Empathy as a Conditional Resource: System-Level Moral Distress as an Indirect Pathway in the Associations of Empathy...

Evidence regarding the relationship between empathy and burnout among nurses remains inconsistent. Moral distress may help explain this complexity. Given the associations of moral distress and burnout with turnover intention, it remains insufficiently understood how empathy is linked to these outcomes through multidimensional moral distress, which is a critical concern for nursing management.

This study examined how empathy relates to burnout and turnover intention among nurses, focusing on indirect associations involving multidimensional moral distress and burnout.

A cross-sectional web-based survey was conducted among Japanese nurses (n = 412). Empathy was assessed using the Jefferson Scale of Empathy, burnout using the Burnout Assessment Tool, and moral distress using the Measure of Moral Distress for Healthcare Professionals, which captures multiple dimensions of moral distress. Turnover intention was measured using a single-item scale. Mediation and moderation analyses were performed.

In the primary parallel mediation analysis, with all four moral distress domains considered simultaneously, positive indirect associations involving system-level moral distress were statistically significant for burnout and turnover intention using 95% bootstrap confidence intervals. Supplementary separate-domain sensitivity analyses also identified indirect associations involving clinical-/patient-level moral distress. The interaction between empathy and burnout in relation to turnover intention was significant. The negative indirect association of empathy with turnover intention through burnout and the positive serial indirect association through system-level moral distress and burnout were both conditional on empathy level.

The opposing indirect associations suggest that empathy should not be viewed as a uniformly protective resource in relation to turnover intention. System-level moral distress showed the most consistent domain-specific pattern across the analyses. The cross-sectional design does not establish temporal or causal relationships.

Nursing managers may consider staffing adequacy, ethical climate, decision-making autonomy, and organizational support alongside individual-focused approaches to empathy and resilience.