Personality and Individual Differences 213 (2023) 112314

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Personality and Individual Differences

journal homepage: www.elsevier.com/locate/paid

The mediating role of self-compassion and repetitive negative thinking in

the relationship between perfectionism and burnout in health-field
students: A prospective study
Carolina Cabaços a, b, c, *, António Macedo a, b, c, Mário Carneiro a, b, Maria João Brito a, b,
Ana Paula Amaral d, Ana Araújo a, b, c, Diogo Telles Correia e, Filipa Novais e, Paulo Vitória f, g, Ana
Telma Pereira a, c
a
Institute of Psychological Medicine, Faculty of Medicine, University of Coimbra, Portugal
b
Department of Psychiatry, Centro Hospitalar e Universitário de Coimbra, Portugal
c
Coimbra Institute for Biomedical Imaging and Translational Research (CIBIT), Institute of Nuclear Sciences Applied to Health (ICNAS), University of Coimbra, Portugal
d
Coimbra Health School, Laboratory for Applied Health Research, Polytechnic University of Coimbra, Portugal
e
Faculdade de Medicina, Universidade de Lisboa, Portugal
f
Social and Human Sciences Faculty, Psychology and Education Department, University of Beira Interior, Covilhã, Portugal
g
CIS - Centre for Psychological Research and Social Intervention, ISCTE - Instituto Universitário de Lisboa, Lisboa, Portugal

A R T I C L E I N F O A B S T R A C T

Keywords: Burnout negatively affects around 40 % of medical and dentistry students, a group with high levels of perfec­
Burnout tionism, repetitive negative thinking (RNT) and low self-compassion. So far, literature has highlighted the
Perfectionism beneficial effects of mindfulness and self-compassion-based interventions on reducing psychological distress;
Self-compassion
nevertheless, the relationship between perfectionism, self-compassion, RNT and burnout has not yet been studied
Repetitive negative thinking
in this population with a prospective study design. The aim of this prospective study was to analyse the role of
Medical students
Dentistry students perfectionism, self-compassion and RNT on burnout levels in medical and dentistry students after approximately
one year and a half. 202 medical and dentistry students answered in T0 and T1 (after 18 months) to a self-report
questionnaire that included measures to assess perfectionism, RNT, self-compassion, and burnout. Perfectionism,
RNT and self-compassion correlated significantly with each other, and all correlated with Burnout. In mediation
analyses, total perfectionism at T0 predicted burnout at T1, both directly and indirectly, through the mediating
effect of self-compassion and RNT at T0. This study reinforces recent findings that self-compassion is a mediator
of the relationship between perfectionism and burnout and adds that RNT also plays an important role in this
predictive pathway.

1. Introduction Although burnout is transversal to multiple professional domains

Burnout was defined by Maslach as a state of physical, emotional,
and mental exhaustion that arises as a response to intense and chronic
stressors in the context of a professional or academic activity. As a
syndrome, burnout comprises three major independent components:
emotional exhaustion (decreased energy and eagerness to perform
tasks), depersonalization (dehumanization, indifference toward others
and emotional dissatisfaction) and reduced personal accomplishment
(absence of personal achievement, as well as of technical competence)
(Maslach & Leiter, 2016).
and even to undergraduates (Frajerman et al., 2019), it affects around
40 % of medical students (Frajerman et al., 2019), as well as a consid­
erable number of dentistry students (Kwak et al., 2021), from the first
year onwards (Boni et al., 2018). In this population group it is associated
with substance abuse (Jackson et al., 2016), anxiety, depression (Leb­
ensohn et al., 2013), and suicidal behavior (van der Heijden et al.,
2008). At a professional level, it leads to more errors and malpractice
(Panagioti et al., 2018).
Burnout arises from the interaction between internal and external
factors. Among the internal ones, some personality traits such as

* Corresponding author at: Institute of Psychological Medicine, University of Coimbra, Coimbra, Portugal.
E-mail address: csm.cabacos@gmail.com (C. Cabaços).

https://doi.org/10.1016/j.paid.2023.112314
Received 31 March 2023; Received in revised form 9 June 2023; Accepted 13 June 2023
Available online 20 June 2023
0191-8869/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
C. Cabaços et al.
perfectionism stand out (Hill & Curran, 2016). Indeed, students with
high levels of this trait may be drawn to the Medicine and Dentistry
areas in the first place (Pereira, Brito, et al., 2022; Pereira, Cabaços,
et al., 2022).
The pursuit of perfection, unrealistic high-performance standards
and critical self-evaluations are all included in the definitions of
perfectionism (Flett & Hewitt, 2002). Perfectionism is a multidimen­
sional trait that includes two well established dimensions: perfection­
istic strivings and perfectionistic concerns (Stoeber & Gaudreau, 2017).
Although the first can be moderately related to positive outcomes, such
as academic achievement (Madigan, 2019), recent meta-analytical
research has shown that, overall, perfectionism is typically maladap­
tive and rarely adaptive (Hill et al., 2021). The most recently developed
and validated measurement model, which operationalizes perfectionism
in three general dimensions - self-critical, rigid, and narcissistic
perfectionism - has confirmed its predominantly negative nature (Feher
et al., 2020; Smith et al., 2016). This model, by recognizing self-criticism
as an inherent component of perfectionism, is consistent with the Hewitt
and colleagues view of self-criticism as a manifestation of a perfection­
istic interpersonal style (Hewitt & Flett, 2002), which was also empiri­
cally shown by Gilbert et al. (2006).
Perfectionism leads to psychological distress, namely depression,
anxiety, and fatigue via the mediation role of negative repetitive
thinking (RNT) (Macedo et al., 2015), which is defined as the repetitive,
passive, intrusive and self-focused thinking about one’s problems, past
experiences, and future concerns, in a way that is complicated to
disengage from (Ehring et al., 2011). It was recently found, also in a
study with medical and dentistry students, that this cognitive emotional
regulation process reinforces the relationship between perfectionism
and burnout (Cunha et al., 2022).
Self-compassion, which involves being supportive toward oneself
when experiencing suffering, caused by personal mistakes and perceived
inadequacies or stressful events (Neff, 2023), has been found to coun­
terbalance the pernicious effect of perfectionism (Abdollahi et al., 2020;
Ferrari et al., 2018; Stoeber et al., 2020; Wei et al., 2021). A recent study
with a sample of medical students found that self-compassion signifi­
cantly mediated the relationship between perfectionism and burnout
(Pereira, Brito, et al., 2022; Pereira, Cabaços, et al., 2022).
Self-compassion is a multifaceted construct organized into three
broad domains: how people emotionally respond to suffering (kindness
vs judgment), how they cognitively understand their difficulties or ad­
versities (as a feeling of common humanity vs isolation), and how they
pay attention to suffering (in a mindful or overly identified manner).
According to Neff (2023), these broader dimensions work together to
alleviate suffering by allowing self-compassionate individuals to
respond to themselves with warmth and keeping them from becoming
overly identified with their negative thoughts or feelings, narrowing
one’s focus and exaggerates implications for self-worth.
Thus, self-compassion might decrease maladaptive cognitive pro­
cesses following a stressor by preventing cognitive elaboration and
maladaptive thinking, as well as associated prolonged negative affect.
Several studies have shown that self-compassion and RNT are negatively
associated with each other (e.g., Mantzios, 2014) and theoretical models
of self-compassion have suggested that its relationship with depression
and anxiety may be due to its impact upon RNT (e.g., Allen & Knight,
2005; Leary et al., 2007). Previous research has highlighted the role of
self-compassion in decreasing the likelihood of developing psychopa­
thology through lessened automatic and negative thinking (Yip & Tong,
2021). These findings suggest that increasing self-compassion may act as
a protective buffer on anxiety and depression symptoms by reducing
RNT (e.g., Schlosser et al., 2022).
Adding to previous results on the role of self-compassion in the
relationship between perfectionism and burnout in health field students
(Pereira, Brito, et al., 2022; Pereira, Cabaços, et al., 2022), the aim of
this longitudinal study is to analyse the role of perfectionism, self-
compassion, and RNT on burnout levels after a period of 18 months,
2
Personality and Individual Differences 213 (2023) 112314
controlling for burnout levels at the baseline. This might help support
the relevance of testing the efficacy of self-compassion interventions to
reduce perfectionistic RNT whose beneficial effects can be maintained
over the time, namely throughout the following school years. Our hy­
pothesis is that RNT and self-compassion may have a mediating role in
the relationship between perfectionism and burnout levels 18 months
later.
2. Material and methods
This is a prospective study covered by the research project “COM­
BURNOUT”, funded by the Calouste Gulbenkian Foundation’s and
approved by the Ethics Committee (ref. nr. 146-CE-2020).
2.1. Procedure and participants
Health field students from Portuguese Universities voluntarily
answered an online self-response Google Forms questionnaire, which
was advertised via email, social media, and students’ organizations.
Before answering, participants were asked to give their informed con­
sent, and confidentiality was guaranteed.
Participants were recruited during finals season in two time periods:
T0 (January–February 2021) and T1 (June–July 2022) interspersed over
a period of approximately 18 months (mean = 17.82 ± 1021). The
sample was composed of 202 participants. Two thirds of the students
were in pre-clinical years (1st–3rd year – 78.2 %; n = 158). Most were
medical students (58.9 %; n = 119); 28.2 % (n = 57) were Dentistry
students and 12.9 % (n = 26) were from other health-related courses;
82,2 % (n = 166) were female. Age ranged from 18 to 41, with a mean of
20.79 (±3.25) years old. The vast majority were Portuguese (95.5 %; n
= 193) and all students were fluent in the Portuguese language.
2.2. Measures
All the questionnaires revealed good reliability and validity
(construct and concurrent) in Portuguese students’ samples. The inter­
nal consistency coefficients (Cronbach’s alpha) obtained with the pre­
sent study’s sample are presented in Table 1.
2.2.1. Perfectionism
We used a short Portuguese version (Pereira et al., 2023) of the Big-3
Perfectionism Scale (BTPS; Feher et al., 2020), composed of 16 items
belonging to three dimensions: rigid perfectionism (e.g., “I strive to be as
perfect as possible”), self-critical perfectionism (e.g., “People are
disappointed in me whenever I don’t do something perfectly”), and
narcissistic perfectionism (e.g., “I am the absolute best at what I do”).
Items are ranked on a 5-point Likert scale from 1 = Strongly disagree to
5 = Strongly agree.
2.2.2. Burnout
The Maslach Burnout Inventory-Student Survey (MBI-SS; Marôco &
Tecedeiro, 2009) is a self-report measure comprising 15 items that
validly and reliably evaluate three factors (emotional exhaustion,
cynicism, and academic efficacy) and an overall burnout measure. Items
are ranked on a 7-point Likert scale from 0 = Never to 6 = Every day.
2.2.3. Repetitive negative thinking/RNT
The sum of the 15 items of the Portuguese version (Chaves et al.,
2013) of the Perseverative Thinking Questionnaire (Ehring et al., 2011)
was used as a global score of RNT (e.g., “The same thoughts keep going
through my mind again and again”). Items are ranked on a 4-point Likert
scale from 0 = Never to 3 = Nearly every day.
2.2.4. Self-compassion
The Portuguese version (Castilho et al., 2015) of the Short Form of
the Self-Compassion Scale, composed of 12 items was used as a global
C. Cabaços et al. Personality and Individual Differences 213 (2023) 112314

Table 1
Descriptive statistics, internal consistencies, and correlations.
Perfectionism T0 RNT T0 Self-compassion T0 Burnout T0 Mean SD α Cronbach
Perfectionism T0 1 40.87 10.57 0.86
RNT T0 0.45 1 30.98 12.65 0.95
Self-compassion T0 − 0.44 − 0.58 1 34.83 9.23 0.89
Burnout T0 0.38 0.52 − 0.44 1 39.31 15.69 0.73
Perfectionism T1 0.81 0.20 − 0.15 0.13 21.72 6.21 0.84
RNT T1 0.37 0.80 − 0.44 0.45 32.54 12.36 0.95
Self-compassion T1 − 0.38 − 0.55 0.80 − 0.45 40.21 9.86 0.88
Burnout T1 0.44 0.50 − 0.37 0.62 40.55 11.84 0.74

Note: SD. Standard deviation; *p<0.05; **p<0.01

score of self-compassion. Items are ranked on a 5-point Likert scale from
1 = Almost never to 5 = Nearly every day.
3. Data analyses
Descriptive, t-test and Pearson correlation analyses were conducted
using the software SPSS, version 27. The mediation analyses were per­
formed using PROCESS macro (Model 6) for SPSS (Hayes, 2018).
The PROCESS macro uses the bootstrapping method, which is a
method of assessing direct and indirect effects of variables in a way that
maximizes power and is robust against non-normality. The indirect ef­
fect represents the impact of the mediator variable(s) on the original
relation (i.e., the relation of the independent variable on the outcome
variable) (Hayes, 2018).
Total perfectionism at T0 was the predictor and burnout at T1 was
the dependent variable, with self-compassion and RNT at T0 as media­
tors 1 and 2, respectively. The direct effect represents the influence
pathway between the predictor (perfectionism) and the outcome vari­
able (burnout), while the mediator remains unaltered. The indirect ef­
fect represents the impact of the mediator variables (self-compassion
and RNT) on this original association. If zero is not contained within the
confidence interval (CI) of the indirect effect, the difference between the
total and direct effects is not zero and thus the indirect effect is signif­
icant. Typically, 95 % bias-corrected (BC) bootstrap confidence intervals
are used to judge the significance of the indirect effect, with confidence
intervals resampled 5000 times for each analysis (Hayes, 2018).
increasing) levels of RNT (at T0) so these were entered as the first and
the second mediators, respectively. The mediation model was used to
test the direct effect of perfectionism at baseline on burnout levels after
18 months, as well as the indirect effects of negative repetitive thinking
and self-compassion (also at baseline) on the outcome.
Burnout levels at T0 were statistically controlled in the tested model
(entered as a covariate), in order to control for burnout levels at baseline
when assessing the effect of the predictors and mediators on the
outcome.
Table 2 presents the summary of the results of the serial mediation
analysis, with an indication of the total (c), direct (c′ ) and indirect effects
that were estimated for all mediations.
The model, presented in Fig. 1, tested whether self-compassion at T0
and repetitive negative thinking at T0 would mediate the relationship
between perfectionism at T0 and Burnout at T1 (Fig. 1).
Results indicated that the total effect of perfectionism on burnout
was significant (Effect = 0.2713 SE = 0.0647, t = 3.1741, p < 0.001), as
well as the direct effect (Effect = 0.2195, SE = 0.0691, t = 4.1949, p <
0.001). Table 2 also shows that the total indirect effect was 0.0519 and
statistically different from zero (95 % CI: 0.0041 to 0.1067). The specific
indirect effect of perfectionism on burnout through self-compassion
(indirect effect 1) was not significant whereas through RNT (indirect
effect 2) was different from zero, so this specific indirect effect was
significantly positive. The indirect sequential effect through self-
compassion and RNT (indirect effect 3) was significant. This model
explained 43.16 % of burnout’s variance at T1 (F = 75.54, p < 0.001).

4. Results

4.1. Descriptive and correlation analyses Table 2

Serial mediation analysis.
Table 1 presents the descriptive data, internal consistencies obtained Effects Coefficient SE p Bootstrapping
for each scale and Pearson’s correlation coefficients between all BC 95 % CI
variables. Lower Upper
The mean comparison of all variables between genders revealed no
PREDICTOR:
significant differences (p > 0.05). Perfectionism at T0
All variables at T0 correlated with themselves with a high magni­ Total effect c 0.2713 0.0647 <0.001 0.0001 0.1438
tude. Perfectionism at T0 significantly correlated with all variables (p < Direct effect c′ 0.2195 0.0691 <0.001 0.0017 0.0831
0.01), showing moderate magnitude correlations with RNT, self- Indirect effects
Total indirect 0.0519 0.0258 0.0041 0.1067
compassion and burnout at T1. RNT and self-compassion at T0 corre­ effect (Perfectionism
lated with all variables (p < 0.01). → Self-Compassion
Thus, the proposed mediators, self-compassion and RNT, were → RNT → Burnout)
correlated with the proposed predictor (Perfectionism) and outcome Indirect effect 1 − 0.0081 0.0279 − 0.0621 0.0521
(Perfectionism →
variable (Burnout).
Self-compassion →
Burnout)
4.2. Serial multiple mediation analyses Indirect effect 2 0.0249 0.0125 0.0034 0.0529
(Perfectionism →
RNT → Burnout)
A serial multiple mediation model was tested to examine the medi­ Indirect effect 3 0.0350 0.0224 0.0014 0.0874
ation roles of self-compassion (M1) and repetitive negative thinking (Perfectionism →
(M2), both at baseline (T0), in the relationship between perfectionism Self-compassion →
(at T0) and burnout (at T1). RNT → Burnout)

Perfectionism (at T0) was hypothesized to have an effect on low self- Note: Total, direct, and indirect effects of the serial mediation model with
compassion (at T0) that in turn was considered to influence (by Burnout at T1 as the outcome.

3
C. Cabaços et al.
Fig. 1. Serial multiple mediation model with perfectionism at T0 as a predictor.
Note. Burnout at T0 (b = 0.3969, SE = 0.0436, t = 9.11, p < 0.001) was controlled. Numbers represent unstandardized coefficients. Numbers in parentheses represent
standard errors. NS: not significant; **p < 0.01; ***p < 0.001.
5. Discussion
The purpose of this study was to thoroughly analyse and investigate,
in a representative sample of Portuguese health field students, the psy­
chological mechanisms that may contribute to burnout, with a focus on
exploring the role of perfectionism, as a predictor, and the potential
mediating effects of self-compassion and RNT.
Our hypothesis was that self-compassion and RNT at baseline might
have a mediating role in the relationship between Perfectionism at
baseline and burnout 18 months later. This study arises from the need to
find effective intervention strategies to prevent and manage burnout, in
a particularly susceptible group – health field students. A recent study
had already shown the mediating effect of self-compassion in the rela­
tionship between perfectionism and burnout in this population (Pereira,
Brito, et al., 2022; Pereira, Cabaços, et al., 2022), however the role of
RNT in this relationship in a prospective manner has not yet been
explored. Our hypothesis was partially confirmed.
We began by analysing gender differences in relation to the evalu­
ated constructs and found no significant differences (p > 0.05). Total
perfectionism at T0 correlated significantly with all variables, positively
with burnout and RNT and negatively with self-compassion both at T0
and T1. Based on the correlation patterns, we performed multiple
mediation analysis where perfectionism at T0 was the predictor and
burnout at T1 was the dependent variable, with self-compassion and
RNT as mediators. Mediators were assessed at the same time point as the
predictor (at baseline) and only the outcome was evaluated prospec­
tively (after an 18-month period), thus helping demonstrate that in­
terventions at the level of mediating processes may possibly have a more
sustained effect on the outcome, which will soon be tested in a clinical
trial.
In the mediation model, perfectionism predicted burnout both
directly and indirectly, through the mediation effect of self-compassion
and RNT. These findings show that the influence of perfectionism on
burnout operates independently of the self-compassion levels, although
the latter may be a path which enhances the influence of perfectionism
on burnout levels.
In short, perfectionism can explain increasing levels of negative re­
petitive thinking, such as worry and rumination (Macedo et al., 2015;
Macedo et al., 2017). RNT at T0 correlates positively with burnout at T1
(moderate magnitude) and is a mediator of the relationship between
perfectionism at T0 and burnout at T1. Self-compassion at T0 does not
directly have a significant effect on burnout, however, if we consider
repetitive negative thinking, the effect is already significant.
Perfectionists tend to have low self-compassion, which will reinforce
RNT that in turn can end up triggering burnout. In other words, if a
student has low self-compassion and thinks repetitively about it (worry
and rumination about perfectionistic and self-critical content) they will
be more susceptible to burnout after one year. RNT is a modifiable
4
Personality and Individual Differences 213 (2023) 112314
cognitive process, as the individual may recognize the ruminative
thoughts as a spectator and distance oneself from the unconstructive
worry and negative and disruptive content. In fact, a study that analysed
the effect of a one-session acceptance and commitment therapy protocol
to reduce RNT showed that out of 11 participants nine showed signifi­
cant reductions in at least three out of the four RNT measures (Ruiz
et al., 2016). Therefore, working on RNT and self-compassion through
recommended interventions, such as those focused on mindfulness and
mindful self-compassion (Fendel et al., 2021), should be a strategy to be
considered in the future. Mindful based interventions have already been
shown to be effective in individuals with low self-compassion. In fact, a
Short-Term Online Version of a Mindfulness-Based Intervention
(Halamová et al., 2018) was already conducted with very promising
results, reporting a significant reduction in self-criticism and self-
uncompassionate behavior. Although the Self-Compassion Scale, used
to assess this construct in our study, measures trait levels of the general
tendency to respond self-compassionately in moments of internal and
external challenges, the author of the scale herself understands self-
compassion as a process of modifiable state of mind (Neff, 2023),
making it a potential target of great interest in the development of in­
terventions aimed at preventing and intervening on burnout in medical
students.
Our results confirm the role of RNT as a pathway by which perfec­
tionism is a predictor of psychological distress and adds that fostering
self-compassion may mitigate this role. By replacing the harsh and re­
petitive self-judgments that often accompany perfectionistic concerns
and worries with tolerance and kindness toward one’s imperfections
(Abdollahi et al., 2020), self-compassion might ease the cognitive and
emotional burden of perfectionism by diminishing the utilization of
negative metacognitive emotional regulation strategies.
It is important to take into account the limitations of our study such
as the high proportion of female participants - while it may limit the
ability to make generalizations, the proportion of the sample is repre­
sentative of the Portuguese population of medicine and dentistry stu­
dents (5:1); also a potential self-selection bias – perfectionist students
were possibly more eager to participate; and the fact that the ques­
tionnaires were applied during the COVID pandemic, a landmark that
changed students’ lives significantly. Another potential limitation might
be the high proportion of students in their pre-clinical years, as empathy
is known to diminish throughout medical course (Spatoula et al., 2019)
and external stressors vary from pre-clinical to clinical years.
This research provides further information on how low self-
compassion can lead to increased negative thoughts, that may be
modified through intervention, namely group programs to enhance
mindfulness and self-compassion. Promoting safer environments as well
as interfering in emotional and cognitive processes that enhance the risk
for burnout in undergraduates may have a significant impact on psy­
chological well-being and academic and professional outcomes.
C. Cabaços et al.
In the future, it would be interesting to implement an experimental
clinical study, in students who have been found to have high levels of
burnout and/or of its known predictors, such as high perfectionism and
RNT. If the efficacy and effectiveness of these interventions are to be
confirmed, it could be relevant to propose the inclusion of these types of
programs in the medical education curricula to prevent and reduce
students’ burnout.
6. Conclusion
To our knowledge, this is the first study to examine the mediation
role of both self-compassion and repetitive negative thinking on medical
students’ perfectionism and burnout with a prospective study design,
providing us more robust information on how to prevent and approach
this problem over time.
Medical students face unique challenges. The findings of this study
highlight the potential advantages that individuals with high levels of
perfectionism, low self-compassion and repetitive negative thinking
could gain from interventions aimed at reducing the pernicious effects of
perfectionism while increasing self-compassion. It is crucial that we take
a long-term approach to preserve the mental health of medical students.
CRediT authorship contribution statement
Carolina Cabaços: Conceptualization, Methodology, Formal anal­
ysis, Investigation, Writing – review & editing. António Macedo:
Writing – review & editing, Supervision. Mário Carneiro: Investigation.
Maria João Brito: Formal analysis, Investigation. Ana Paula Amaral:
Investigation. Ana Araújo: Investigation, Writing – review & editing.
Diogo Telles Correia: Investigation. Filipa Novais: Investigation.
Paulo Vitória: Investigation. Ana Telma Pereira: Conceptualization,
Methodology, Formal analysis, Investigation, Data curation, Writing –
review & editing, Supervision, Project administration, Funding
acquisition.
Declaration of competing interest
The authors declare no competing interests.
Data availability
The data that has been used is confidential.
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