Nurse Education in Practice 51 (2021) 102999

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Nurse Education in Practice

journal homepage: www.elsevier.com/locate/issn/14715953

Original research

Prevalence and predictors for compassion fatigue and compassion

satisfaction in nursing students during clinical placement
Xiaoyi Cao, Lei Wang, Shenyi Wei, Jin Li, Shu Gong *
Department of Nursing, West China Hospital/West China School of Nursing, Sichuan University, 610041, Chengdu, Sichuan province, China

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

Keywords: Background: Compassion fatigue and compassion satisfaction affect clients’ care satisfaction and nurses’ well-
Clinical placement being. However, little attention is paid to compassion fatigue and satisfaction in nursing students during clin­
Compassion fatigue ical placement.
Compassion satisfaction
Objectives: To explore the relationships between social support, empathy, resilience, coping strategies, and
Coping strategies
compassion fatigue and satisfaction in nursing students during clinical placement in China.
Empathy
Nursing students Design: A cross-sectional study was performed from May 1 to May 31, 2020.
Resilience Settings: and participants: A total of 972 nursing students from 15 universities or colleges in Sichuan province, who
Social support received clinical training for at least 10 months were investigated.
Methods: The instruments included Perceived Social Support Scale, Jefferson Scale of Empathy, Connor-Davidson
Resilience Scale, Simple Coping Style Questionnaire and Professional Quality of Life Scale. Descriptive, corre­
lation and regression analyses of these variables were conducted.
Results: The prevalence of low, moderate and high risk of burnout were 1.3%, 97.8% and 0.9%, respectively. The
prevalence of low, average and high levels of secondary traumatic stress were 43.6%, 55.3% and 1.1%. More­
over, 9 (0.9%), 316 (32.5%) and 647 (66.6%) respondents reported low, moderate and high levels of compassion
satisfaction. Cognitive empathy and resilience were significant protectors from compassion fatigue, and signif­
icant contributors to compassion satisfaction. Less compassionate care and more passive coping were significant
risk factors for compassion fatigue. Adaptive coping predicted burnout significantly and negatively, and pre­
dicted compassion satisfaction significantly and positively. Family support was a significant contributor to
compassion satisfaction.
Conclusion: It is essential to develop strategies to increase empathy and resilience, avoid passive coping and
enhance adaptive coping, and improve family support in order to reduce compassion fatigue and facilitate
compassion satisfaction in nursing students during clinical clerkship.

1. Introduction Commission of the People’s Republic of China, 2019). Meanwhile,

The constant increase in aging population and clients with chronic
disease, the significant reduction in length of hospital stays, and the
continuous development of new medical technologies result in
increasing complexity of healthcare and rising demand for nurses. The
shortage of nurses receives global concern, which affects patient safety
and the quality of care. In China, there are 4.09 million nurses in 2018,
which increase by 7.63% than those (3.80 million) in 2017. However,
the nurses per thousand people in China are only 2.94, which is not only
dramatically lower than those in Western countries, but also lower than
those in Asian countries such as Japan and Singapore (National Health
another 360,000 new nursing positions will be created in 2020, which
implies that a growing number of novice nurses will be employed to fill
in existing and future demand for nurses in China (National Health
Commission of the People’s Republic of China, 2016).
Several factors contributed to nursing human resources crisis, which
consisted of poor recruitment, high turnover, aging workforce, and
ineffective use of nursing resources (Marć et al., 2019). Attrition in
nursing students is a global issue, it may commence during lecture ed­
ucation or clinical placement, and risk factors for attrition include aca­
demic failure (Roos et al., 2016), gap between expectations and
experiences in clinical environment (Ashghali Farahani et al., 2017),

* Corresponding author.
E-mail address: posteducation@126.com (S. Gong).

https://doi.org/10.1016/j.nepr.2021.102999
Received 27 August 2020; Received in revised form 29 January 2021; Accepted 15 February 2021
Available online 19 February 2021
1471-5953/© 2021 Elsevier Ltd. All rights reserved.
X. Cao et al.
and perceived lack of support from mentors (Ten Hoeve et al., 2017). In
general, nursing students receive clinically-oriented training during
their 3rd and 4th years, they are often exposed to similar stressful
workplace and real-life traumatic situations as professional nurses,
which affect their physical and mental well-being (Valero-Chillerón
et al., 2019).
Professional quality of life (ProQOL) refers to the quality which a
caregiver perceives regarding his/her work as a helper, that is a cumu­
lative experience of negative (compassion fatigue, CF) and positive as­
pects (compassion satisfaction, CS) (Stamm, 2010). A literature review
indicated that, CF and CS had major influence on clients’ care satisfac­
tion and nurses’ well-being (Sinclair et al., 2017). Nevertheless, for
nursing students in clinical clerkship, most of earlier studies focused on
the subjects of stress (Admi et al., 2018), satisfaction of clinical envi­
ronment (Woo and Li, 2020), and burnout syndrome (Valero-Chillerón
et al., 2019), little attention was paid to CF and CS in this population.
Therefore, to explore the specific mechanism that triggers CF and CS in
nursing students during clinical clerkship is beneficial to developing
strategies for protecting these students and forming an emotionally
healthy nursing workforce.
2. Background
CF is first defined as “lost the ability to nurture” in emergency nurses
(Joinson, 1992). Later, CF is described as a caregiver’s costs of caring
and reduced capability in being empathic of the suffering of the clients
(Figley, 2002). Stamm (2010) depicts ProQOL as a combination of CS
and CF, with the latter evaluated by burnout (BO) and secondary trau­
matic stress (STS). Of these, CF is linked to empathy, which occurs
suddenly and represents negative aspects of working with clients who
suffer from traumatic events. CS refers to the pleasure of a caregiver,
which derives from being capable of engaging in work and dealing with
costs of caring well (Stamm, 2010). Over the last two decades, CF and CS
received widespread attention that affected nurses’ job satisfaction and
turnover intention (Wells-English et al., 2019). Reported predictors for
CF and CS in nurses comprised: demographic factors, job-related factors,
and personal variables (Sinclair et al., 2017). However, most of previous
studies explored CF and CS in professional nurses, fewer studies paid
attention to these variables and their predictors in nursing students
during clinical practice.
Social support is defined as support from social interactions among
persons or groups or communities, which consists of family, friend and
other support (Lin et al., 1979). Social support had a significant negative
effect on CF, and a significant positive effect on CS in Korean nurses
(Yom and Kim, 2012). Family support was a significant protector from
CF, but friend and other support (e.g., manager and co-worker support)
did not predict CF significantly in Iranian nurses (Ariapooran, 2014).
Furthermore, relationships with co-workers significantly affected CF
and CS in trauma nurses (Hinderer et al., 2014). Although the associa­
tions between social support and CF and CS in nurses were examined
extensively in prior studies, to our knowledge, no studies explored the
associations between social support, and CF and CS in nursing students
during clinical placement.
Empathy refers to the perception and understanding of another
person’s feelings and thoughts from that person’s perspective, which
comprises cognitive and affective empathy (Morse et al., 1992).
Empathy was the main etiology for CF (Figley, 2002). Nonetheless,
empirical studies indicated equivocal relationships between the two
variables. Perspective taking (cognitive empathy) predicted high CS
significantly, but compassionate care (affective empathy) did not predict
CF and CS significantly in cancer nurses (Yu et al., 2016). Empathic
concern (affective empathy) was positively and significantly related to
CS, and negatively and significantly related to CF among medical social
workers (Yi et al., 2019). Another study on oncology healthcare pro­
fessionals showed a significant and positive relationship between
perspective taking and CS, and between empathic concern and CF.
2
Nurse Education in Practice 51 (2021) 102999
However, the relationships between perspective taking and CF, and
between empathic concern and CS were not significant (Hunt et al.,
2019). Therefore, although the significant positive correlations between
cognitive empathy and CS were consistent across studies, the in­
consistencies existed in the associations between cognitive empathy and
CF, and between affective empathy and CF and CS in healthcare pro­
fessionals. On the other hand, there were still no prior studies which
examined the correlations between empathy and CF and CS in nursing
students during clinical clerkship.
Resilience refers to recovery from stressful events and sustainable
capability under adversity (Werner, 1995). Then, Luthar (2006) de­
scribes resilience as a positive adaptive process when facing stressors,
which consists of positive adaptation and significant adversity (Luthar,
2006). Resilience affected nurses’ job performance and turnover inten­
tion significantly (Walpita and Arambepola, 2020). Regarding the as­
sociations between resilience, and CF and CS, it was demonstrated that,
resilience had a moderate positive relationship with CS, and a moderate
negative relationship with CF in hospice volunteers (Jo et al., 2020).
Resilience contributed to CF and CS significantly in critical care nurses
(Alharbi et al., 2020). Despite the consistencies in the correlations be­
tween resilience, and CF and CS in healthcare providers, the effects of
resilience on CF and CS in nursing students during clinical placement
received little attention.
Coping strategies represent stable strategies to overcome challenges
under stressful events. An early study showed that, nurses who adopted
more passive coping reported significantly higher CF, however, adaptive
coping was not positively and significantly related to CS (Yu et al.,
2016). Another study indicated that, coping strategies, including
problem-oriented coping and emotion-oriented coping, did not predict
CF and CS significantly (Alharbi et al., 2020). Moreover, competence in
coping with death significantly and negatively predicted CF, and
significantly and positively predicted CS in palliative care professionals
(Sansó et al., 2015). CF in trauma nurses was significantly and nega­
tively associated with the coping strategies of hobbies, and CS was
significantly and positively related to the coping strategies of exercise,
use of meditation and not use of medicinals (Hinderer et al., 2014).
Therefore, the correlations between coping strategies and CF and CS in
nurses were inconsistent across studies. Meanwhile, no studies explored
whether and to which extent coping strategies affected CF and CS in
nursing students during clinical placement.
The ProQOL model was used to guide the study. According to the
model, individual, job-related, and personal characteristics contribute to
negative (CF) or positive (CS) aspects of helping others (Stamm, 2010).
Based on literature review, individual factors mainly comprised sex, age
and education level; job-related variables comprised work units, job
stress, and manager and colleague support; and personal factors
included empathy, personality, and coping strategies (Sinclair et al.,
2017). Therefore, according to the model, we proposed the following
hypotheses: 1) as a combination of personal and job-related variables,
more support from family, friends, and managers or colleagues were
signifincantly related to lower CF and higher CS; 2) as personal re­
sources, higher empathy and resilience were signifincantly related to
lower CF and higher CS; and 3) as personal variables, more adaptive
coping were signifincantly associated with lower CF and higher CS, but
more passive coping were signifincantly associated with higher CF and
lower CS.
Therefore, the objectives of the study were to explore the correla­
tions between social support, empathy, resilience, coping strategies, and
CF and CS among nursing students during clinical placement in China.
3. Methods
3.1. Design and sample
This was a cross-sectional study which investigated 1131 nursing
students from 15 universities or colleges in Sichuan province, and a total
X. Cao et al. Nurse Education in Practice 51 (2021) 102999

of 972 nursing students voluntarily and successfully completed this
study (85.9%). The number of nursing students in each university or
college was shown in Table 1. Because CF or CS in Chinese nursing
students during clinical clerkship were not reported in prior studies, the
sample size in the study was calculated based on a study on CF in nursing
students during clinical placement in the United States (standard devi­
ation = 3.28) (Michalec et al., 2013). Based on the expected error of
estimation of 0.3 and a 5% margin of error, a minimal sample size of 460
was required.
A snowball sampling method was used. Firstly, all of the nursing
students receiving clinically-exposed training in a largest tertiary hos­
pital (4300 beds) in Sichuan province participated in an online ques­
tionnaire survey. Then, these participants invited their classmates
receiving clinical practice in other tertiary hospitals in Sichuan province
to attend the study. Nursing students meeting the following criteria were
eligible: 1) attended a 3-year associate or 4-year undergraduate nursing
program; 2) received clinical placement in tertiary hospitals in Sichuan
province; and 3) received clinical training for at least 10 months.
4-point Likert scale. The Cronbach’s α of the Chinese scale is 0.90, and
exploratory factor analysis supports a 2-factor structure in Chinese un­
dergraduate students (Xie, 1998). The Cronbach’s α of each subscale
ranged from 0.80 to 0.97 in the study.
The Professional Quality of Life Scale (ProQOLS) measures the
negative and positive aspects of helping others who experience trauma.
It is a 30-item instrument with 3 domains: CS, BO and STS, with the
latter two subscales reflecting CF. It is based on a 5-point Likert scale
with each subscale rated independently. The score of each subscale
ranges from 10 to 50 and is classified into 3 levels, with 22 or less
indicating low level, from 23 to 41 indicating average level, and 42 or
more indicating high level. The Cronbach’s α of each subscale ranges
from 0.72 to 0.87 (Stamm, 2010). The Chinese version supports the
3-factor structure, and the Cronbach’s α of each subscale ranged from
0.72 to 0.88 in clinical nurses (Wu, 2014). In the study, the Cronbach’s α
of each domain ranged from 0.84 to 0.87.
3.3. Data collection

The study was performed from May 1 to May 31, 2020. The data
3.2. Variables and instruments
collection process was conducted through an online survey. Firstly, after
the samples agreed to participate in the study, they were required to
The Perceived Social Support Scale (PSSS) assesses a person’s
scan a designated QR code. Next, an electronic written informed consent
experience of support from family, friends and others. It consists of 12
was signed by each participant. Finally, each participant was instructed
items and 3 domains (family, friend, and other support). Each item is
to complete these questionnaires step by step. The researchers left their
rated by a seven-point scale. The original scale reports satisfactory
mobile phone numbers in case of possible questions.
psychometric properties (Zimet et al., 1988). The Chinese version also
supports the 3-factor structure, and shows an appropriate reliability
3.4. Analysis
with a Cronbach’s α of 0.85 (Jiang, 2001). In the study, the Cronbach’s a
of the subscales ranged from 0.84 to 0.87.
The SPSS 23.0 was used for data analysis. As the data was normally
The Jefferson Scale of Empathy (JSE) evaluates empathic qualities in
distributed, the differences on CF (BO and STS) and CS between sub­
patient care. It consists of 20 items and 3 subscales (standing in the
groups were tested using independent t-tests. The relationships between
patient’s shoes, compassionate care, and perspective taking). A seven-
social support, empathy, resilience, coping strategies, and CF and CS
point scale is used, and the original scale has a Cronbach’s α of 0.80
were explored using Pearson correlation analysis. Multiple regression
(Hojat et al., 2002). The Chinese version is developed based on clinical
analysis was conducted to explore the effects of demographic factors,
nurses, and demonstrates a good reliability with a Cronbach’s α of 0.75,
social support, empathy, resilience, coping strategies on CF and CS. P <
and exploratory factor analysis extracts a 3-factor structure (An et al.,
0.05 was significant statistically (two-tailed test).
2008). In the study, the Cronbach’s α of the scale was 0.81.
The Connor-Davidson Resilience Scale (CDRS) appraises the ability
3.5. Ethical consideration
of a person to cope with adversity. It is an uni-dimensional construct
with 10 items. Each item is rated by a 5-point Likert scale. The Cron­
The study was approved by the Human Subjects Ethics Sub-
bach’s α of the original scale is 0.85 (Campbell-Sills and Stein, 2007).
committee of West China Hospital (no. 2020281). The participants
The translated Chinese scale has a Cronbach’s α of 0.93 in medical
could attend the study voluntarily, and could withdraw when they
students (Lu et al., 2016). The Cronbach’s α of the scale in the study was
wanted it at any time.
0.92.
The Simple Coping Style Questionnaire (SCSQ) appraises the coping
4. Results
strategies which individuals adopt to deal with challenges under
adversity which is developed by a Chinese scholar. It comprises 20 items
The sample characteristics were presented in Table 2.
and 2 subscales (adaptive coping and passive coping), and is based on a
Thirteen respondents (1.3%) reported low levels of BO, and 950
(97.8%) and 9 (0.9%) respondents reported average and high levels of
Table 1 BO. The prevalence of low, average and high levels of STS were 43.6%,
The number of nursing students in each university or college.
55.3%, and 1.1%, respectively. Moreover, 9 (0.9%) and 316 (32.5%)
University or college (study site) Number (n) Percentage (%) respondents showed low and high levels of CS, and the majority of the
Site 1 64 6.6 respondents reported average levels of CS (66.6%). The average scores
Site 2 96 9.9 of BO, STS, and CS were 29.85 (SD = 3.69), 23.96 (SD = 5.97), and
Site 3 88 9.1 39.44 (SD = 5.93), respectively. There were not significant differences
Site 4 78 8.0
Site 5 85 9.7
on each subscale in nursing students with or without clinical training in
Site 6 69 7.1 different work departments. Male students reported significantly higher
Site 7 72 7.4 BO than female students. However, no significant differences on STS and
Site 8 48 4.9 CS were found between male and female students. Moreover, under­
Site 9 77 7.9
graduate students reported significantly higher STS and lower CS than
Site 10 69 7.1
Site 11 70 7.2 those in associate programs (Table 2).
Site 12 68 7.0 Moreover, resilience and all of the domains of social support,
Site 13 44 4.5 empathy and coping strategies were associated with STS and CS signif­
Site 14 20 2.1 icantly. BO was significantly related to all of the subscales of empathy,
Site 15 24 2.5
coping strategies, resilience and family support, but BO was not related

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X. Cao et al. Nurse Education in Practice 51 (2021) 102999

Table 2 Table 3
Sociodemographic characteristics. Associations between social support, empathy, resilience, coping strategies, and
Variables n (%) Burnout Secondary Compassion
compassion fatigue and compassion satisfaction.
Mean (SD) traumatic stress satisfaction Mean Variables Burnout Secondary Compassion
Mean (SD) (SD) traumatic stress satisfaction
Gender Family support 0.066* − 0.205*** 0.501***
Male 134 30.57 24.51 (6.99) 39.55 (5.95) Friend support 0.050 − 0.211*** 0.461***
(13.8) (4.09) Other support 0.062 − 0.214*** 0.503***
Female 838 29.73 23.87 (5.79) 39.43 (5.93) Perspective taking − 0.119** − 0.231*** 0.594***
(86.2) (3.61) Compassionate care − 0.389*** − 0.591*** 0.398***
t (p) 2.437 1.150 (0.251) − 0.226 (0.827) Standing in the − 0.294*** − 0.504*** 0.415***
(0.015) patient’s shoes
Education level Resilience 0.103** − 0.257*** 0.619***
Associate 477 29.69 23.43 (6.10) 40.12 (5.71) Adaptive coping − 0.093** − 0.200*** 0.501***
(49.1) (3.74) Passive coping 0.227*** 0.302*** − 0.149***
Bachelor 495 30.00 24.47 (5.81) 38.80 (6.08)
(50.9) (3.64) ***p < 0.001; **p < 0.01; *p < 0.05.
t (p) − 1.311 − 2.731 (0.006) 3.492 (0.001)
(0.190)
students who participated in undergraduate nursing programs, had
Work departments during clinical placement
Department of internal medicine
lower levels of all of the domains of empathy, and higher levels of
No 153 29.97 24.63 (6.22) 39.24 (6.65) passive coping, as well as lower levels of resilience reported significant
(15.7) (4.23) higher levels of STS, explaining 38.1% of the variance. Furthermore,
Yes 819 29.83 23.83 (5.91) 39.48 (5.79) education level, family support, perspective taking, standing in the pa­
(84.3) (3.58)
tient’s shoes, resilience, and adaptive coping were significant predictors
t (p) 0.437 1.529 (0.127) − 0.475 (0.635)
(0.663) for CS, which explained 54.8% of the variance. Undergraduate nursing
Department of surgery students reported significantly lower CS than those in associate nursing
No 149 30.07 24.81 (6.16) 39.28 (6.05) programs. Perspective taking, resilience and standing in the patient’s
(15.3) (4.08)
shoes were relatively stronger contributors to CS (Table 4).
Yes 823 29.81 23.80 (5.93) 39.48 (5.91)
(84.7) (3.61)
t (p) 0.813 1.887 (0.059) − 0.378 (0.705) 5. Discussion
(0.417)
Department of obstetrics and gynecology Our study found that, the prevalence of high risk of CF (BO and STS)
No 537 29.96 24.13 (6.18) 39.59 (5.94)
in Chinese nursing students during clinical exposure was low, which are
(55.2) (3.83)
Yes 435 29.72 23.74 (5.71) 39.27 (5.93) similar to the findings of previous studies (Beaumont et al., 2016;
(44.8) (3.51) Mathias and Wentzel, 2017). However, the prevalence of high risk of CF
t (p) − 1.004 1.038 (0.300) 0.839 (0.402) in our study are substantially lower than those of nurses (Berger et al.,
(0.316) 2015). BO in nursing students during clinical practice was associated
Department of pediatrics
No 498 29.83 24.25 (6.05) 39.27 (6.11)
with their increased time spent with clients. Generally speaking, nursing
(51.2) (3.79) students receive clinically-oriented training in the 3rd and 4th year,
Yes 474 29.86 23.65 (5.87) 39.63 (5.74) maybe the negative influence of clinical exposure has to take shape.
(48.8) (3.59) Clinical exposure provides students with opportunities to perform clin­
t (p) − 0.125 1.586 (0.113) − 0.934 (0.351)
ical tasks. Nonetheless, compared to nurses, nursing students are pro­
(0.901)
Department of emergency tected from medical errors under strict clinical supervision, as all of the
No 563 29.83 24.25 (6.05) 39.27 (6.11) parties actually attribute client-related outcomes to professional staff.
(57.9) (3.79) The role of nursing students offers a “safety net”, which contributes to
Yes 409 29.86 23.65 (5.87) 39.63 (5.74) their lower prevalence of high risk of CF (Michalec et al., 2013). On the
(42.1) (3.59)
t (p) − 1.026 − 1.259 (0.208) 0.808 (0.419)
other hand, almost all of the nursing students in the study showed
(0.305) moderate and high levels of CS, which are in line with the results of prior
Intensive care unit studies (Beaumont et al., 2016; Mathias and Wentzel, 2017). During
No 499 30.01 24.14 (6.29) 39.43 (6.03) clinical exposure, nursing students were provided with actual venue
(51.3) (3.92)
where they practiced their knowledge and skills learned in the class­
Yes 473 29.68 23.76 (5.62) 39.46 (5.84)
(48.7) (3.43) rooms and simulation labs. These experiences could assist them in
t (p) − 1.409 1.005 (0.315) − 0.095 (0.924) developing their competencies and confidence, the actualization of their
(0.159) role as nurses, and the understanding of their responsibilities in care,
Outpatient clinic which could enhance their enthusiasm for helping others (Michalec
No 697 29.89 24.00 (6.07) 39.45 (5.80)
(71.7) (3.78)
et al., 2013).
Yes 275 29.73 23.84 (5.72) 39.43 (6.25) Our study uncovered that, nursing students in undergraduate pro­
(28.3) (3.44) grams reported significantly higher STS and lower CS than those in
t (p) 0.601 0.371 (0.711) 0.063 (0.950) associate programs, which are similar to the results of a prior study on
(0.548)
nurses (Sacco et al., 2015). Nurses with higher education degrees usually
have higher expectations for nursing profession. However, compared to
to friend and other support significantly (Table 3). nurses in Western countries, nurses in China usually have lower social
After including possible predictors (p < 0.2 in univariate analysis), status and salary, and are less respected from clients and other health­
all of the domains of empathy, resilience, and adaptive and passive care professionals. The enormous gap between idealistic expectations
coping were significant predictors for BO, which explained 28.2% of the and reality in clinical practice may result in increasing CF, unpleasure to
variance, with compassionate care as the strongest contributor followed help others, and unwilling to engage with nursing in nurses with higher
by perspective taking and standing in the patient’s shoes. Nursing education levels. Therefore, nursing educators in lecture education and
nursing managers in clinical practice should pay more attention to the

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X. Cao et al. Nurse Education in Practice 51 (2021) 102999

Table 4 Moreover, we found that, compassionate care was the strongest

Multiple regression model of predictors for compassion fatigue and compassion negative predictor for CF, which is in line with the findings of an earlier
satisfaction. study on nurses (Hunt et al., 2019). Compassionate care refers to a
Independent variables b SEb b’ t p caregiver’s ability to perceive and share in client’s feelings (Morse et al.,
Burnout
1992). Compassionate care and patient-centered care reflect nurses’
Constant term 39.275 1.348 29.145 0.000 professional values, and nurses are expected to engage in their job in an
Gender − 0.456 0.295 − 0.043 − 1.545 0.123 empathic way. Emotional engagement can also facilitate positive in­
Education level 0.277 0.207 0.038 1.342 0.180 teractions between healthcare providers and clients, and develop
Clinical training in ICU − 0.261 0.204 − 0.035 − 1.280 0.201
reciprocal trust within the therapeutic relationships. Meanwhile,
Family support 0.010 0.031 0.011 0.327 0.744
Perspective taking − 0.126 0.016 − 0.264 − 7.841 0.000 increased emotive empathy can promote greater satisfaction with the
Compassionate care − 0.220 0.019 − 0.502 − 11.723 0.000 reciprocal relationships between staff and clients, which can reduce CF
Standing in the patient’s − 0.074 0.054 − 0.048 − 1.148 0.041 in healthcare providers. Furthermore, our study revealed that,
shoes perspective taking and standing in the patient’s shoes significantly
Resilience − 0.067 0.024 − 0.102 − 2.750 0.006
Adaptive coping − 0.045 0.016 − 0.101 2.775 0.006
predicted CF and CS, respectively. As two types of cognitive empathy,
Passive coping 0.066 0.021 0.095 3.203 0.001 perspective taking refers to the tendency to adopt the clients’ views
2 2
F = 39.148, p = 0.000, R = 0.289, Adjusted R = 0.282 spontaneously, and standing in the patient’s shoes represents the ability
Secondary traumatic stress to consider from the perspective of the clients. The understanding of the
Constant term 43.609 1.980 22.029 0.000
clients’ feelings and thought from their perspectives is beneficial to
Education level 0.921 0.313 0.077 2.942 0.003
Clinical training in the 0.316 0.517 0.019 0.612 0.541 identifying clients’ needs and offering needs-based care, which acilitate
department of internal clients’ satisfaction (Moghaddasian et al., 2013). In turn, positive
medicine feedback from clients reduces a negative feeling driven by fear and
Clinical training in the − 0.560 0.514 − 0.034 − 1.090 0.276 work-related trauma, and facilitates a pleasure from helping others in
department of surgery
nursing students during clinical placement. Our study supports the
Clinical training in the − 0.552 0.319 − 0.046 − 1.733 0.083
department of pediatrics ProQOL model, which pinpoints that, empathy as a personal factor
Family support 0.004 0.059 0.003 0.065 0.950 protects individuals from CF, and facilitates CS (Stamm, 2010). How­
Friend support − 0.075 0.069 − 0.046 − 1.086 0.278 ever, our results are opposed to the compassion stress and fatigue model,
Other support − 0.035 0.070 − 0.022 − 0.499 0.618
proposing that empathy renders the caregivers vulnerable to CF (Figley,
Perspective taking − 0.051 0.024 − 0.065 − 2.080 0.038
Compassionate care − 0.337 0.028 − 0.476 − 11.954 0.000 2002). Based on our findings, it is essential to establish strategies of
Standing in the patient’s − 0.248 0.097 − 0.100 − 2.564 0.011 psychological formulation in increasing and sustaining empathy for
shoes nursing students during clinical practice.
Resilience − 0.063 0.037 − 0.060 − 1.694 0.041 In addition, it was revealed that, resilience was a significant
Adaptive coping 0.018 0.025 0.025 0.738 0.461
contributor to all of the domains of ProQOL, with the strongest predic­
Passive coping 0.142 0.031 0.126 4.513 0.000
2 2
F = 46.982, p = 0.000, R = 0.389, Adjusted R = 0.381 tive effect on CS. Resilience to workplace stressors was associated with
Compassion satisfaction their capabilities in reducing risk factors for CF, and increasing pro­
Constant term 27.777 1.724 16.117 0.000 tectors for CS in critical care nurses (Alharbi et al., 2020), which are in
Residence before 0.112 0.166 0.015 0.680 0.497
parallel to the results of our study. Resilience reflects an adaptive pro­
nursing education
Education level − 1.243 0.261 − 0.105 − 4.762 0.000
cess when encountering with adversity. Individuals with higher resil­
Family support 0.141 0.050 0.098 2.827 0.005 ience are more capable of adopting problem solving coping, avoiding
Friend support 0.014 0.058 0.009 0.241 0.810 emotion-centered coping, and seeking social support to deal with
Other support 0.083 0.059 0.053 1.396 0.163 workplace stressors, which result in less CF. Our findings also support
Perspective taking 0.232 0.021 0.301 11.263 0.000
the ProQOL model, which proposes that, as a type of personal resources,
Compassionate care 0.003 0.024 0.004 0.109 0.913
Standing in the patient’s 0.291 0.082 0.119 3.556 0.000 individuals with high resilience will not regard client’s needs as a threat
shoes and will have a positive compassionate feelings towards others and low
Resilience 0.300 0.031 0.286 9.529 0.000 perception of CF (Stamm, 2010). Our results suggest that, effective
Adaptive coping 0.076 0.021 0.105 3.626 0.000
strategies to facilitate resilience in nursing students during clinical
Passive coping − 0.050 0.027 − 0.045 − 1.877 0.061
F = 108.121, p = 0.000, R2 = 0.552, Adjusted R2 = 0.548
training are necessary in future studies.
In line with the results of an earlier study (Yu et al., 2016), we found
that, passive coping significantly and positively predicted CF. Coping is
unique needs of nursing students with advanced degrees, and develop a process of fitting into the ward culture, and passive coping can prevent
strategies to prevent CF and enhance CS at their entry phase of nursing individuals from direct exposure to workplace stressors. In general,
career. nurses with passive coping are prone to possess low self-efficacy, and
Our study revealed that, family support was a significant contributor cannot have self-confidence to deal with stressful events, which may
to CS. However, our study did not support the significant negative re­ affect their ability to work with clients who experience stressful events
lationships between friends and other support and CF, which are not in and result in more CF (Yu et al., 2016). Moreover, our study revealed
line with the results of previous studies on nurses. Co-worker relation­ that, adaptive coping predicted CS positively and significantly, and
ship was a significant negative predictor for CF, and a significant posi­ predicted STS inversely and significantly, which are similar to the
tive predictor for CS in nurses (Hinderer et al., 2014). Unlike nurses in findings on nurses (Al Barmawi et al., 2019). In addition, a prior study
the workplace, nursing students usually receive clinically-oriented showed that, problem-solving coping promoted high levels of CS (Potter
training in their 3rd and 4th years, and they cannot establish a et al., 2013). Adaptive coping was significantly and negatively associ­
long-term collaborative relationships with professional staff in such a ated with CF, and problem-focused coping strategies significantly
short time. The short-term relationships between nursing students, mediated emotional intelligence and CF relationships (Zeidner et al.,
nurses and nursing managers may lead to less colleague and manager 2013). Therefore, it is essential to develop coping training in nursing
support perceived by nursing students. Therefore, it is important to students during nursing education in the classrooms, which focus on
develop strategies to enhance nursing students’ intense contact with avoiding passive coping and enhancing adaptive coping, in order to
their clinical preceptors and nursing managers, and promote supports reduce their CF and enhance their CS in clinical placement.
from co-workers and managers in clinical placement. Three limitations were noted. Firstly, the study used a cross-sectional

5
X. Cao et al.
design, which could not analyze the causal mechanisms between these
variables. Secondly, the respondents were only from universities or
colleges in Sichuan province, which may limit generalizability of our
results. Finally, even if the effects of social support, empathy, resilience,
and coping strategies on CF and CS were examined, the reciprocal as­
sociations among these predictors such as mediating or moderating roles
were not explored. A proper theoretical framework are required to
propose a hypothesized model, which explored the reciprocal associa­
tions among these included predictors in future studies.
6. Conclusion
The findings indicate that, it is essential to develop effective strate­
gies to increase cognitive and affective empathy, promote resilience,
avoid passive coping and enhance adaptive coping, as well as improve
family support to facilitate nursing students’ low CF and high CS in
clinical placement.
Funding source
There is no funding source.
Ethical approval
The study was approved by the Human Subjects Ethics Sub-
committee of West China Hospital (no. 2020281).
CRediT authorship contribution statement
Xiaoyi Cao: Conceptualization, Data curation, Formal analysis,
Investigation, Methodology, Project administration, Validation, Visual­
ization, Writing - original draft. Lei Wang: Conceptualization, Data
curation, Formal analysis, Investigation, Methodology, Validation,
Visualization, Writing - review & editing. Shu Gong: Conceptualization,
Data curation, Validation, Visualization, Writing - review & editing.
Declaration of competing interest
We declare that there are no conflicts of interest in the study.
Acknowledgments
The authors would like to thank all of the nursing students partici­
pating in the study.
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