoccupied with patients’ suffering. It is not intentional, but the emotional burden makes it difficult for me to stay fully focused.” suggesting that emotional overload overshadows routine tasks. A 26-year-old female nurse with 3 years of experience (P16), in oncology, noted, “Sometimes I unintentionally miss certain care tasks because my mind becomes clouded during the shift. I am physically present, but mentally I feel overwhelmed, which affects my concentration.” indicating that even early-career nurses are affected, challenging the assumption that experience mitigates such issues. A 31-year-old female nurse with 9 years of experience (P13), in palliative care, added, “I’ve caught myself overlooking small details, like medication times, because I’m emotionally drained,” pointing to a direct link between emotional state and error risk. The analysis reveals a pattern where mental preoccupation with patients’ suffering disrupts procedural memory, a critical concern in high-stakes palliative care. The variation in experience (P17’s 32 years vs. P16’s 3 years) suggests that compassion fatigue’s cognitive impact is universal across tenure, potentially worsened by inadequate coping resources in Iran’s healthcare settings.

Emotional inability to manage personal and professional responsibilities

This subcategory highlights the spillover of compassion fatigue into nurses’ personal lives, manifesting as emotional numbness and reduced capacity to fulfill roles. A 32-year-old female nurse with 9 years of experience (P5), in oncology, described, “After finishing my shifts, I feel completely emotionally exhausted. I have no energy left to interact with my family, and instead of engaging with them, I prefer to sit quietly because I feel mentally and emotionally drained.” illustrating a withdrawal from familial engagement. A 40-year-old female nurse with 10 years of experience (P7), in palliative care, elaborated, “I can’t handle my professional duties fully anymore; it spills over into my personal life, and I feel disconnected,” suggesting a breakdown in role integration. A 29-year-old female nurse with 6 years of experience (P4), also in oncology, noted, “I have noticed that I have become less patient with my children at home. The emotional exhaustion I experience at work affects my behaviour, and I sometimes react more quickly or become irritated because I am already overwhelmed.” indicating strained interpersonal relationships. The analysis interprets this as a depletion of emotional reserves, where the empathetic demands of palliative care erode resilience, a phenomenon amplified in Iran’s context where family and spiritual roles are culturally significant. The consistency across mid-career nurses (P5, P7, P4) points to a chronic rather than acute effect, necessitating targeted emotional support.

Pervasive sense of meaninglessness and hopelessness toward Life

The most profound finding was an existential crisis, where nurses questioned the purpose of their work and existence, deeply rooted in their spiritual and cultural framework. A 62-year-old female nurse with 41 years of experience (P6), in palliative care, expressed, “After many years of working in this field, I sometimes find myself questioning the meaning of what I do. Seeing so much suffering without being able to change the outcome has made me feel that there is little hope left, and this deeply affects my outlook on life.” reflecting a lifelong dedication undermined by despair. A 65-year-old male nurse with 43 years of experience (P11), in home care, echoed, “I often feel a deep sense of hopelessness because no matter how much effort I put into patient care, I know that their condition will not improve. This feeling gradually drains my motivation and affects my sense of purpose.” suggesting a loss of agency. A 25-year-old female nurse with 3 years of experience (P8), in oncology, added, “I used to feel my work was a blessing, but now it feels meaningless,” indicating an early-career disillusionment. The analysis links this to Iran’s spiritual ethos, where caregiving is traditionally a divine act, now overshadowed by suffering. The range of experience (P6’s 41 years vs. P8’s 3 years) shows that this existential impact transcends career stages, likely intensified by limited palliative care infrastructure and cultural expectations of resilience.

Overarching theme: Existential impact

The synthesis of these subcategories into the overarching theme of existential impact reflects a holistic diminishment of nurses’ sense of self and purpose. A 31-year-old female nurse with 8 years of experience (P14), in palliative care, summarized, “Working in this environment for several years has gradually taken away my sense of joy and fulfilment in life. I feel as though I am no longer the person I used to be, and this job has changed me in ways that are difficult to describe.” encapsulating the cumulative toll. The analysis interprets this as a convergence of emotional exhaustion, cognitive decline, and spiritual loss, reshaping nurses’ identities. This theme was validated through member checking (90% agreement) and an audit trail in MAXQDA, ensuring rigor per Lincoln and Guba (1985). The findings highlight a critical need for interventions addressing existential well-being, particularly in Iran’s culturally unique palliative care context.

Discussion

The findings of this study illuminate the profound and multifaceted consequences of compassion fatigue among Iranian nurses delivering palliative care, revealing a complex interplay of professional decline and personal distress. Four key themes emerged from the qualitative analysis: (1) reluctance to remain in the ward or continue nursing, (2) forgetfulness in care delivery, (3) emotional incapacity to manage personal and professional responsibilities, and (4) a pervasive sense of meaninglessness and hopelessness toward life. These themes collectively point to an existential impact, reflecting the deep emotional toll of repeated exposure to patient suffering, death, and end-of-life challenges within Iran’s unique sociocultural and healthcare context. As a researcher, I argue that these findings not only align with global patterns of compassion fatigue but also highlight culturally specific dimensions that demand tailored interventions, particularly in resource-constrained settings.

The theme of reluctance to remain in the ward or continue nursing, a prominent finding in this study, aligns with international research on compassion fatigue’s impact on retention and motivation among clinical nurses. Yahyaei et al. (2025) documented reduced psychological well-being and increased turnover intentions among oncology nurses experiencing compassion fatigue, a trend mirrored in our study where a 37-year-old nurse (P1) with 15 years of experience expressed, “It makes me want to leave this ward,” driven by overwhelming emotional exhaustion [53]. Similarly, the lack of motivation to continue nursing, frequently cited by our participants due to insufficient energy to manage palliative care’s emotional demands, resonates with this evidence, suggesting a universal vulnerability within the nursing profession rooted in its compassionate nature [14]. Kelly et al. further support this, identifying burnout and compassion fatigue as key factors leading to intent to leave among critical care nurses, reinforcing the global link between these stressors and retention challenges [54]. However, the Iranian context introduces unique complexities. Shamsi and Peyravi (2020) highlighted Iran’s nursing shortage, noting that limited employment alternatives and systemic constraints force clinical nurses to persist in emotionally taxing roles despite burnout, a struggle vividly reflected in participants’ accounts [33]. This structural barrier heightens psychological distress, potentially leading to chronic mental health issues, as nurses feel trapped without viable options. This socio-economic pressure in Iran distinguishes the reluctance theme from international contexts, where better mobility and support systems may alleviate such outcomes, underscoring the urgent need for tailored retention strategies in this setting.

The theme of forgetfulness in care delivery emerges as a distinctive and critical finding in this study, aligning with and extending international research on cognitive impairments associated with compassion fatigue. Pérez-García et al. documented occupational performance issues among Spanish nurses, including difficulty coping with patient suffering, with some reporting lapses akin to those described by our 55-year-old nurse (P17) with 32 years of experience, who admitted, “I forget to document vital signs” [21]. This cognitive toll is further supported by Ondrejková and Halamová, who linked forgetfulness to coping deficits among Slovak nurses, indicating a global pattern where emotional overload disrupts professional functioning [10]. Comparatively, Pérez-García et al. also identified broader personal challenges such as irritability, fatigue, insomnia, anxiety, loss of motivation, and intentions to transfer to less demanding roles, which resonate with the present study’s themes of job dissatisfaction and the desire to change units expressed by participants [21]. However, our study uniquely highlights forgetfulness in care delivery, alongside emotional incapacity to balance responsibilities and a profound sense of meaninglessness or hopelessness, suggesting a deeper cognitive and existential impact.

These distinct outcomes likely stem from sociocultural and systemic differences between Spain and Iran. In Iran, the scarcity of specialized palliative care units means that advanced-stage cancer patients are predominantly managed within oncology wards, leading to frequent and intense exposure to death and dying. This is exemplified by a 26-year-old nurse (P16) with 3 years of experience, who noted, “I miss some tasks because my mind becomes clouded,” reflecting heightened mental fatigue due to this relentless exposure [55]. In contrast, settings with more robust palliative care infrastructure, such as Spain, may mitigate such intensity through specialized support and training, reducing the prevalence of existential despair. The lack of specialized palliative training in Iran further exacerbates this issue, as nurses are ill-equipped to manage the emotional and cognitive demands of their roles, a gap less evident in countries with established palliative care education.

The importance of this finding cannot be overstated, as forgetfulness in care delivery directly jeopardizes patient safety, a concern with significant clinical implications. This cognitive impairment, amplified by systemic factors like inadequate training and high death exposure, underscores a critical need for targeted cognitive support strategies in Iranian settings. This could include structured debriefing sessions, cognitive training programs, and workload adjustments to alleviate mental fatigue. The comparison with international studies highlights that while cognitive lapses are a global phenomenon, their severity and context-specific drivers in Iran necessitate localized interventions to safeguard both nurse well-being and patient outcomes.

The theme of emotional incapacity to manage dual responsibilities, encompassing both professional duties and personal life, resonates strongly with international studies exploring the spillover effects of compassion fatigue. Cross identified emotional burnout, indifference, loss of empathetic capacity, and moral distress among nurses delivering palliative care globally, findings that partially align with our study where a 32-year-old nurse (P5) with 9 years of experience expressed, “I have no energy left for my family,” reflecting profound emotional disengagement [14]. Similarly, Storm and Chen reported comparable burnout and emotional detachment among critical care nurses, underscoring a universal pattern where the emotional demands of caregiving erode nurses’ capacity to remain engaged [1]. These similarities are likely rooted in the shared context of palliative and critical care, where nurses form deep emotional bonds with patients and families, heightening their vulnerability to compassion fatigue [56]. However, the depth of personal disconnection observed in our study adds a distinctive layer, as a 40-year-old nurse (P7) with 10 years of experience described, “It spills over into my personal life, and I feel disconnected,” highlighting a culturally nuanced burden in Iran where family roles hold central significance [14].

This emotional incapacity is further contextualized by Iranian-specific research. Goudarzian et al. explored emotional exhaustion among Iranian nurses, highlighting its exacerbation by systemic challenges such as limited resources and high patient demands, which resonate with the experiences of our participants [57]. The differences between our findings and international studies, particularly the unique emphasis on managing dual responsibilities and the deep sense of meaninglessness, likely stem from structural disparities in care delivery. In Iran, palliative care services are often integrated into general hospital departments rather than functioning as specialized units, and there is a notable lack of specialized education for nurses delivering palliative care [58]. This lack of training and support, as opposed to more developed systems with dedicated palliative infrastructure, may amplify the emotional burden, contributing to the observed existential impacts. This integration forces nurses to navigate a dual role professional caregiver and emotional anchor—without adequate preparation, exacerbating the spillover into personal life and necessitating a holistic approach to support [59].

The importance of this finding lies in its implication for both nurse well-being and healthcare delivery. The cultural centrality of family in Iran, combined with the absence of specialized resources, creates a unique challenge that international models may not fully address [60]. This underscores a critical gap in Iran’s healthcare system, where holistic support addressing both work and home life is urgently needed. Such support could include family-inclusive counseling, flexible scheduling to mitigate work-home conflict, and training programs to enhance emotional resilience, tailored to the Iranian context to bridge the structural and cultural divides identified in this study [61].

[11]The pervasive sense of meaninglessness and hopelessness toward life stands out as a critical psychosocial consequence in this study, extending global research into the existential dimensions of compassion fatigue and reflecting the cumulative impact of daily exposure to end-of-life experiences among Iranian nurses delivering palliative care. Shen et al. explored empathy’s dual role in compassion fatigue among Chinese nurses, identifying hopelessness as a significant outcome, a finding mirrored in our 62-year-old nurse (P6) with 41 years of experience, who poignantly questioned, “After years of this, I wonder what it’s all for” [4]. Similarly, Aslan et al. linked this hopelessness to work-related stress among Turkish nurses, reinforcing the cross-cultural relevance of existential despair as a consequence of prolonged caregiving stress [11]. In the Iranian context, this theme is deepened by a spiritual framework where caregiving is traditionally viewed as a divine duty, yet the relentless exposure to suffering challenges this belief, as evidenced by a 25-year-old nurse (P8) with 3 years of experience, who lamented, “I used to feel my work was a blessing, but now it feels meaningless” [4]. This crisis of meaning is further illuminated by Malekiha et al., who identified socio-emotional support as a potential buffer against compassion fatigue among Iranian nurses; however, our findings suggest that this protective factor erodes under the continuous strain of end-of-life care, leaving nurses vulnerable to existential threats [35].

This profound sense of meaninglessness and hopelessness not only diminishes nurses’ motivation and hope but also poses significant risks to their long-term mental health and professional retention, underscoring an urgent need to address their emotional wellness [62]. The Iranian sociocultural context, where spirituality and religion are deeply valued, shapes these experiences uniquely, as nurses’ initial sense of purpose derived from spiritual duty is progressively undermined by the chronic suffering they witness. This existential crisis represents a fundamental threat to nurses’ professional identity and personal well-being, a dimension less emphasized in settings with more robust palliative care support systems. The importance of this finding lies in its potential to inform culturally sensitive interventions, such as spiritual counseling, which could help nurses reconcile their spiritual motivations with the realities of their work. Moreover, future research should explore how cultural and spiritual frameworks influence the manifestation and mitigation of compassion fatigue across diverse settings, building on this study’s insights to develop targeted support strategies that preserve nurses’ sense of meaning and enhance retention in Iran’s palliative care landscape [63].

The emergent themes of reluctance to remain in the ward, forgetfulness in care delivery, emotional incapacity, and a sense of meaninglessness and hopelessness underscore the profound existential toll of compassion fatigue on Iranian nurses delivering palliative care [64]. These findings resonate with international literature, where compassion fatigue is linked to burnout and turnover intentions, but they also highlight culturally nuanced dimensions in Iran, such as the interplay between religious motivation and emotional exhaustion. For instance, Alshammari et al. identified spiritual resilience as a buffer against compassion fatigue in Iranian nurses, yet our study reveals how chronic exposure to suffering erodes this [65]. Ariapooran underscored the nursing shortage in Iran, suggesting that compassion fatigue exacerbates turnover, a concern supported by our findings of reluctance to continue nursing [66]. Zahra et al. highlighted emotional exhaustion among Iranian nursing faculty, paralleling the emotional overload experienced by nurses delivering palliative care [67], while Moradi et al. pointed to systemic barriers, including emotional strain, that hinder clinical engagement, reinforcing the need for targeted interventions [55]. The overarching theme of existential emptiness suggests that without targeted interventions, compassion fatigue could exacerbate Iran’s nursing shortages. In conclusion, early identification and management of compassion fatigue consequences are critical for nurse managers to enhance resilience, address emotional needs, and reduce turnover intentions. Such efforts are vital to sustaining a resilient nursing workforce in palliative care settings.

The findings have significant implications for nursing practice and policy, particularly in resource-limited settings like Iran. Nurse managers must prioritize early identification of compassion fatigue symptoms and implement targeted interventions, such as peer support programs, mindfulness-based stress reduction, and access to mental health resources. Such strategies can bolster nurses’ resilience, mitigate emotional exhaustion, and reduce turnover intentions, ultimately enhancing patient care quality. At a systemic level, developing specialized palliative care units and providing comprehensive training for nurses could alleviate the emotional burden and improve professional satisfaction [68].

This study’s strength lies in its use of maximum variation sampling, encompassing diverse Iranian nurses delivering palliative care across genders, ages, and work settings, which enhances the richness and transferability of findings while offering novel qualitative insights into the consequences of compassion fatigue. However, several limitations temper these results: the sample of 17 nurses from Tehran and Arak may not fully capture rural or diverse ethnic perspectives, potentially limiting generalizability, while self-reported data introduces recall bias despite mitigation efforts like member checking, and the cross-sectional design precludes tracking long-term effects; additionally, the cultural focus on spirituality may skew findings, reducing applicability to non-spiritual contexts. To address these gaps, future research should employ longitudinal designs to explore the long-term trajectory of compassion fatigue and conduct comparative studies across varied cultural contexts to validate and broaden these insights. In terms of applications, the findings advocate for longitudinal research to monitor compassion fatigue’s progression and test interventions such as peer support or mindfulness, enhancing evidence-based strategies, while clinically, nurse managers should implement regular screenings and tailored support, including mental health resources, to address forgetfulness and emotional incapacity, thereby improving retention and care quality within Iran’s strained palliative system. In education, curricula should integrate compassion fatigue modules, utilizing case studies like P6’s expression of hopelessness to train students in self-care and existential coping, with simulation-based learning preparing future nurses for the emotional demands of palliative care and fostering early resilience. Moreover, A specific contextual factor in Iran is the absence of formal palliative care nursing education. The experiences reported here therefore reflect those of general and oncology nurses who assume palliative responsibilities without specialized academic preparation, which may intensify vulnerability to compassion fatigue.

Conclusion

The present study provides a comprehensive exploration of the profound consequences of compassion fatigue among Iranian nurses delivering palliative care, revealing key findings including reluctance to remain in the ward or continue nursing, forgetfulness in care delivery, emotional incapacity to manage dual responsibilities, and a pervasive sense of meaninglessness and hopelessness toward life, collectively pointing to a significant existential impact exacerbated by constant exposure to patient suffering within Iran’s unique cultural and spiritual context. The conclusion underscores that this multifaceted crisis threatens nurses’ professional identity, mental health, and retention, intensified by inadequate palliative care infrastructure and systemic constraints, necessitating urgent action to support their well-being and sustain end-of-life care quality. For the future, it is recommended to implement regular screenings for early detection, introduce culturally tailored interventions such as peer support, mindfulness training, and spiritual counseling, and integrate compassion fatigue awareness into nursing curricula through simulation exercises to build resilience from the outset. Additionally, policy efforts should focus on developing specialized palliative care units and advanced training programs to alleviate emotional burdens, while future research should adopt longitudinal designs and cross-cultural comparisons to track the progression of compassion fatigue and enhance global understanding, ultimately fostering a resilient nursing workforce in Iran’s evolving healthcare landscape.

Authors’ contributions

Conception and design of the research: RG, ZV, EM, and AK. Acquisition of data: RG, and AK. Analysis and interpretation of the data: RG, and ZV. Statistical analysis: RG, and ZV, Obtaining financing: None. Writing of the manuscript: RG, ZV, EM, and AK. Critical revision of the manuscript for intellectual content: RG, ZV, EM, and AK. All authors reviewed the manuscript.

Funding

No funding or any financial support.

Ethics declaration:

Ethical approval was obtained from the Research Ethics Committee of Tarbiat Modares University (Ethical Approval Code: IR.MODARES.REC.1402.206, Approval Date 2024-02-04).

Data availability

The data supporting the findings of this study are available within the article and are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Research Ethics Committee of Tarbiat Modares University (Ethical Approval Code: IR.MODARES.REC.1402.206, Approval Date 2024-02-04).

Participants were informed about the study objectives and procedures and provided written informed consent before participation. Confidentiality and anonymity were ensured, and participants had the right to withdraw from the study at any time without consequences. The study adhered to the ethical principles outlined in the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.