The aging population and rising chronic disease burden are driving a surge in demand for nursing services. However, the current number of registered nurses per 1,000 population (3.7 as of 2022) falls short of the World Health Organization's minimum recommendation of 4.45[1, 2]. A growing nursing shortage significantly impacts patient care quality and healthcare efficiency[3]. To address the nursing shortage, healthcare system is significantly hiring more new graduate nurses and utilizing nursing interns[4, 5]. However, a significant portion (13.9%) of nursing interns experience compassion fatigue during their internships[6, 7], leading many to reconsider pursuing a career in nursing[8].
Compassion fatigue, a state of emotional and psychological distress, develops in nurses from chronic exposure to patient suffering[9, 10]. It manifests in two distinct domains: secondary traumatic stress (STS) and burnout (BO). STS arises from various exposure to patients’ traumatic experiences, while BO stems from workload demands, perceived stress, and a consequent decline in self-efficacy. Nursing interns, akin to experienced nurses, frequently encounter real-life traumatic scenarios during internships, rendering them highly susceptible to compassion fatigue[8]. The existing body of research demonstrates a significant prevalence of compassion fatigue among this population[8, 11, 12]. A US study reported moderate levels among Doctor of Nursing Practice students, while a Turkish study identified a high average scores on the Compassion Fatigue Short Scale (CFSS) among nursing students[11, 12]. In China, an online survey of 2,256 nursing interns revealed that nearly 20% scored above the CFSS threshold for compassion fatigue[8]. The consequences of compassion fatigue on nursing interns are extensive and negatively impact their well-being. These effects include sleep disturbances, increased alcohol consumption, depressive symptoms, intrusive thoughts, and decline in self-reflection. Ultimately, this can lead to burnout, career uncertainties, and a higher likelihood of attrition from the nursing workforce[13, 14]. Given the significant detrimental effects of compassion fatigue on the physical and mental health, as well as career development of nursing interns, a deeper exploration of its causes and mechanisms is imperative. This knowledge is instrumental in developing effective intervention strategies to mitigate compassion fatigue and safeguard the well-being of future nursing professionals.
Moral distress arises when nurses recognize the ethically sound course of action but are unable to act on their convictions due to internal or external constraints[15]. Nursing interns are particularly susceptible to moral distress. This vulnerability stems from challenges in patient communication, feelings of powerlessness around physicians, exposure to inaccurate treatment information, a sense of isolation inherent to trainees roles, and a perceived inability to advocate within the clinical setting[16, 17]. Chronic exposure to moral distress can have deleterious consequences for the psychological and emotional well-being of nursing interns, manifesting as anxiety, self-doubt, guilt, and emotional exhaustion, ultimately contributing to compassion fatigue. A robust of research demonstrates a positive correlation between moral distress and compassion fatigue among nurses[18–22]. Dodek et al. identified a positive association between moral distress and compassion fatigue in a study of 499 Canadian critical care physician, while Maiden et al. reported similar findings among 205 American critical care nurses[18, 19]. Furthermore, several studies have documented this positive association among clinical nurses in emergency department and department of rheumatological immunology[20–22]. However, a critical gap exists in research regarding the specific influence of moral distress on compassion fatigue among nursing interns.
Moral resilience, defined as the capacity to maintain or restore one’s ethical integrity despite encountering moral complexities, confusion, distress, or setbacks[23], serves as a critical protective factor for nurses’ mental health and ethical decision-making[24]. This ability empowers nurses to navigate ethically challenging situations, prioritize ethical conduct, and resist pressures to compromise their professional principles, even in the face of exhaustion. Moral resilience is particularly crucial for nursing interns, who are more susceptible to compassion fatigue due to their developing professional identify[25]. Some studies support this notion, demonstrating a negative association between moral resilience and compassion fatigue[12, 26].
Professional identity in nursing practice encompasses an individual's understanding of their role in the profession’s core values. This includes the nurse’s perception of their professional worth and the ongoing development of their skills within the nursing field[27]. A robust professional identity is paramount for nurses, serving as a critical source of psychological resilience in the face of ethical and clinical challenges[28]. A study by Sabanciogullari et al. suggests that programs fostering professional identity can significantly reduce job burnout among clinical nurses. This findings highlights the potential of a strong professional identity to safeguard the well-being of healthcare providers[29]. Two cross-sectional studies demonstrates an inverse relationship between professional identity and compassion fatigue among[30]. This indicates that a well-developed professional identify may buffer against compassion fatigue experienced by both registered nurses and nursing interns.
Although prior research has established linkages between compassion fatigue, moral distress, moral resilience, and professional identity[14], existing literature primarily explores the bivariate relationship between these factors. Notably, the potential for moral resilience and professional identity to mediate the influence of moral distress on compassion fatigue remains unexamined in the context of nursing interns. This knowledge gap hinders the development of targeted interventions for mitigating compassion fatigue in this vulnerable population[3, 24, 28, 31–34]. To address this limitation, this study investigates the influence of moral distress on compassion fatigue among Chinese nursing interns, with a particular focus on the mediating roles of moral resilience and professional identity. The findings from this study will contribute valuable insights to inform interventions aimed at fostering moral resilience and professional identify among nursing interns, ultimately promoting their well-being and reducing their susceptibility to compassion fatigue and moral distress. To contribute to the ongoing discourse on ethical decision-making in nursing practice, and informed by relevant empirical research, this study aims to investigate five key hypotheses:
H1: Nursing interns' moral distress is positively correlated with their compassion fatigue.
H2: Nursing interns' moral distress is negatively correlated with their moral resilience and professional identity.
H3: Nursing interns' moral resilience is positively correlated with their professional identity.
H4: Nursing interns' moral resilience and professional identity are negatively correlated with their compassion fatigue.
H5: Moral resilience and professional identity simultaneously mediate the influence of nursing interns' moral distress on their compassion fatigue.