Burnout and its relationship to empathy in nursing: a review of the literature

Introduction

The need for compassion is high on the nursing agenda both in the United Kingdom (Department of Health, 2012) and Ireland (Health Service Executive, 2016). Delivering compassionate care requires nurses to engage in empathic interactions with patients, highlighting the emotional nature of nursing work. For some nurses, emotional work can result in compassion satisfaction (Hooper et al., 2010; Slocum-Gori et al., 2011; Smart et al., 2014), but for others it increases the risk of burnout, emotional exhaustion and compassion fatigue (Abendroth and Flannery, 2006; Barnard et al., 2006; Galsema et al., 2006; Joinson, 1992; Slocum-Gori et al., 2011; Trufelli et al., 2008). Experiencing burnout could challenge nurses’ ability to provide compassionate care as it is reported that experiencing the negative consequences of caring directly impacts on the provision of quality patient care (Dominguez-Gomez and Rutledge, 2009; Mealer and Jones, 2013; Poghosyan et al., 2010).

The purpose of this paper is to examine the relationship between burnout and empathy in the nursing literature. This review provides insight into how adaptive empathic engagement may reduce the risk of burnout. Implications for clinical practice and research are discussed in view of the findings.

Review objectives

The objectives of this review are to:

identify and summarise published papers on burnout and its relationship to empathy in adult general nursing;

Methodology

Searches were conducted on The Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE and PsycINFO databases. Search terms of abstracts included burnout, empath* and nurs*. Date parameters were set at January 1983–January 2016. Inclusion and exclusion criteria (Table 1) were used to identify key literature. A flow chart of the process of literature selection is provided (Figure 1). Two areas of nursing excluded from the review were paediatric nursing and mental health nursing. These specialties were considered sufficiently different in clinical specialism to be excluded. Two papers included in the review, Omdahl and O’Donnell (1999) and Ferri et al. (2015), included paediatric nurses and student nurse participants, respectively. The rationale for including these studies is that there was sufficient analysis within the study by Ferri et al. (2015) to extrapolate results for registered nurses, and only four paediatric nurses (n = 163) were included in the analysis by Omdahl and O’Donnell.

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Table 1.

Inclusion and exclusion criteria.

Inclusion criteria	Exclusion criteria
Published academic literature	Unpublished theses
English language papers	Non-English language papers
Registered nurse participants	Health professions other than nurses
Primary research	Paediatric and neonatal specialities
	Mental health
	Midwives
	Student nurses

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Figure 1.

Flow chart of literature selection process.

Results of the literature review

Five studies met the inclusion criteria (Table 2). The studies gathered demographic variables including age, gender and years in nursing. Job stress variables were examined by Lee et al. (2003) and Ferri et al. (2015); shift type and hospital type were examined by Lee et al. (2003). Omdahl and O’Donnell (1999) gathered information on nurses’ role specialisation. Pålsson et al. (1996) described demographic information but did not report on any differences. The findings suggest that burnout may decrease with age (Lee et al., 2003) and that empathic tendency decreases with age (Ferri et al., 2015). Years of experience did not correlate with burnout (Omdahl and O’Donnell, 1999).

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Table 2.

Studies that met inclusion criteria.

Authors	Year	Constructs studied	Sample population and clinical setting	Sample size	Measurement tools used	Statistically significant results
Ferri et al.	2015	Empathy, burnout	Registered nurses, tutors and nursing students in a general hospital in northern Italy	n = 259, registered nurses n = 162	Italian version of the Balanced Emotional Empathy Scale (BEES), Maslach Burnout Inventory (MBI)	Emotional exhaustion was negatively correlated with the BEES mean total score in nurses. Personal accomplishment was positively correlated with BEES mean total score in nurses. Superior empathic tendency in ‘emotional spread responsiveness’ in female nurses. Depersonalisation scores of female nurses superior to males.
Lee et al.	2003	Empathy, burnout, job stress, empowerment	Registered nurses in hospitals >300 beds in South Korea.	n = 178	MBI. Job stress. Mehrabian Emotional Empathy Scale. Barrett-Lennard Empathy Scale. Two questions of nurses' perception of empowerment	Role conflict and employment in tertiary hospital predictors of depersonalisation. Working night shifts, role overload, role conflict, and working in tertiary hospitals predictors of emotional exhaustion. Reduced role ambiguity, cognitive empathy, and empowerment a significant predictor of personal accomplishment.
Omdahl and  O’Donnell	1999	Empathy, burnout, communicative responsiveness, occupational commitment	Registered nurses from two large metropolitan hospitals in north-eastern United States of America	n = 164	Interpersonal Reactivity Index (empathic concern dimension). Emotional Empathy Measure (emotional contagion dimension), 5 items measuring communicative responsiveness, Organisational Commitment Questionnaire (occupational commitment dimension), MBI.	Negative relationship between empathic concern and depersonalisation. Empathic concern had a negative relationship with reduced personal accomplishment. Emotional contagion had a positive association with reduced personal accomplishment. Emotional contagion had a positive relationship with emotional exhaustion.
Pålsson et al.	1996	Empathy, burnout, sense of coherence	District nurses in south-eastern Sweden	n = 33; intervention group n = 21, comparison group n = 12	Karolinska Scales of Personality, The Burnout Measure, The Empathy Construct Rating Scale, Sense of Coherence Scale.	Negative correlation between burnout and empathy scores.
Tei et al.	2014	Empathy, burnout, alexithymia, emotional dissonance	Registered nurses in Kyoto, Japan.	n = 25	Interpersonal Reactivity Index. MBI (emotional exhaustion and depersonalisation dimensions). The Emotion Work Requirements Scale (hide negative emotion dimension). The Toronto Alexithymia Scale. Functional magnetic resonance imaging (fMRI).	Burnout severity and dispositional empathy showed a positive correlation. Burnout severity showed a positive correlation with emotional dissonance and alexithymia. Emotional exhaustion showed a positive correlation with perspective taking, hide negative emotion, and difficulty in identifying feelings.

Participant numbers varied from 25 to 164 (total participants in the five studies, n = 562). Participant gender was predominantly female (n = 521). Lee et al. (2003) and Pålsson et al. (1996) recruited only females, and the remaining three studies recruited a small percentage of male participants. Only Ferri et al. (2015) were able to report on gender differences where females demonstrated a superior empathic predisposition in comparison to males.

Four of the studies (Ferri et al., 2015; Lee et al., 2003; Omdahl and O’Donnell, 1999; Tei et al., 2014) used the MBI, and Pålsson et al. (1996) used The Burnout Measure. Two studies did not use the MBI in full. Tei et al. (2014) measured only the negative aspects of burnout, namely emotional exhaustion and depersonalisation. Omdahl and O’Donnell (1999) used 21 out of a possible 22 items on the MBI, and altered the scale from 7 to 5 Likert responses, and they reported such changes had previously been tested for validity and reliability.

Five different measures of empathy were used. Tei et al. (2014) and Lee et al. (2003) used a measure of both cognitive and emotional empathy. Pålsson et al. (1996) did not identify whether the empathy tool measured emotional or cognitive or both dimensions of empathy. Omdahl and O’Donnell (1999) and Ferri et al. (2015) used measures of emotional empathy.

Only one study (Ferri et al., 2015) used a measure of empathy and burnout exclusively. The remaining four studies gathered additional information on a variety of constructs, such as empowerment, alexithymia, sense of coherence, occupational commitment and communicative responsiveness. All studies used self-report instruments.

Three studies indicated that nurses with lower empathy scores reported higher burnout scores in either depersonalisation and emotional exhaustion or both (Ferri et al., 2015; Omdahl and O’Donnell, 1999; Pålsson et al., 1996). Pålsson et al. (1996) did not report any distinction between cognitive and emotional empathy, whilst Ferri et al. (2015) and Omdahl and O’Donnell (1999) measured emotional empathy only. The results differ somewhat from those of Lee et al. (2003).

Lee et al. (2003) reported that nurses with higher cognitive empathy revealed lower scores on burnout dimensions, but no association between emotional empathy and any burnout dimension was reported. Lee concludes that in this study nurses showing simultaneous inadequate levels of cognitive empathy and high levels of emotional empathy may have difficulty in detaching from patient problems.

Contradictory to the other studies, Tei et al. (2014) found that nurses with greater self-reported empathic disposition did have higher burnout scores. The addition of functional magnetic resonance imaging (fMRI) in this study enabled Tei et al. to conclude that these nurses also had reduced empathy-related brain activity, indicating that these nurses may have difficulty in identifying their own emotional reactions.

Personal accomplishment was measured in three studies (Ferri et al., 2015; Lee et al., 2003; Omdahl and O’Donnell, 1999). Nurses reporting higher levels of empathy reported higher scores in personal accomplishment (Ferri et al., 2015) and Omdahl and O’Donnell (1999) indicate that nurses reported higher personal accomplishment if they had higher empathic concern and lower emotional contagion. However, Lee et al. (2003) reported that only nurses’ cognitive empathy, and not emotional empathy, was positively related to personal accomplishment

Discussion

This review sought to examine the relationship between burnout and empathy in adult nursing. All of the studies included used quantitative research designs, namely measuring the concepts of burnout and empathy using self-report questionnaires. The use of different measurement tools across the five studies made comparisons difficult. No qualitative studies were identified exploring both concepts together, although these have been explored individually (Austin et al., 2009; Melvin, 2012; Stayt, 2009; Wiseman, 2007). The predominant use of quantitative methods in empathy research has been questioned (Burks and Kobus, 2012; Pedersen, 2009), particularly as it is argued that qualitative research makes an important contribution to theory development (Bergdahl and Berterö, 2015). Utilisation of both qualitative and quantitative research approaches could strengthen theory development of empathy and burnout.

Three demographic variables, age, experience and gender, are worthy of discussion. The findings suggest burnout decreases with age (Lee et al., 2003), which is consistent with other studies (Hunsaker et al., 2015; Williams, 1989). The review also indicated that burnout does not increase with experience (Omdahl and O’Donnell, 1999), which is supported in studies of nurses and other health care professionals (Gleichgerrcht and Decety, 2013; Hooper et al., 2010; Raižienė and Endriulaitienė, 2007). These findings can be interpreted on two levels. First, increasing age and experience can lead to greater autonomy at work (Amini et al., 2015) and may allow for the development of high quality relationships with leaders and colleagues (Bishop, 2013), both of which have been suggested as possible job resource buffers in the development of burnout according to the Job Demands-Resources Model (JD-RM; Bakker and Demerouti, 2006; Bakker et al., 2005). The JD-RM proposes that high job demands relate to job strain leading to exhaustion, whereas job resources relate to job motivation, where a lack of job resources leads to disengagement at work (Bakker and Demerouti, 2006; Demerouti et al., 2001) and depersonalisation (Zapf et al., 2001). Second, findings relating to age and experience might indicate that nurses who have already experienced burnout have left the profession (Raižienė and Endriulaitienė, 2007) or choose not to participate in research of this nature. Only one study (Ferri et al., 2015) was able to examine gender differences, and this indicated that females demonstrated higher empathic predisposition than males. This is consistent with other studies in nursing (Williams, 1989) and in medicine (Gleichgerrcht and Decety, 2013; Hojat et al., 2002), but highlights the need to include male and female nurse participants in studies so that meaningful conclusions can be drawn.

The conclusions of this review indicate a complex but important relationship between empathy and burnout. There was a negative correlation between burnout and empathy in three of the studies (Ferri et al., 2015; Omdahl and O’Donnell, 1999; Pålsson et al., 1996), although a positive correlation was found between emotional contagion and burnout by Omdahl and O’Donnell (1999), indicating nurses who absorb the emotional distress of the patients may be at higher risk of burnout. Two of these studies used measures of emotional empathy, and Pålsson et al. (1996) used a global unidimensional empathy measure. It is with the addition of a measure of cognitive empathy that the results become interesting, indicating a crucial nuance in the relationship between emotional and cognitive empathy, and burnout. Lee et al. (2003) found that some nurses experienced low levels of cognitive empathy whilst also experiencing high levels of emotional empathy. They suggest that nurses with these empathy characteristics may not be able to deal effectively with the emotional burden of distressing clinical situations, thus increasing the risk of burnout. Although nurses identify empathy as an important part of ethical practice (Austin et al., 2009), there is a risk of over-arousal when engaging empathically with patients. Emotion work, such as nursing, has been identified as being demanding on personal resources, and if not supported by an increase in resources may have negative consequences (Zapf, 2002). Hospice nurses who overly identify emotionally with patients, that is, vicariously experiencing patients’ distress, were at higher risk of compassion fatigue than those who do not (Abendroth and Flannery, 2006). Emotional over-arousal and an inability to regulate one’s own emotions may contribute to moral distress in health care professionals (Rushton et al., 2013). Overall, these findings theoretically suggest that the emotional demands of being empathic need to be buffered by an increase in resources. These resources may be intrinsic, for example employing adaptive cognitive empathy, or extrinsic, for instance further support from the organisation in the form of managerial support or further education. These results also point to the importance of using a multi-dimensional empathy instrument in research that encompasses both cognitive and emotional components.

Advances in social neuroscience empathy research indicate that there is a close interaction between emotional and cognitive empathy (Goerlich-Dobre et al., 2015). The automatic ‘bottom-up’ emotional empathic process is where emotional contagion or emotional over-arousal may induce personal distress (Decety and Lamm, 2006). The cognitive process or intentional ‘top–down’ empathic process enables self-regulation of emotions to occur (Decety and Lamm, 2006). The evidence from Decety and Lamm (2006) points to a necessary ability to regulate one’s own emotions in order to control emotional over-arousal when empathising with another individual. Regulation of one’s own emotions is a part of emotion management, and this appears to be important in lowering the risk of compassion fatigue and burnout (Zeidner et al., 2013). Tentative conclusions between the advances in social neuroscience empathy research and the study by Lee et al. (2003) can be inferred. It may be that when some nurses were experiencing empathy, the automatic process of emotional empathy was causing over-arousal of negative emotions. At the same time the intentional cognitive process was not engaging self-regulation of these emotions, leading to higher burnout scores. This may indicate a reduced emotion regulation ability in these nurses.

The addition of fMRI imaging to the study by Tei et al. (2014) enabled the researchers to conclude that some nurses with greater self-reported empathy and higher burnout scores also showed reduced empathy-related brain activity. This indicated that these nurses may have difficulty in identifying their own emotional reactions (Tei et al., 2014), which is an important factor in self-regulation. Self-regulation has been described as self-awareness during empathic engagement with patients, present in nurses with well-developed empathy skills (Wiseman, 2007), protective against burnout (Visintini et al., 1996), and is an important component of compassionate care (Van Der Cingel, 2009).

The implications of these findings suggest that whether nurses have high or low empathy there still seems to be a risk of burnout for some; but emotion regulation appears crucial. Without the ability to regulate one’s own emotions, excessive emotional empathy may be detrimental to the wellbeing of the nurse. It is postulated that emotional empathy is only useful to the patient if it results in action by the nurse (Morse et al., 2006). However, it appears from this review that emotional empathy may only be useful to the nurse and the patient if the nurse employs cognitive empathy in an adaptive way, that is, with an ability to emotionally self-regulate. The concept of regulating one’s own emotions is a part of emotional intelligence (Mayer et al., 2004). A study of physicians, social workers and psychologists found that those higher in emotional intelligence reported lower burnout and secondary traumatic stress (Zeidner et al., 2013). It could be theorised that nurses who are more emotionally intelligent may be at lower risk of the negative consequences of caring when they engage empathically with patients, as they will be better able to engage in the intentional cognitive empathic process.

It is important to acknowledge that studies have shown that individual nurses experience compassion satisfaction and personal accomplishment (Morrison and Korol, 2014; Williams, 1989). Three of the studies in this review measured personal accomplishment. High levels of empathy were reported in nurses who reported higher scores of the personal accomplishment factor in the MBI (Ferri et al., 2015; Omdahl and O’Donnell, 1999), although Lee et al. (2003) reported this finding with cognitive and not emotional empathy. Utrianinen et al. (2015) suggest that it is timely that the positive aspects of nursing work are researched. Therefore there is an argument for investigating both the positive and negative aspects of nursing work concurrently, particularly in light of the reconceptualisation of burnout on a continuum with work engagement (Schaufeli et al., 2009).

This review points to a possibility that nurses who are less able to self-regulate their emotions during empathic engagement may be at higher risk of burnout. Unfortunately, the cultural spread of studies in this review makes it difficult to draw general conclusions. Indeed, it is not known whether the nurses in these studies were aware of their emotions or had an ability to identify the emotions they were feeling. It may be important that nurses are taught, and continue to develop, emotion regulation strategies through pre- and post-registration education. Neumann et al. (2009) argue that empathy can be learned and improved. Nurses who have undertaken empathy-related training have been identified as showing higher empathy scores than those who have not had training (Kuo et al., 2012). A workforce that is able to develop healthy empathic engagement is particularly important, as empathy in health care practice has been shown to improve patient outcomes and patient decision making (Lelorain et al., 2012; Parkin et al., 2014), and may be beneficial in avoiding burnout (Raižienė and Endriulaitienė, 2007). Researchers argue that measures should be implemented by organisations and educators to maintain empathy levels (Burks et al., 2012). In order for nurses to develop empathic skills and resilience to the negative consequences of caring, policy makers, health care organisations and educators have to work together to develop a strategic direction in developing empathy and compassion.

Limitations of the studies

All studies except that of Omdahl and O’Donnell (1999) reported on limitations of the research. The limitations fall into four categories. The first relates to study design and methods. One study used clinical supervision as an intervention (Pålsson et al., 1996), four of the studies used a descriptive cross-sectional design, and none reported on a sampling frame (Ferri et al., 2015; Lee et al., 2003; Omdahl and O’Donnell, 1999; Tei et al., 2014). A cross-sectional study design is useful as it is inexpensive, data is collected at a single point in time, and relationships between constructs can be described (Bowling, 2002). However, studies using a cross-sectional design limit the applicability of findings beyond the study population, particularly if a sampling frame has not been reported, and causal relationships between variables cannot be determined. The use of more robust methods such as structural equation modelling (Leiter and Maslach, 2009) would determine variable relationships in a proposed model.

The second limitation relates to conceptual clarity. Defining a concept is important to provide the theoretical underpinning for testing relationships between variables (Carter and Henderson, 2005). Only two studies provided a definition of each of the concepts being measured (Ferri et al., 2015; Omdahl and O’Donnell, 1999), but neither of these studies made the distinction between the emotional and cognitive dimensions of empathy. Lee et al. (2003) made the distinction between cognitive and emotional empathy, which was important to the framework of the study. It is incumbent on researchers to clearly describe the concepts to be measured. This enables study variables to be tested and results to be interpreted in the context of current theory. In doing this, the study findings build on current theory and provide meaning to clinical practice. Additionally, concepts direct the choice of appropriate research design and measurement tools in a study.

The third limitation relates to the validation of measures and the use of self-report questionnaires. Measurement tools should be tested for validity and reliability to ensure they are measuring what they purport to measure in the population of interest (Bowling, 2005). All but one of the studies in this review used the MBI to measure burnout. The MBI is a robust measurement tool that has been tested for validity and reliability in many languages, and is being used increasingly in health care research (Trufelli et al., 2008). However, comparisons between studies were complicated as five different measures of empathy were used.

Although self-report questionnaires are inexpensive and easy to administer, one limitation is that people may be poor judges of their own abilities (Cherniss, 2010), and although this notion has been challenged (Ackerman et al., 2002), there is a reported potential to ‘fake’ responses (Tett et al., 2012); and a second is that self-report questionnaires may produce different responses to those elicited in face-to-face interviewing (Bowling, 2002). A solution may be to combine qualitative and quantitative methods within studies.

The fourth limitation relates to the geographical spread of the studies. The studies crossed three continents, Asia, Europe and the United States of America. Clearly, this makes comparisons across studies difficult. For example, Lee et al. (2003) reported much higher levels of burnout in Korean nurses than in previous studies across other continents. Cross-cultural validation of instruments is time consuming and requires a rigorous approach to ensuring validity and reliability are established in different cultures (Sousa and Rojjanasrirat, 2011). These findings support the importance of cultural context in research and the need for rigorous psychometric testing of translated instruments, as well as highlight the differences in individuals and health care organisations across the globe.

Implications

The results of this review have implications for nursing practice, nurse education, nursing research and health care policy, although these have to be viewed with caution as none of the studies were conducted in Ireland or the UK. The cultural differences in nursing in Ireland and the UK may reveal different results from the studies included in this review. Evidence suggests that burnout is higher in the Japanese, US and Canadian workforce, but the majority of studies do not use random sampling so it is difficult to draw firm conclusions (Maslach et al., 2001). However, saying that, compassion is high on the nursing agenda in the UK and Ireland (Department of Health, 2012; Health Service Executive, 2016), and it is known that burnout is present in the nursing profession in the UK (Sheward et al., 2005; Trufelli et al., 2008), therefore it would be pertinent to address the risk of burnout as part of the nursing agenda. The complex relationship identified between empathy and burnout in this review indicates that neither should be addressed in isolation. Health care organisations can work to identify nurses at high risk of burnout before nurses leave the profession. Provision of a supportive environment where nurses feel able to discuss burnout without risk of stigma, and ongoing professional education in health care organisations regarding the risks of burnout and the importance of healthy empathic engagement, could be implemented.

This review suggests that an ability to self-regulate emotions during empathic engagement may be an important factor in reducing the risk of burnout in nurses, but there are too few studies with a wide geographical spread to draw firm conclusions. This points to a need to undertake studies examining the relationship between burnout and empathy, particularly in the UK and Ireland. Academic institutions are well placed to undertake such research, and could work closely with health care organisations to recruit to such studies. Finally, researchers should use instruments that measure cognitive and emotional empathy, both the positive and negative consequences of clinical practice, and identify the reasons why some nurses do not participate in research of this nature. Nurses who do not participate in this type of research may be a particularly vulnerable group as the reasons for non-participation are currently unknown.

Conclusion

This paper has attempted to summarise published papers on burnout and its relationship to empathy in adult general nursing. The studies reviewed measured burnout and empathy. The results of this review demonstrate that there is a complex relationship between the two constructs of empathy and burnout. Tentative findings suggest that to reduce the risks of burnout over-arousal during the engagement of emotional empathy requires a well-developed ability to self-regulate emotions during the process of cognitive empathy. The results imply a need to evaluate both cognitive and emotional aspects of empathy, and to include measures of work engagement along with burnout.

If burnout is to be addressed, policy developers, academic institutions and health care organisations have a responsibility to undertake robust research in this area, and provide support and interventions for those nurses at high risk. This research and support could be undertaken in the context of the JD-RM, where the emotional nature of empathising with patients in distress could be seen as a high job demand, and cognitive empathy could be viewed as a job resource. This model could provide a framework for supportive interventions, such as the provision of educational initiatives to improve cognitive empathy and emotion self-regulation, and improving organisational commitment in providing a better balance between work demands and nurses' and organisations’ values.

Key points for policy, practice and/or research

For some nurses, burnout is a consequence of empathic and compassionate practice.