Factors associated with compassion fatigue and compassion satisfaction in obstetrics and gynaecology nurses: A cross‐sectional study
INTRODUCTION Compassion is the understanding and sharing of the emotional state of others. Compassion has long played a positive and active role in both academic research and social life. Research has found that compassion promotes pro‐social behaviour (Singer & Klimecki, ), improves interpersonal relationships and increases an individual's level of well‐being (Saunders, ). According to the International Council of Nurses Code of Ethics for nurses, compassion is one of the eight professional values required of nurses (ICN, ). Compassion is both an essential quality and one of the required competencies for nurses. However, beneath these positive auras, compassion may also have certain negative effects. Due to the high workload of prolonged contact with illness, disability and death, nurses' compassion is highly susceptible to compassion fatigue. Studies have shown that approximately two in five clinical nurses surveyed suffer from compassion fatigue (Duarte & Pinto‐Gouveia, ), which has adverse physical, psychological, emotional and cognitive effects (Alharbi et al., ). It is also known as the ‘cost of care’. In order to scientifically and effectively reduce the generation of compassion fatigue and improve the compassion satisfaction of nurses, it is crucial to identify the influencing factors that induce compassion fatigue and compassion satisfaction generation in nurses. Several studies have been conducted in clinical departments. For example, a study in an intensive care unit showed that female nurses aged between 18 and 25 years, with a bachelor's degree and 1–3 years of service had higher levels of compassion fatigue (İlter et al., ); for oncology and palliative care nurses, long patient stays and high mortality rates trigger compassion fatigue while decreasing compassion satisfaction (Frey et al., ; Jarrad & Hammad, ); women and the experience of traumatic events in their lives are exacerbating compassion fatigue, while poor work environment, poor colleague relationships and irregular working hours are influencing factors of low compassion satisfaction (Kartsonaki et al., ). However, no studies have focused on compassion fatigue and compassion satisfaction among obstetrics and gynaecology nurses. In recent years, with the opening of the three‐child policy, an ageing population and the promotion of assisted reproductive technologies, the incidence of obstetric and gynaecological diseases has increased, nursing workload has increased and nurses are under correspondingly greater stress (Favrod et al., ). Obstetrics and gynaecology nurses are prone to compassion fatigue and low compassion satisfaction as they serve vulnerable groups such as women or children for long periods of time. Persistent compassion fatigue leads to decreased productivity, increases the incidence of adverse care events and directly reduces the quality of care and patient satisfaction (Labrague & de Los Santos, ). Therefore, this study aimed to investigate the current status of compassion fatigue among obstetrics and gynaecology nurses and analyse its influencing factors. And based on conservation of resources theory, it further explored the influence of lack of professional efficacy on compassion fatigue and the role of social support as a bridge between the two. Thus, prevention and intervention targets were identified to improve the quality of obstetrical and gynaecological care. 1.1 Background The term ‘compassion fatigue’ was originally described by Joinson  to refer to the emotional, physical and psychological exhaustion of healthcare workers as a result of work‐related stress. Compassion fatigue was prevalent among nurses, and it not only decreased work efficiency, but also increased the incidence of adverse nursing events, which directly reduced the quality of care and patient satisfaction (Ondrejková & Halamová, ). Therefore, compassion fatigue was also named ‘cost of caring’ (Figley, ). Compassion fatigue caused some physical symptoms and mental symptoms (Alharbi et al., ). The current state of compassion fatigue among nurses cannot be ignored. Compassion fatigue has been studied in various contexts and was found in several areas of health care: intensive care (İlter et al., ), emergency (Yu & Gui, ) and paediatrics (Kartsonaki et al., ). We all know that obstetrics and gynaecology is a special unit in hospitals because the majority of patients are women during pregnancy, childbirth, postpartum and illness. Nurses often witness women's most stressful moments, trauma and pain, and may absorb patients' pain and suffering while experiencing traumatic distress (Berger & Gelkopf, ). Chronic compassion fatigue led to decreased quality of care, reduced job satisfaction for nurses and increased turnover (Labrague & de Los Santos, ). The causes of compassion fatigue are not yet clear. Conservation of resources theory was based on the concept that individuals have a tendency to preserve, protect and acquire resources (Hobfoll, ). In 2017, conservation of resources theory was applied to the study of compassion fatigue in nursing (Coetzee & Laschinger, ). When the resources available to caregiver are adequate, caregiver will provide caring and compassionate resources that will help alleviate the patient's suffering. However, once the nurse experienced the lack of understanding from the patients and the lack of support from the hospital leadership, her resources would be consumed more than replenished, that is, a loss of resources occurred, resulting in compassion fatigue for the nurse (Coetzee & Laschinger, ). According to conservation of resources theory, nurses' emotional labour is an important resource and an influencing factor on compassion fatigue. Emotional labour was defined as the management of feelings to create a publicly observable facial and bodily display (Hochschild, ). Hospitals, in order for patients to feel that they are being cared for appropriately and safely, require nurses to work without reflecting the negative emotions they experience to patients, families and colleagues, which greatly increases the level of emotional labour in nursing (Hwang et al., ). Emotional labour leads to emotional dysregulation, which manifests as a conflict between the underlying emotion and the actual emotion expressed. A study found that the level of emotional labour in nurses was strongly associated with the occurrence of compassion fatigue (Barnett et al., ). In addition, a Korean study found that 117 nurses had moderate to high levels of emotional labour, which correlated strongly with compassion fatigue. And 23% of the nurses had medical errors in the past 6 months and had a desire to leave nursing (Kwon et al., ). Prolonged emotional labour can drain nurses, make them feel fatigued and will lead to burnout (Morris & Feldman, ). Burnout was also known as a syndrome of emotional exhaustion, cynicism and lack of professional efficacy (Maslach & Jackson, ). When burnout occurs, the nurse's resources are depleted. Nurses feel that patient poses a threat to their resources and exhibits cynicism and lack of professional efficacy. Some studies have shown that the occurrence of burnout was positively correlated with compassion fatigue (Ruiz‐Fernández et al., ). Frequent emotional labour can lead to burnout or compassion fatigue and reduce the quality of life and work‐related care of nurses (Kwak et al., ). According to conservation of resources theory, when individuals have insufficient internal resources, they look for supportive resources in the work environment to supplement the lost internal resources. Individuals' social support is a typical supportive resource, it helps individuals to regulate the relationship between stress and physical and mental health, thus helping to alleviate compassion fatigue. Social support was defined as the level of helpful social interaction in the workplace from both co‐workers and supervisors (Karasek et al., ). In a study of paediatric oncology nurses, it was found that when nurses felt more social support, it would reduce nurses' compassion fatigue, thus increasing their productivity and well‐being (Sullivan et al., ). In addition, in a study of critical care, nurses who received leadership and administrative support had lower levels of compassion fatigue (Alharbi et al., ). Therefore, social support is an important influential factor in reducing compassion fatigue. In summary, many factors influence the occurrence of compassion fatigue in obstetrics and gynaecology nurses. Most studies focused on the effect of a single factor on compassion fatigue, while ignoring the combined results of multiple factors. Therefore, the purpose of this study was to understand the levels of nurses' compassion fatigue and compassion satisfaction and to examine their relationships with multiple variables. To this end, the research questions for this study were as follows. What are the levels of compassion fatigue and compassion satisfaction among obstetrics and gynaecology nurses? What are the influencing factors of compassion fatigue and compassion satisfaction among obstetrics and gynaecology nurses? Are there any associations between these influencing factors?   Background The term ‘compassion fatigue’ was originally described by Joinson  to refer to the emotional, physical and psychological exhaustion of healthcare workers as a result of work‐related stress. Compassion fatigue was prevalent among nurses, and it not only decreased work efficiency, but also increased the incidence of adverse nursing events, which directly reduced the quality of care and patient satisfaction (Ondrejková & Halamová, ). Therefore, compassion fatigue was also named ‘cost of caring’ (Figley, ). Compassion fatigue caused some physical symptoms and mental symptoms (Alharbi et al., ). The current state of compassion fatigue among nurses cannot be ignored. Compassion fatigue has been studied in various contexts and was found in several areas of health care: intensive care (İlter et al., ), emergency (Yu & Gui, ) and paediatrics (Kartsonaki et al., ). We all know that obstetrics and gynaecology is a special unit in hospitals because the majority of patients are women during pregnancy, childbirth, postpartum and illness. Nurses often witness women's most stressful moments, trauma and pain, and may absorb patients' pain and suffering while experiencing traumatic distress (Berger & Gelkopf, ). Chronic compassion fatigue led to decreased quality of care, reduced job satisfaction for nurses and increased turnover (Labrague & de Los Santos, ). The causes of compassion fatigue are not yet clear. Conservation of resources theory was based on the concept that individuals have a tendency to preserve, protect and acquire resources (Hobfoll, ). In 2017, conservation of resources theory was applied to the study of compassion fatigue in nursing (Coetzee & Laschinger, ). When the resources available to caregiver are adequate, caregiver will provide caring and compassionate resources that will help alleviate the patient's suffering. However, once the nurse experienced the lack of understanding from the patients and the lack of support from the hospital leadership, her resources would be consumed more than replenished, that is, a loss of resources occurred, resulting in compassion fatigue for the nurse (Coetzee & Laschinger, ). According to conservation of resources theory, nurses' emotional labour is an important resource and an influencing factor on compassion fatigue. Emotional labour was defined as the management of feelings to create a publicly observable facial and bodily display (Hochschild, ). Hospitals, in order for patients to feel that they are being cared for appropriately and safely, require nurses to work without reflecting the negative emotions they experience to patients, families and colleagues, which greatly increases the level of emotional labour in nursing (Hwang et al., ). Emotional labour leads to emotional dysregulation, which manifests as a conflict between the underlying emotion and the actual emotion expressed. A study found that the level of emotional labour in nurses was strongly associated with the occurrence of compassion fatigue (Barnett et al., ). In addition, a Korean study found that 117 nurses had moderate to high levels of emotional labour, which correlated strongly with compassion fatigue. And 23% of the nurses had medical errors in the past 6 months and had a desire to leave nursing (Kwon et al., ). Prolonged emotional labour can drain nurses, make them feel fatigued and will lead to burnout (Morris & Feldman, ). Burnout was also known as a syndrome of emotional exhaustion, cynicism and lack of professional efficacy (Maslach & Jackson, ). When burnout occurs, the nurse's resources are depleted. Nurses feel that patient poses a threat to their resources and exhibits cynicism and lack of professional efficacy. Some studies have shown that the occurrence of burnout was positively correlated with compassion fatigue (Ruiz‐Fernández et al., ). Frequent emotional labour can lead to burnout or compassion fatigue and reduce the quality of life and work‐related care of nurses (Kwak et al., ). According to conservation of resources theory, when individuals have insufficient internal resources, they look for supportive resources in the work environment to supplement the lost internal resources. Individuals' social support is a typical supportive resource, it helps individuals to regulate the relationship between stress and physical and mental health, thus helping to alleviate compassion fatigue. Social support was defined as the level of helpful social interaction in the workplace from both co‐workers and supervisors (Karasek et al., ). In a study of paediatric oncology nurses, it was found that when nurses felt more social support, it would reduce nurses' compassion fatigue, thus increasing their productivity and well‐being (Sullivan et al., ). In addition, in a study of critical care, nurses who received leadership and administrative support had lower levels of compassion fatigue (Alharbi et al., ). Therefore, social support is an important influential factor in reducing compassion fatigue. In summary, many factors influence the occurrence of compassion fatigue in obstetrics and gynaecology nurses. Most studies focused on the effect of a single factor on compassion fatigue, while ignoring the combined results of multiple factors. Therefore, the purpose of this study was to understand the levels of nurses' compassion fatigue and compassion satisfaction and to examine their relationships with multiple variables. To this end, the research questions for this study were as follows. What are the levels of compassion fatigue and compassion satisfaction among obstetrics and gynaecology nurses? What are the influencing factors of compassion fatigue and compassion satisfaction among obstetrics and gynaecology nurses? Are there any associations between these influencing factors?   METHODS 2.1 Design An online cross‐sectional study was conducted. 2.2 Instrument with validity and reliability The questionnaires used in this study included socio‐demographic characteristics, the Chinese version of the Compassion Fatigue Scale, the Maslach Burnout Inventory General Survey (MBI‐GS), the Emotional Labour Scale and the Social Support Rate Scale (SSRS). All questionnaires were reviewed by five professors (three professors in the field of obstetrics and gynaecology, one professor in psychological care and one professor in care management) in the field and then used. 2.2.1 Socio‐demographic characteristics Self‐designed after a pre‐review of the literature. This includes age, marital status, the only‐child, number of children, education level, work experience, professional title, employment status, night shift, average weekly hours and physical condition. 2.2.2 Chinese version of the Compassion Fatigue Scale The Professional Quality of Life Scale (ProQOL) was revised by Stamm  to form the Chinese version of the Compassion Fatigue Scale, which was used in this study. The scale includes three dimensions: compassion satisfaction, burnout and secondary traumatic stress, each with 10 entries, for a total of 30 entries. The scale is based on Likert 5‐point scale, with the frequency of occurrence ranging from ‘none’ to ‘always’, and the reverse scoring method is used for items 14, 15, 17 and 29. The total score for each of the three dimensions is 50, and the threshold values are <37, >27 and >17 respectively. The total score of one dimension exceeded the threshold value for mild empathy fatigue, two dimensions exceeded the threshold value for moderate compassion fatigue and all three dimensions exceeded the threshold value for high compassion fatigue. In this study, the sum of the scores of the two dimensions was used as the compassion fatigue score. The total Cronbach's alpha coefficient of the scale in this study was 0.821, the Cronbach's alpha coefficient of compassion fatigue was 0.820 and the Cronbach's alpha coefficient of compassion satisfaction was 0.882. 2.2.3 Maslach Burnout Inventory General Survey The MBI‐GS scale formulated was used, which includes 15 items (Maslach et al., ). Scores range from ‘never (0)’ to ‘very frequently (6)’. The scale is divided into three dimensions: cynicism, emotional exhaustion and lack of professional efficacy. Cynicism and emotional exhaustion are positive scores, that is, the higher the score, the more serious the degree of job burnout. However, the lack of professional efficacy dimension is scored in reverse, that is, the lower the score, the more obvious the lack of professional efficacy. And the sum of the scores of the two dimensions of cynicism and emotional exhaustion was used as the job burnout score. The total Cronbach's alpha coefficient of the scale in this study was 0.885, the Cronbach's alpha coefficient of the total score of the two dimensions was 0.943 and the Cronbach's alpha coefficient of the low achievement dimension was 0.902. 2.2.4 Emotional Labour Scale The Chinese Emotional Labour Scale for Nurses compiled by Grandey  was used, which has sub‐categories for surface acting (seven items), emotional expression requirements (four items) and deep acting (three items). Each item was measured using a 6‐point Likert scale from 1 point (‘strongly disagree’) to 6 points (‘strongly agree’). The total score ranges from 14 to 84, with higher scores indicating higher levels of emotional labour. In this study, the total Cronbach's α coefficient of the scale was 0.870. 2.2.5 Social Support Rate Scale The SSRS was originally developed by Xiao Shuiyuan (Yu et al., ), including subjective support, objective support and support utilization, with a total of 10 entries, of which entries 1–4 and 8–10 are single‐choice questions, each entry has four options, and the first, second, third and fourth answers are scored 1, 2, 3 and 4 respectively; entry 5 has five options, A, B, C, D and E, and each option is scored from ‘none’ to ‘fully support’. Each option from ‘none’ to ‘fully support’ will be scored from 1 to 4 points, and the score of the entry will be the sum of the scores of each option; entries 6 and 7 will be scored 0 points if you answer ‘no source’, and 0 points if you choose from ‘the following sources’. If you choose from the ‘following sources’, you will be given several points. The total score of the scale ranged from 12 to 66, and the higher the total score, the more social support was received. The total Cronbach's alpha coefficient for the scale in this study was 0.815. 2.3 Sampling and recruitment This is a cross‐sectional study, using convenience sampling, in which obstetrics and gynaecology nurses from January to February 2022 from five tertiary care hospitals in ‘XX’ were selected for recruitment. We collected data through a mobile phone questionnaire star mini programme. After the questionnaire was created, the mini programme generated a two‐dimensional code, and the investigators asked participants to carefully review the informed consent form and then fill out the questionnaire anonymously. 2.4 Sample size and power Sample size calculation formula: N = [( t α/2 + t β ) S / δ ] 2 . Interpretation: α = 0.05, β = 0.10, power (1− β ) = 0.90. t α,∞ = t 0.05, ∞ = 1.96; t β,∞ = t 0.10, ∞ = 1.645. S is the standard deviation obtained from the pre‐experiment. δ is the allowable error, which is set by 0.25 times or 0.50 times the standard deviation according to the literature for cases where the allowable error level is not given in a professional sense. N is the sample size, and 208 samples are obtained by calculation. If a 20% error rate is set, 250 are obtained. 2.5 Quality appraisal Design: The study participants were selected according to the inclusion and exclusion criteria, exclusion bias was controlled, the purpose of the study was informed and consent was sought from the study participants to ensure the quality of the survey. Implementation: A uniform guideline was used to inform the survey about the entries of the questionnaire and the precautions for filling it out, so that the study participants could obtain cooperation. If there are any questions, the researcher or investigator promptly answers them and provides objective guidance to fill them out, requiring the survey participants to fill them out anonymously and independently, so as to control confounding bias. Data collation and analysis: After data collection, the investigator checked and accepted the returned questionnaires one by one, eliminating invalid questionnaires such as missing items ≥5%, misfilled, regular responses and identical questionnaires. The data entry was done by two‐person double‐computer entry method, and the data were compared item by item to ensure the accuracy of the data before statistical analysis. According to the nature of the variables and the purpose of the study, appropriate statistical analysis methods were selected to ensure the reliability of the study results. 2.6 Population and sample There are 11 public hospitals in ‘XX’, of which five tertiary hospitals containing obstetrics and gynaecology departments (including four grade A hospitals and one grade B hospital), with an estimated overall number of nurses 444. In this study, obstetrics and gynaecology nurses in public tertiary hospitals containing obstetrics and gynaecology departments in ‘XX’ area were studied as a whole, and a total of 329 cases were investigated, with a valid sample of 311 cases. A convenience sampling method was used, and according to the formula, the minimum sample size was 250, so this sample of 311 cases could represent the obstetrics and gynaecology nurses in the whole ‘XX’ tertiary hospitals. 2.7 Inclusion and/or exclusion criteria The inclusion criteria were as follows: (1) working registered nurses (midwives should hold a maternal and child health certificate); (2) more than 1 year of work experience. Intern nurses, nurses who were studying, nurses on rotation or nurses who were on leave for various reasons during the survey period were excluded from the study. 2.8 Data analysis The data were checked by Excel 2019 and analysed by SPSS 24.0. Categorical variables were expressed as frequency and percentage, continuous variables were described by mean ± standard deviation. Demographic data were analysed by univariate analysis, including independent samples T test, one‐way ANOVA test and Kruskal–Wallis test. Pearson's correlation analysis was used to access the relationships between the two variables and Spearman's correlation analysis was used when the data did not conform to normal distribution. The influencing factors of variables were evaluated by stepwise multiple linear regression analysis. Harman's single factor analysis was performed to test the degree of variation. Meanwhile, model 4 and model 8 in the Process macro of SPSS software were conducted to analyse the mediating effect, a level of p < 0.05 was accepted as statistically significant difference. Bootstrap procedure (5000 duplicate samples) was performed to test the significance of the mediating effect and 95% confidence interval (CI) without zero indicates a significant indirect effect. 2.9 Ethical considerations This study was approved by the Ethics Committee of ‘XX’ (REDACTED). All participants provided informed consent and voluntarily participated in the study, which was conducted anonymously. Their information was confidential. All information collected was kept by the investigator, and only the investigator had access to the survey information. All methods used in this study were in accordance with the principles of the Institutional Research Committee and the Declaration of Helsinki.   Design An online cross‐sectional study was conducted.   Instrument with validity and reliability The questionnaires used in this study included socio‐demographic characteristics, the Chinese version of the Compassion Fatigue Scale, the Maslach Burnout Inventory General Survey (MBI‐GS), the Emotional Labour Scale and the Social Support Rate Scale (SSRS). All questionnaires were reviewed by five professors (three professors in the field of obstetrics and gynaecology, one professor in psychological care and one professor in care management) in the field and then used. 2.2.1 Socio‐demographic characteristics Self‐designed after a pre‐review of the literature. This includes age, marital status, the only‐child, number of children, education level, work experience, professional title, employment status, night shift, average weekly hours and physical condition. 2.2.2 Chinese version of the Compassion Fatigue Scale The Professional Quality of Life Scale (ProQOL) was revised by Stamm  to form the Chinese version of the Compassion Fatigue Scale, which was used in this study. The scale includes three dimensions: compassion satisfaction, burnout and secondary traumatic stress, each with 10 entries, for a total of 30 entries. The scale is based on Likert 5‐point scale, with the frequency of occurrence ranging from ‘none’ to ‘always’, and the reverse scoring method is used for items 14, 15, 17 and 29. The total score for each of the three dimensions is 50, and the threshold values are <37, >27 and >17 respectively. The total score of one dimension exceeded the threshold value for mild empathy fatigue, two dimensions exceeded the threshold value for moderate compassion fatigue and all three dimensions exceeded the threshold value for high compassion fatigue. In this study, the sum of the scores of the two dimensions was used as the compassion fatigue score. The total Cronbach's alpha coefficient of the scale in this study was 0.821, the Cronbach's alpha coefficient of compassion fatigue was 0.820 and the Cronbach's alpha coefficient of compassion satisfaction was 0.882. 2.2.3 Maslach Burnout Inventory General Survey The MBI‐GS scale formulated was used, which includes 15 items (Maslach et al., ). Scores range from ‘never (0)’ to ‘very frequently (6)’. The scale is divided into three dimensions: cynicism, emotional exhaustion and lack of professional efficacy. Cynicism and emotional exhaustion are positive scores, that is, the higher the score, the more serious the degree of job burnout. However, the lack of professional efficacy dimension is scored in reverse, that is, the lower the score, the more obvious the lack of professional efficacy. And the sum of the scores of the two dimensions of cynicism and emotional exhaustion was used as the job burnout score. The total Cronbach's alpha coefficient of the scale in this study was 0.885, the Cronbach's alpha coefficient of the total score of the two dimensions was 0.943 and the Cronbach's alpha coefficient of the low achievement dimension was 0.902. 2.2.4 Emotional Labour Scale The Chinese Emotional Labour Scale for Nurses compiled by Grandey  was used, which has sub‐categories for surface acting (seven items), emotional expression requirements (four items) and deep acting (three items). Each item was measured using a 6‐point Likert scale from 1 point (‘strongly disagree’) to 6 points (‘strongly agree’). The total score ranges from 14 to 84, with higher scores indicating higher levels of emotional labour. In this study, the total Cronbach's α coefficient of the scale was 0.870. 2.2.5 Social Support Rate Scale The SSRS was originally developed by Xiao Shuiyuan (Yu et al., ), including subjective support, objective support and support utilization, with a total of 10 entries, of which entries 1–4 and 8–10 are single‐choice questions, each entry has four options, and the first, second, third and fourth answers are scored 1, 2, 3 and 4 respectively; entry 5 has five options, A, B, C, D and E, and each option is scored from ‘none’ to ‘fully support’. Each option from ‘none’ to ‘fully support’ will be scored from 1 to 4 points, and the score of the entry will be the sum of the scores of each option; entries 6 and 7 will be scored 0 points if you answer ‘no source’, and 0 points if you choose from ‘the following sources’. If you choose from the ‘following sources’, you will be given several points. The total score of the scale ranged from 12 to 66, and the higher the total score, the more social support was received. The total Cronbach's alpha coefficient for the scale in this study was 0.815.   Socio‐demographic characteristics Self‐designed after a pre‐review of the literature. This includes age, marital status, the only‐child, number of children, education level, work experience, professional title, employment status, night shift, average weekly hours and physical condition.   Chinese version of the Compassion Fatigue Scale The Professional Quality of Life Scale (ProQOL) was revised by Stamm  to form the Chinese version of the Compassion Fatigue Scale, which was used in this study. The scale includes three dimensions: compassion satisfaction, burnout and secondary traumatic stress, each with 10 entries, for a total of 30 entries. The scale is based on Likert 5‐point scale, with the frequency of occurrence ranging from ‘none’ to ‘always’, and the reverse scoring method is used for items 14, 15, 17 and 29. The total score for each of the three dimensions is 50, and the threshold values are <37, >27 and >17 respectively. The total score of one dimension exceeded the threshold value for mild empathy fatigue, two dimensions exceeded the threshold value for moderate compassion fatigue and all three dimensions exceeded the threshold value for high compassion fatigue. In this study, the sum of the scores of the two dimensions was used as the compassion fatigue score. The total Cronbach's alpha coefficient of the scale in this study was 0.821, the Cronbach's alpha coefficient of compassion fatigue was 0.820 and the Cronbach's alpha coefficient of compassion satisfaction was 0.882.   Maslach Burnout Inventory General Survey The MBI‐GS scale formulated was used, which includes 15 items (Maslach et al., ). Scores range from ‘never (0)’ to ‘very frequently (6)’. The scale is divided into three dimensions: cynicism, emotional exhaustion and lack of professional efficacy. Cynicism and emotional exhaustion are positive scores, that is, the higher the score, the more serious the degree of job burnout. However, the lack of professional efficacy dimension is scored in reverse, that is, the lower the score, the more obvious the lack of professional efficacy. And the sum of the scores of the two dimensions of cynicism and emotional exhaustion was used as the job burnout score. The total Cronbach's alpha coefficient of the scale in this study was 0.885, the Cronbach's alpha coefficient of the total score of the two dimensions was 0.943 and the Cronbach's alpha coefficient of the low achievement dimension was 0.902.   Emotional Labour Scale The Chinese Emotional Labour Scale for Nurses compiled by Grandey  was used, which has sub‐categories for surface acting (seven items), emotional expression requirements (four items) and deep acting (three items). Each item was measured using a 6‐point Likert scale from 1 point (‘strongly disagree’) to 6 points (‘strongly agree’). The total score ranges from 14 to 84, with higher scores indicating higher levels of emotional labour. In this study, the total Cronbach's α coefficient of the scale was 0.870.   Social Support Rate Scale The SSRS was originally developed by Xiao Shuiyuan (Yu et al., ), including subjective support, objective support and support utilization, with a total of 10 entries, of which entries 1–4 and 8–10 are single‐choice questions, each entry has four options, and the first, second, third and fourth answers are scored 1, 2, 3 and 4 respectively; entry 5 has five options, A, B, C, D and E, and each option is scored from ‘none’ to ‘fully support’. Each option from ‘none’ to ‘fully support’ will be scored from 1 to 4 points, and the score of the entry will be the sum of the scores of each option; entries 6 and 7 will be scored 0 points if you answer ‘no source’, and 0 points if you choose from ‘the following sources’. If you choose from the ‘following sources’, you will be given several points. The total score of the scale ranged from 12 to 66, and the higher the total score, the more social support was received. The total Cronbach's alpha coefficient for the scale in this study was 0.815.   Sampling and recruitment This is a cross‐sectional study, using convenience sampling, in which obstetrics and gynaecology nurses from January to February 2022 from five tertiary care hospitals in ‘XX’ were selected for recruitment. We collected data through a mobile phone questionnaire star mini programme. After the questionnaire was created, the mini programme generated a two‐dimensional code, and the investigators asked participants to carefully review the informed consent form and then fill out the questionnaire anonymously.   Sample size and power Sample size calculation formula: N = [( t α/2 + t β ) S / δ ] 2 . Interpretation: α = 0.05, β = 0.10, power (1− β ) = 0.90. t α,∞ = t 0.05, ∞ = 1.96; t β,∞ = t 0.10, ∞ = 1.645. S is the standard deviation obtained from the pre‐experiment. δ is the allowable error, which is set by 0.25 times or 0.50 times the standard deviation according to the literature for cases where the allowable error level is not given in a professional sense. N is the sample size, and 208 samples are obtained by calculation. If a 20% error rate is set, 250 are obtained.   Quality appraisal Design: The study participants were selected according to the inclusion and exclusion criteria, exclusion bias was controlled, the purpose of the study was informed and consent was sought from the study participants to ensure the quality of the survey. Implementation: A uniform guideline was used to inform the survey about the entries of the questionnaire and the precautions for filling it out, so that the study participants could obtain cooperation. If there are any questions, the researcher or investigator promptly answers them and provides objective guidance to fill them out, requiring the survey participants to fill them out anonymously and independently, so as to control confounding bias. Data collation and analysis: After data collection, the investigator checked and accepted the returned questionnaires one by one, eliminating invalid questionnaires such as missing items ≥5%, misfilled, regular responses and identical questionnaires. The data entry was done by two‐person double‐computer entry method, and the data were compared item by item to ensure the accuracy of the data before statistical analysis. According to the nature of the variables and the purpose of the study, appropriate statistical analysis methods were selected to ensure the reliability of the study results.   Population and sample There are 11 public hospitals in ‘XX’, of which five tertiary hospitals containing obstetrics and gynaecology departments (including four grade A hospitals and one grade B hospital), with an estimated overall number of nurses 444. In this study, obstetrics and gynaecology nurses in public tertiary hospitals containing obstetrics and gynaecology departments in ‘XX’ area were studied as a whole, and a total of 329 cases were investigated, with a valid sample of 311 cases. A convenience sampling method was used, and according to the formula, the minimum sample size was 250, so this sample of 311 cases could represent the obstetrics and gynaecology nurses in the whole ‘XX’ tertiary hospitals.   Inclusion and/or exclusion criteria The inclusion criteria were as follows: (1) working registered nurses (midwives should hold a maternal and child health certificate); (2) more than 1 year of work experience. Intern nurses, nurses who were studying, nurses on rotation or nurses who were on leave for various reasons during the survey period were excluded from the study.   Data analysis The data were checked by Excel 2019 and analysed by SPSS 24.0. Categorical variables were expressed as frequency and percentage, continuous variables were described by mean ± standard deviation. Demographic data were analysed by univariate analysis, including independent samples T test, one‐way ANOVA test and Kruskal–Wallis test. Pearson's correlation analysis was used to access the relationships between the two variables and Spearman's correlation analysis was used when the data did not conform to normal distribution. The influencing factors of variables were evaluated by stepwise multiple linear regression analysis. Harman's single factor analysis was performed to test the degree of variation. Meanwhile, model 4 and model 8 in the Process macro of SPSS software were conducted to analyse the mediating effect, a level of p < 0.05 was accepted as statistically significant difference. Bootstrap procedure (5000 duplicate samples) was performed to test the significance of the mediating effect and 95% confidence interval (CI) without zero indicates a significant indirect effect.   Ethical considerations This study was approved by the Ethics Committee of ‘XX’ (REDACTED). All participants provided informed consent and voluntarily participated in the study, which was conducted anonymously. Their information was confidential. All information collected was kept by the investigator, and only the investigator had access to the survey information. All methods used in this study were in accordance with the principles of the Institutional Research Committee and the Declaration of Helsinki.   RESULTS 3.1 Current situation of compassion fatigue and compassion satisfaction in gynaecology and obstetrics nurses with different characteristics In this study, 311 valid questionnaires were returned, with an effective rate of 94.5%. There were 75 (24.12%) normal and mild compassion fatigue, 148 (47.59%) moderate and 88 (28.30%) high compassion fatigue among obstetrics and gynaecology nurses; there were 42 (13.50%) low compassion satisfaction, 248 (79.74%) moderate and 21 (6.75%) high compassion satisfaction among obstetrics and gynaecology nurses. The analysis of general information of obstetrics and gynaecology nurses is shown in Table . 3.2 Survey respondents' scores on each scale Table showed that obstetrics and gynaecology nurses had moderate to high levels of compassion fatigue and moderate level of compassion satisfaction. And of the three dimensions of emotional labour, the surface acting played the highest score and dominates. 3.3 Correlational analysis From Table , compassion satisfaction was negatively associated with compassion fatigue ( p < 0.01); emotional exhaustion, cynicism, lack of professional efficacy and emotional labour were positively associated with compassion fatigue ( p < 0.01) and social support was negatively associated with compassion fatigue ( p < 0.01). 3.4 Stepwise multiple linear regression analysis of compassion fatigue and compassion satisfaction of nurses in obstetrics and gynaecology A stepwise multiple linear regression analysis was conducted with compassion satisfaction and compassion fatigue as dependent variables, and meaningful general demographic data in univariate analysis, cynicism score, emotional exhaustion score, lack of professional efficacy score, emotional labour score and social support score as independent variables. According to the results (Table ), significant predictors of compassion satisfaction were lack of professional efficacy, cynicism, social support, work experience, employment status and night shift ( p < 0.01); significant predictors of compassion fatigue were physical condition, number of children, emotional labour, lack of professional efficacy, emotional exhaustion and the none‐only‐child ( p < 0.05). 3.5 Common method deviation test Since the data for this study were obtained from self‐report, common method bias may exist. We used Harman's single factor method to test deviation. Results showed 15 factors with characteristic root greater than ‘1’ and the variance contribution rate of the first factor without rotation was 22.86%, indicating that there was no serious common method deviation in this study. 3.6 Mediating effect analysis According to conservation of resources theory, when individuals have insufficient internal resources, they will look for supportive resources in the work environment to supplement the lost internal resources. The social support perceived by individuals is a typical supportive resource, which helps individuals regulate the relationship between stress and physical and mental health, and it has a facilitating effect on the formation of psychological resources, thus helping to alleviate compassion fatigue. Therefore, this study used social support as a mediating variable and confirmed the mediating role of social support between lack of professional efficacy and compassion fatigue using Model 4 in the Process macro. Results of the mediation effect analysis have been presented in Table and Figure . The total effect of lack of professional efficacy on compassion fatigue was significant ( ß = 0.147, 95% CI [0.042, 0.252]); the direct effect of lack of professional efficacy on social support and social support on compassion fatigue were also significant. Furthermore, the direct effect of lack of professional efficacy on compassion fatigue was significant after adjusting for social support ( ß = 0.112, 95% CI [0.006, 0.219]), suggesting that social support partially mediates the relationship between lack of professional efficacy and compassion fatigue. That is, social support can effectively mitigate the exacerbation of lack of professional efficacy on compassion fatigue.   Current situation of compassion fatigue and compassion satisfaction in gynaecology and obstetrics nurses with different characteristics In this study, 311 valid questionnaires were returned, with an effective rate of 94.5%. There were 75 (24.12%) normal and mild compassion fatigue, 148 (47.59%) moderate and 88 (28.30%) high compassion fatigue among obstetrics and gynaecology nurses; there were 42 (13.50%) low compassion satisfaction, 248 (79.74%) moderate and 21 (6.75%) high compassion satisfaction among obstetrics and gynaecology nurses. The analysis of general information of obstetrics and gynaecology nurses is shown in Table .   Survey respondents' scores on each scale Table showed that obstetrics and gynaecology nurses had moderate to high levels of compassion fatigue and moderate level of compassion satisfaction. And of the three dimensions of emotional labour, the surface acting played the highest score and dominates.   Correlational analysis From Table , compassion satisfaction was negatively associated with compassion fatigue ( p < 0.01); emotional exhaustion, cynicism, lack of professional efficacy and emotional labour were positively associated with compassion fatigue ( p < 0.01) and social support was negatively associated with compassion fatigue ( p < 0.01).   Stepwise multiple linear regression analysis of compassion fatigue and compassion satisfaction of nurses in obstetrics and gynaecology A stepwise multiple linear regression analysis was conducted with compassion satisfaction and compassion fatigue as dependent variables, and meaningful general demographic data in univariate analysis, cynicism score, emotional exhaustion score, lack of professional efficacy score, emotional labour score and social support score as independent variables. According to the results (Table ), significant predictors of compassion satisfaction were lack of professional efficacy, cynicism, social support, work experience, employment status and night shift ( p < 0.01); significant predictors of compassion fatigue were physical condition, number of children, emotional labour, lack of professional efficacy, emotional exhaustion and the none‐only‐child ( p < 0.05).   Common method deviation test Since the data for this study were obtained from self‐report, common method bias may exist. We used Harman's single factor method to test deviation. Results showed 15 factors with characteristic root greater than ‘1’ and the variance contribution rate of the first factor without rotation was 22.86%, indicating that there was no serious common method deviation in this study.   Mediating effect analysis According to conservation of resources theory, when individuals have insufficient internal resources, they will look for supportive resources in the work environment to supplement the lost internal resources. The social support perceived by individuals is a typical supportive resource, which helps individuals regulate the relationship between stress and physical and mental health, and it has a facilitating effect on the formation of psychological resources, thus helping to alleviate compassion fatigue. Therefore, this study used social support as a mediating variable and confirmed the mediating role of social support between lack of professional efficacy and compassion fatigue using Model 4 in the Process macro. Results of the mediation effect analysis have been presented in Table and Figure . The total effect of lack of professional efficacy on compassion fatigue was significant ( ß = 0.147, 95% CI [0.042, 0.252]); the direct effect of lack of professional efficacy on social support and social support on compassion fatigue were also significant. Furthermore, the direct effect of lack of professional efficacy on compassion fatigue was significant after adjusting for social support ( ß = 0.112, 95% CI [0.006, 0.219]), suggesting that social support partially mediates the relationship between lack of professional efficacy and compassion fatigue. That is, social support can effectively mitigate the exacerbation of lack of professional efficacy on compassion fatigue.   DISCUSSION In our study, we surveyed obstetrics and gynaecology nurses in different tertiary hospitals in ‘XX’ to find out the compassion fatigue and compassion satisfaction of obstetrics and gynaecology nurses. Also, compassion fatigue was determined by job burnout and secondary traumatic stress, as these are the variables used in the survey instrument. According to our data, 75.88% of obstetrics and gynaecology nurses reported moderate to high levels of compassion fatigue. Only 6.75% of obstetrics and gynaecology nurses reported high levels of compassion satisfaction. Compared to oncology nurses (Xie et al., ), emergency nurses (O'Callaghan et al., ) and haematology cancer nurses (Chen et al., ), obstetrics and gynaecology nurses in this study had lower levels of compassion satisfaction. And the level of compassion fatigue among nurses in the context of maternal and perinatal deaths was comparable to this study (Mashego et al., ). All of the above studies used ProQOL Version 5, as did our study. These differences may be related to differences in personal environment and work environment (Stamm, ). According to our findings, the nurse's personal environment is a factor that influences compassion fatigue, including physical condition and the number of children. This article showed that the poorer the physical condition of nurses, the higher the level of compassion fatigue, which was consistent with the previous study (Qu et al., ). The body is the source of energy, and when individuals are in poor health, their resource balance is disrupted, their compassion decreases and compassion fatigue occurs in severe cases (Hobfoll & Wells, ). In addition, the number of children were associated with compassion fatigue. The number of children of nurses is an important factor affecting their quality of life and work (Jarrad & Hammad, ). In this study, 87.5% of the nurses were in their young adulthood, taking on various roles as mothers, daughters and wives in their lives, making family–work conflicts inevitable. Given this, we hypothesized that when nurses are faced with a larger number of people to care for, work and family are prone to conflict, which constitutes a risk factor for compassion fatigue. The nurse's work environment is a factor that influences compassion satisfaction, including work experience, and night shift. First, compassion satisfaction was higher among nurses with <4 years of experience and more than 16 years of experience. Nurses with <4 years of experience are new to the profession, have light family responsibilities and full work ambitions; nurses with more than 16 years of experience are more competent and mature in their thinking (Alharbi et al., ). In contrast, the lower compassion satisfaction of nurses with 4–16 years may be related to their inability to reconcile family and work. What is more, night shift work was associated with high levels of burnout and secondary traumatic stress. A study of Chinese midwives working in the delivery room showed that night shift work increase their level of compassion fatigue (Qu et al., ). Other study found that night shift work resulted in lower levels of physical and mental health in obstetrics and gynaecology nurses (Coetzee & Klopper, ). Night shift work has an irregular schedule, leading to the onset of lower compassion satisfaction. In response to the above factors, nursing managers should use flexible scheduling and pay more attention to the emotional status of nurses with 4–16 years of experience. As revealed in our study, compassion fatigue was higher in nurses with high emotional labour and compassion satisfaction was higher in nurses with high social support. Emotional labour is work that requires individuals to control their emotions in order to achieve desired outcomes, and is usually associated with negative outcomes (Hwang et al., ). Continuous and regular emotional labour can lead to burnout or compassion fatigue and reduce the quality of life and work‐related care of nurses (Kwak et al., ). The results of our study also showed such results. The negative effects of nurses' emotional labour are an important factor affecting patient service delivery (Kim, ). Similar to the results of some studies (Hunsaker et al., ; Yu et al., ), we found that social support was a protective factor for compassion satisfaction. Social support facilitates physical and mental health, and promotes the formation of psychological resources, thus contributing to the improvement of compassion satisfaction (Park et al., ). Studies have shown that social support can reduce the occurrence of compassion fatigue in nurses and that recognition and support from leaders and colleagues were the main sources of social support that can effectively improve nurses' compassion (Kelly & Lefton, ). Alternatively, a good work environment (e.g. peer or social support, recognition of professional values, manageable workload) increased nurses' job satisfaction, which led them to be more proactive in their work and increased compassion satisfaction (Qu et al., ). In addition, lack of professional efficacy was a predictor of both compassion satisfaction and compassion fatigue. It has been found that lack of professional efficacy led to high compassion fatigue and low compassion satisfaction, and can also affect an individual's productivity and sense of accomplishment at work (Fan & Lin, ; Koutra et al., ). Specifically, individuals who lack professional efficacy have a lower recognition of themselves and are always in a negative state, resulting in lower compassion ability. We were surprised to find that lack of professional efficacy can influence compassion fatigue and compassion satisfaction through social support. Studies have demonstrated that lack of professional efficacy negatively predicted social support, while social support was a protective factor for compassion satisfaction against compassion fatigue, supporting existing theoretical perspectives and empirical studies (Hunsaker et al., ; Ye et al., ). For individuals, social support was an important form of resource that provided nurses with emotional support and affirmation of self‐worth (Park et al., ). According to our mediation analysis, social support is a critical intermediary between lack of professional efficacy and compassion fatigue/compassion satisfaction. Social support can buffer and compensate for the loss of resources due to lack of professional efficacy, and reduce the incidence of compassion fatigue, and increase nurses' compassion satisfaction. In summary, social support acted as a ‘bridge’ between lack of professional efficacy and compassion fatigue/compassion satisfaction. Therefore, nursing managers can provide an external resource (e.g. social support) for obstetrics and gynaecology nurses to better retain a compassionate and dedicated obstetrics and gynaecology nurse workforce based on the findings. 4.1 Strength and limitations of the work The research topic is relatively new. Compassion fatigue among obstetrics and gynaecology nurses in ‘XX’ provincial tertiary hospitals is hardly a focus; the impact of ‘XX’ comprehensive two‐child policy on compassion fatigue among obstetrics and gynaecology nurses also opens up a new area of research; this may raise concerns about the occupational health of obstetrics and gynaecology nurses in ‘XX’ and motivate the government to increase the training of related professionals. Limitations of this study include the cross‐sectional survey was conducted in XX and most participants were from tertiary care hospitals, which may limit the generalizability of the results; this subject group captured the views of participants at a specific time without follow‐up and the results only reflect what participants really thought at that time; self‐report bias is an inherent limitation of the study design. Finally, due to the lack of research in this area, this article was only a preliminary study of the current situation, with the hope of conducting more in‐depth research, such as interviews and consultations with professionals. 4.2 Recommendations for further research It is recommended that subsequent studies will focus on obstetrics and gynaecology nurses who have been working for 4–16 years and may incorporate semi‐structure interviews to further explore in depth more factors influencing compassion fatigue in obstetrics and gynaecology nurses; this study presents only a simple mediating model with moderation, and there are more potential mediators and moderators between these two variables that are worth exploring; appropriate interventions may also be developed based on the results obtained in this study.   Strength and limitations of the work The research topic is relatively new. Compassion fatigue among obstetrics and gynaecology nurses in ‘XX’ provincial tertiary hospitals is hardly a focus; the impact of ‘XX’ comprehensive two‐child policy on compassion fatigue among obstetrics and gynaecology nurses also opens up a new area of research; this may raise concerns about the occupational health of obstetrics and gynaecology nurses in ‘XX’ and motivate the government to increase the training of related professionals. Limitations of this study include the cross‐sectional survey was conducted in XX and most participants were from tertiary care hospitals, which may limit the generalizability of the results; this subject group captured the views of participants at a specific time without follow‐up and the results only reflect what participants really thought at that time; self‐report bias is an inherent limitation of the study design. Finally, due to the lack of research in this area, this article was only a preliminary study of the current situation, with the hope of conducting more in‐depth research, such as interviews and consultations with professionals.   Recommendations for further research It is recommended that subsequent studies will focus on obstetrics and gynaecology nurses who have been working for 4–16 years and may incorporate semi‐structure interviews to further explore in depth more factors influencing compassion fatigue in obstetrics and gynaecology nurses; this study presents only a simple mediating model with moderation, and there are more potential mediators and moderators between these two variables that are worth exploring; appropriate interventions may also be developed based on the results obtained in this study.   CONCLUSION The study found that 75.88% of obstetrics and gynaecology nurses had moderate to high levels of compassion fatigue. Based on the results, it was found that among the personal factors of obstetrics and gynaecology nurses, physical condition and the number of children raised were influential factors closely related to compassion fatigue. Secondly, nurses with 4–16 years of work experience among the work environment factors were more likely to experience low satisfaction. What is more, nurses who lacked professional efficacy were more likely to experience compassion fatigue, and the mediated analysis revealed that compassion fatigue could be effectively reduced by obtaining social support. In response to these findings, nursing managers are advised to focus on caring for obstetrics and gynaecology nurses who are in poor health or have more children; to provide appropriate interventions to reduce the incidence of compassion fatigue for the nurses who have worked for 4–16 years and to provide more social support for nurses to achieve more satisfaction and happiness in their work. In this study, after identifying the influencing factors of compassion fatigue, we will develop appropriate interventions, such as positive stress reduction therapy, reflective debriefing and group drawing, to effectively prevent and reduce compassion fatigue among obstetrics and gynaecology nurses.   Jia Wang and Mei Su contributed to the conceptualization of the study, performed the analysis, wrote the manuscript; Wenzhong Chang, Yuchong Hu and Peijuan Tang contributed significantly to investigation and project administration; Yujia Ma assisted with data curation; Jiaxin Sun contributed to the conceptualization of the study and reviewed the manuscript. All authors have read and approved the manuscript.   This study was supported by the Inner Mongolia Science and Technology Planning Project Fund (2020GG011).   The authors declare that they have no conflict of interests.   