Background: Moral sensitivity, moral injury, and compassion fatigue are critical factors affecting the mental health and professional development of nursing interns, which have been studied in recent years. Moral development and mental health of nursing interns directly impact the quality of nursing care and patient safety.
Aim: To explore the relationship among moral sensitivity, compassion fatigue, and moral injury among nursing interns and to analyze the role of moral injury in the relationship between moral sensitivity and compassion fatigue among nursing interns.
Design: A correlational study design was employed. From October 2024 to January 2025, 206 eligible full-time nursing interns were recruited from Xi’an Medical University, Shaanxi Province. Data collection involved demographic questionnaires, Moral Sensitivity Questionnaire, Moral Injury Symptom Scale-Healthcare Professionals version, and the Compassion Fatigue-Short Scale. The relationships between moral sensitivity, moral injury, and compassion fatigue were examined using Pearson’s correlation coefficient. Statistical significance was determined by a p-value of 0.05 or below. The mediation effect analysis was performed using the bootstrap method with 5000 bootstrap values. Data analysis was conducted using SPSS 27.0 and STATA 18.0.
Ethical Considerations: This study was approved by Xi’an Medical University (XYLS2025001). The researchers ensured that participants were fully informed about the study’s purpose and guaranteed that non-participation or withdrawal would not adversely affect their academic or internship outcomes. Informed consent was obtained from all participants.
Results: There was a positive correlation between moral sensitivity and moral injury (r = 0.783, p < .001), and a positive correlation between moral sensitivity and compassion fatigue (r = 0.869, p < .001). The findings indicated a positive correlation between moral injury and compassion fatigue (r = 0.644, p < .001). The relationship between moral sensitivity and compassion fatigue was fully mediated by moral injury (β = 1.707, 95% CI: 1.252–2.162).
Conclusion: Future studies could explore strategies to mitigate the adverse impact of moral sensitivity and moral injury on compassion fatigue among nursing interns.
EidusonCGuilletRMianA, et al.Pediatric dialysis: ethical dilemmas faced by pediatric intensive care nurses. Nephrol Nurs J2024; 51: 539–547.
2.
AnastasiGGravanteFBarbatoP, et al.Moral injury and mental health outcomes in nurses: a systematic review. Nurs Ethics2024; 32: 9697330241281376.
3.
Lotfi-BejestaniSAtashzadeh-ShooridehFGhafouriR, et al.Is there any relationship between nurses' perceived organizational justice, moral sensitivity, moral courage, moral distress and burnout?BMC Nurs2023; 22: 368.
4.
YeLTangXLiY, et al.The prevalence and related factors of compassion fatigue among nursing interns: a cross-sectional study. BMC Nurs2024; 23: 762.
5.
ShadiAZZohrehVEesaM, et al.Moral sensitivity of nursing students: a systematic review. BMC Nurs2024; 23: 99.
6.
RestJR. Moral development : advances in research and theory. New York: Praeger, 1986.
7.
NezhadhoseiniPMousaviSKJavadzadehA. The relationship between academic motivation and moral sensitivity in nursing students. BMC Med Educ2024; 24: 1487.
8.
AhansazNAdib-HajbagheryMBaghaeiR. Missed nursing care and its relationship with nurses’ moral sensitivity: a descriptive-analytical study. BMC Nurs2024; 23: 169.
9.
TaheriMAbbasiMTavakolM, et al.Does moral sensitivity contribute to patient satisfaction? A cross-sectional survey in educational hospitals. J Prev Med Hyg2023; 64: E40–E47.
10.
TurkmenEVaizogluDYesilyurtT, et al.Effect of moral sensitivity on professional values of undergraduate nursing students: mediating effect of empathic tendency. J Prof Nurs : Official Journal of the American Association of Colleges of Nursing2023; 49: 44–51.
11.
WeiLLiDHuL, et al.Post-traumatic growth, moral sensitivity and service behaviour among healthcare workers in the post-pandemic era of COVID-19 in mainland China: a cross-sectional study. BMJ Open2024; 14: e086264.
12.
ChenXLFei HuangFZhangJ, et al.Tertiary hospital nurses' ethical sensitivity and its influencing factors: a cross-sectional study. Nurs Ethics2022; 29: 104–113.
13.
KandemirDYükselS. Professional values, cultural competence, and moral sensitivity of surgical nurses: mediation analysis and structural equation modeling. Nurs Ethics2024; 25: 9697330241295373.
14.
TangFWKNgMSNChoiKC, et al.Impacts of ethical climate and ethical sensitivity on caring efficacy. Nurs Ethics2024; 31: 1428–1440.
15.
WilliamsonVMurphyDPhelpsA, et al.Moral injury: the effect on mental health and implications for treatment. Lancet Psychiatry2021; 8: 453–455.
16.
LesleyM. Psychoanalytic perspectives on moral injury in nurses on the frontlines of the COVID-19 pandemic. J Am Psychiatr Nurses Assoc2021; 27: 72–76.
17.
JafariMNassehiAJafariJ, et al.Severity and associated factors of moral injury in healthcare workers during the coronavirus pandemic: a comprehensive meta-analysis. Archives of public health = Archives belges de sante publique2025; 83: 37.
18.
Gilbert-OuimetMZahiriharsiniALamLY, et al.Associations between self-compassion and moral injury among healthcare workers: a cross-sectional study. Nurs Ethics2024; 15: 9697330241299536.
19.
NazarovAForchukCAHouleSA, et al.Exposure to moral stressors and associated outcomes in healthcare workers: prevalence, correlates, and impact on job attrition. Eur J Psychotraumatol2024; 15: 2306102.
20.
LancasterSLMillerM. Moral decision making, religious strain, and the experience of moral injury. Psychol Trauma2020; 12: 156–164.
21.
CartolovniAStoltMScottPA, et al.Moral injury in healthcare professionals: a scoping review and discussion. Nurs Ethics2021; 28: 590–602.
22.
LiFSunLJiaF. The impact of moral injury on healthcare workers' career calling: exploring authentic self-expression, ethical leadership, and self-compassion. BMC Med Ethics2025; 26: 18.
GündüzESYildirimNAkatinY, et al.Relationship between nurses’ resilience and quality of professional life. Int Nurs Rev2024; 71(4): 1023–1031.
25.
El-AshryAMElsayedSMGhoneamMA, et al.Compassion fatigue and stress related to cardiopulmonary resuscitation: a study of critical care nurses' experiences. BMC Nurs2023; 22: 482.
26.
CaoXChenL. Relationships between resilience, empathy, compassion fatigue, work engagement and turnover intention in haemodialysis nurses: a cross-sectional study. J Nurs Manag2021; 29: 1054–1063.
27.
NoorAMSuryanaDKamarudinEME, et al.Compassion fatigue in helping professions: a scoping literature review. BMC Psychol2025; 13: 349.
28.
KayalarAHiçdurmazD. I put a wall between me and my emotions, but that wall was coming towards me: a descriptive qualitative study on determining emotion regulation experiences of oncology nurses. Semin Oncol Nurs2025; 41: 151840.
29.
YiLShuaiTZhouJ, et al.Development and validation of a machine learning-based predictive model for compassion fatigue in Chinese nursing interns: a cross-sectional study utilizing latent profile analysis. BMC Med Educ2024; 24: 1495.
30.
RossAMRahmanRHuangD, et al.Investigating correlates of home visitor burnout, compassion fatigue, and compassion satisfaction in New York state: implications for home visiting workforce development and sustainability. Matern Child Health J2023; 27: 1787–1794.
31.
WilkieTJonesRMRamshawL, et al.Contributors to physician burnout and well-being in forensic psychiatrists in Canada. J Am Acad Psychiatry Law2024; 52: 41–50.
32.
MichalecBDiefenbeckCMahoneyM. The calm before the storm? Burnout and compassion fatigue among undergraduate nursing students. Nurse Educ Today2013; 33: 314–320.
33.
AhmadiMHHeidarzadehMFathiazarA, et al.Investigating the relationship between compassion fatigue and moral injury in nurses. Nurs Ethics2025; 32: 201–211.
34.
KulakacNUzunS. The effect of burnout and moral sensitivity levels of surgical unit nurses on job satisfaction. J Perianesth Nurs2023; 38: 768–772.
35.
LutzenKJohanssonANordstromG. Moral sensitivity: some differences between nurses and physicians. Nurs Ethics2000; 7: 520–530.
36.
HuangFFYangQZhangJ, et al.Cross-cultural validation of the moral sensitivity questionnaire-revised Chinese version. Nurs Ethics2016; 23: 784–793.
37.
MantriSLawsonJMWangZ, et al.Identifying moral injury in healthcare professionals: the moral injury symptom scale-HP. J Relig Health2020; 59: 2323–2340.
38.
ZhizhongWKoenigHGYanT, et al.Psychometric properties of the moral injury symptom scale among Chinese health professionals during the COVID-19 pandemic. BMC Psychiatry2020; 20: 556.
39.
FerketichSVerranJ. An overview of data transformation. Res Nurs Health1994; 17: 393–396.
40.
BaghcheghiNKoohestaniHRKarimyM, et al.Predictive moral sensitivity in nursing students: the roles of empathy and spiritual health. J Educ Health Promot2024; 13: 477.
41.
ShaoHLyuXZhiguangD. A new journey of medical ethics education pathway in China. Medicine & Philosophy2024; 45: 52–56.
42.
JafariMNassehiAJafariJ, et al.Severity and associated factors of moral injury in healthcare workers during the coronavirus pandemic: a comprehensive meta-analysis. Arch Public Health2025; 83: 37.
43.
Lu-yingWANGYun-liC. Moral injury and management from the perspective of confucian culture. Medicine & Philosophy2019; 40: 35–39.
44.
KarabeyT. Compassion fatigue and psychological resilience levels of nursing final students: a descriptive, cross-sectional, and relational study. Palliat Support Care2023; 21: 1034–1040.
45.
YiLCaiJShuaiT, et al.Mediating effect of moral sensitivity and professional identity between moral courage and compassion fatigue among nursing interns: a cross-sectional study. BMC Nurs2024; 23: 551.
46.
KaracaTAydin OzkanS. Moral sensitivity, spiritual care perception, and compassion fatigue of nurses caring for earthquake victims. Int Nurs Rev2024; 12: 13066.
47.
JavidpourMRamezani-BadrFHamidiL, et al.Balancing ethics, burnout and job satisfaction: the challenges facing nurses in teaching hospitals. BMC Health Serv Res2025; 25: 289.
48.
ErtuğrulBArslanGGAyikC, et al.The effects of an ethics laboratory program on moral sensitivity and professional values in nursing students: a randomized controlled study. Nurse Educ Today2022; 111: 105290.
49.
RashidiKAshktorabTBirjandiM. Impact of poetry-based ethics education on the moral sensitivity of nurses: a semi-experimental study. Nurs Ethics2022; 29: 448–461.
50.
Yüksel KaçanC. The effect of transcultural nursing course on students' moral sensitivity: a quasi-experimental study. J Transcult Nurs2022; 33: 427–436.
51.
AbdelmonaemYMMOsmanMAKarimN. Mental health stigma and internship nursing students' attitudes toward seeking professional psychological help: a cross-sectional study. BMC Nurs2024; 23: 275.
52.
VermeeschALCoroAMattesK, et al.Nature-based feasibility intervention to influence mitigation strategies for perceived stress. Int J Environ Res Publ Health2022; 19: 12277.
53.
EngbersRABekhetAKJerofke-OwenT, et al.Psychometric properties of the Positive Thinking Skills Scale among undergraduate nursing students. Arch Psychiatr Nurs2024; 50: 21–26.
54.
AlbaqawiHMAlshammariMH. Resilience, compassion fatigue, moral distress and moral injury of nurses. Nurs Ethics2024; 32: 9697330241287862.
55.
BerdidaDJE. The mediating roles of moral courage and moral resilience between nurses’ moral distress and moral injury: an online cross-sectional study. Nurse Educ Pract2023; 71: 103730.
56.
NarvaezDRestJR. The four components of acting morally. Moral behavior and moral development: an introduction. In:Handbook of moral and character education. Boston: Allyn & Bacon, 1995, pp. 385–400.
57.
EunyoungJ. Mediating role of self-compassion in the association between moral injury and depression among Korean youths. Heliyon2022; 8: e09429.
58.
KotiSDemyanLDeperaltaD, et al.A palliative care curriculum may promote resident self-reflection and address moral injury. J Surg Res2024; 301: 29–36.
59.
DavidHSRosellTHughesD. Moral injury among transplant providers: evaluating the effects of training in end-of-life counseling. Kans J Med2023; 16: 324–327.
60.
MannAShahANThibodeauPS, et al.Online well-being group coaching program for women physician trainees: a randomized clinical trial. JAMA Netw Open2023; 6: e2335541.
61.
JasemiMGoliRZabihiRE, et al.Educating ethics codes by lecture or role-play; which one improves nursing students' ethical sensitivity and ethical performance more? A quasi-experimental study. J Prof Nurs2022; 40: 122–129.
62.
WatsonALDrakeJAndersonM, et al.Triage ethics in mass casualty incident simulation: a phenomenological exploration. Nurs Ethics2024; 14: 9697330241299526.
63.
BlackwellA. Overcoming compassion fatigue and burnout in pediatric oncology nurses: implementation of a staff well-being program. J Pediatr Hematol Oncol Nurs2024; 41: 408–418.
64.
GanetiDDDereje FufaBBayana KebedeE, et al.Compassion fatigue and associated factors among nurses working in Jimma Zone public hospitals, southwest Ethiopia: a facility based cross-sectional study. PLoS One2025; 20: e0312400.
65.
Zare-KasebABorhaniFAbbaszadehA, et al.Moral distress, ethical climate, and compassion fatigue among oncology nurses: the mediating role of moral distress. BMC Nurs2025; 24: 15.
66.
HuangJLCurranPGKeeneyJPoposkiEMDeShonRP. Detecting and Deterring Insufficient Effort Responding to Surveys. J Bus Psychol. 2011; 27: 99–114.
67.
NiehausJZPalmerMMSlavenJEFettigL. Teaching Empathic Communication to Pediatric Interns: Immediate and 3-Month Impact. Am J Hosp Palliat Care. 2021; 38: 1451–6.
