Sleep Quality and Pain Empathy Among Nursing Interns: The Serial Mediating Roles of Burnout and Moral Identity

Empathy for patients' pain is a core component of compassionate nursing care and is increasingly recognised as important for care quality and workforce sustainability. Nursing interns commonly experience poor sleep quality and burnout during clinical placement, yet the interrelationships between these factors and pain empathy remain unclear.

To examine the association between sleep quality and pain empathy among nursing interns and the potential serial mediating roles of burnout and moral identity in this association.

A multicentre cross-sectional study.

A convenience sample of 1108 final-year nursing interns undertaking clinical placements at 102 public hospitals in East and North China was recruited between October and November 2025 through participating nursing schools. Data were collected using the Pittsburgh Sleep Quality Index, Maslach Burnout Inventory, Moral Identity Measure and Empathy for Pain Scale. Descriptive statistics and Pearson correlations were performed using SPSS 27.0. Serial mediation was examined using PROCESS Macro (Model 6) with 5000 bootstrap resamples after adjustment for age, gender and educational level.

Poorer sleep quality, higher burnout and lower moral identity were each significantly associated with lower pain empathy (all p < 0.001). Burnout and moral identity demonstrated significant independent and serial indirect associations in the relationship between sleep quality and pain empathy, with the total indirect effect accounting for 31.43% of the total effect.

Sleep quality was significantly associated with pain empathy among nursing interns, with burnout and moral identity demonstrating significant independent and serial indirect associations. Strategies targeting sleep health, burnout and professional value development may be relevant for supporting empathic care during the transition to professional nursing practice.

Nurse managers should consider sleep-supportive placement scheduling, early burnout monitoring and value-based mentorship strategies to strengthen empathy, wellbeing and workforce readiness among nursing interns.