Mediating effect of coping style between empathy and burnout among Chinese nurses working in medical and surgical wards

Abstract Aim This study aimed to investigate burnout, coping style and empathy among Chinese nurses working in medical and surgical wards and to examine the mediating effect of coping style between empathy and burnout among this group of nurses. Design A cross‐sectional questionnaire survey. Method The study recruited a convenience sample of 363 nurses from three university‐affiliated tertiary hospitals in Shiyan City, Hubei, China. A set of self‐administered questionnaires was used to measure the variables of burnout, coping style and empathy. Structural equation modelling was performed using AMOS 20.0. Results Nurse burnout was prevalent among Chinese nurses in medical and surgical wards, and coping style and empathy were significantly associated with burnout. Positive coping strategies and high levels of empathy could reduce burnout in nurses. Coping strategies were found to play a partial mediating role between empathy and burnout among this group of nurses.

Brown-Mahoney, Van Zundert, & Knape, 2010) and critically influences the ability of health care organizations to operate smoothly and sustainably (Maslach, 1982). It is also associated with the negative impact on patient quality care; in other words, patients' safety can be compromised (Nantsupawat, Nantsupawat, Kunaviktikul, Turale, & Poghosyan, 2016).
According to Maslach (1982, p-80), burnout refers to "burn [ing] one's self out" and is a metaphor to describe people experiencing emotional exhaustion like the draining of a battery. Among individuals who work with people, burnout syndrome and chronic stress reactions consist of emotional exhaustion, depersonalization and reduced personal accomplishment (Maslach, 1982).
Although much is known about the influence of coping styles on nurses' burnout, most of the studies have explored the relation between empathy and burnout, with few studies investigating the relations among coping style, empathy and burnout in the population of medical and surgical nurses. Moreover, it is unclear whether the relation between empathy and burnout is mediated by coping style.
Furthermore, most of the previous studies targeted on the nurses who worked at critical or special wards, for example intensive care unit, emergency department and psychiatry ward. The present study is therefore designed to target on medical and surgical nurses and aims to address the following research questions. (1) What is the status of burnout, coping style and empathy among medical and surgical nurses in China? and (2) What is the mediating effect of coping style between empathy and burnout among the nurses in China?
In this study, a hypothesized model was developed according to our literature review ( Figure 1). In this model, we proposed the relationships among empathy, coping style and burnout among medical and surgical nurses in China. Nurses' empathy level and coping style are significantly associated with their burnout. We hypothesized that: (1) empathy has significantly negative influence on burnout; (2) positive coping style has significantly negative influence on burnout whereas negative coping style has significantly positive influence on burnout; and (3) coping style is a mediator between burnout and empathy.

| Study design and settings
This study adopted a cross-sectional, descriptive correlational design using self-reported questionnaires. The study was conducted at three tertiary hospitals in Shiyan, Hubei Province, China.

| Study participants
A convenience sample was used. Nurses who met the following inclusion criteria were invited to participate in this study: (1) fulltime RNs working in China; (2) aged 18 years or older; (3) work in a general medical or general surgical ward; and (4) able to read and understand Chinese. We excluded those nurses who worked part-time and were on leave of absence during the data collection period. To perform a SEM analysis, Fan (1999)

| Instruments
The questionnaire consisted of items on the socio-demographic data of the participants and three validated assessment tools,
The Chinese version of MBI-GS consists of 15 items grouped under three subscales: emotional exhaustion (5 items), depersonalization (4 items) and personal accomplishment (6 items). Items are rated using a seven-point Likert scale (0 = never and 6 = everyday), with higher scores indicating higher levels of burnout. The overall score of MBI-GS is calculated by weighing coefficients and scores of the original response dimensions (0.40 * emotional exhaustion + 0.30 * depersonalization + 0.30 x (6 -personal accomplishment). The level of burnout experienced by nurses was determined by the following cut-off scores: 0-1.49 indicated no burnout, 1.50-3.49 indicated some burnout and 3.50-6 indicated severe burnout (Kalimo, Pahkin, Mutanen, & Toppinen-Tanner, 2003). The Chinese version of the MBI-GS has been demonstrated to have good reliability and validity.
The internal consistency of MBI-GS is acceptable, with Cronbach's alpha ranging from 0.672-0.872 for the subclasses (p < .01). The F I G U R E 1 Hypothesized model test-retest reliability is also satisfactory, with an intraclass correlation coefficient (ICC) of 0.713 (p < .01) (Zhu et al., 2007).

| SECCN
In our study, nurses' level of empathy was measured using the SECCN.
The SECCN developed by Wang in 2009 consists of 28 items grouped under three subscales and rated using a five-point Likert scale ranging from 1 (strongly disagree)-5 (strongly agree). The three subscales are "nurses' cognition of patients' psychology" (15 items), "nurses' experience of patients' emotion" (5 items) and "nurses' behaviour in assisting patients" (8 items) (Wang, 2009). The scale has good reliability, with Cronbach's alpha value of 0.86 for the overall scale and 0.71-0.86 for the three subscales (Wang, 2009). The test-retest reliability of the subscales is satisfactory, with ICC of 0.75-0.84.

| CSS
We assessed the participants' coping style using CSS. It is a 20-item instrument developed by Xie ( 1998 ) using a sample of 846 Chinese urban residents. CSS consists of two subscales: "positive coping style" (12 items) and "negative coping style" (8 items). The scale is rated using a four-point scale from 'never' (0)-'often' (3), with higher scores indicating higher levels of coping. It has good reliability, with Cronbach's alpha of 0.78 and 0.90 for the two subscales of positive and negative coping style, respectively. Its test-retest reliability is satisfactory, with ICC of 0.90 for the CSS total and 0.78-0.90 for the subscales (Xie, 1998).

| Data collection procedure
The data were collected from January-April 2017. After obtaining the approval from the Research Ethics Committee of Hubei University of Medicine, we informed the nursing directors of the study hospitals regarding the study and sought their permission to conduct the study. We personally distributed the self-reported questionnaires to the nurses who met the study criteria. The participants were asked to return the completed questionnaire in a sealed envelope to the researchers. The returned completed questionnaire was considered as the participant's informed consent.

| Data analysis
Data were analysed using SPSS 20.0 and AMOS 20.0. We used descriptive statistics to analyse the demographic data and the mean and standard deviations of the outcome measures. Pearson correlation coefficient was used to test the correlations among nurses' burnout, coping style and empathy. In addition, we performed SEM analysis to test the hypothesized model. The coping methods were positive and negative coping styles.

| Ethical consideration
Institutional review board approval was obtained before the study.
Prior to the survey, the researchers contacted the nursing departments of the three hospitals and consent was obtained from their directors. The participants were informed that participation in the study was voluntary and that they could withdraw at any time.
Confidentiality and anonymity of data were maintained throughout the study.

| Socio-demographic characteristics
Among the 380 nurses who received the questionnaires, 372 completed and returned the questionnaires. Of the returned questionnaires, 363 were valid and included in the final data analysis, giving a valid response rate of 95.53%. The socio-demographic characteristics of the nurses are presented in Table 1. The mean age of the 363 nurses was 29.33 (SD 6.16) years, and the average duration of working experience was 7.68 (SD 6.96) years.
We performed the comparison of burnout, empathy and coping style among different socio-demographic subgroups using independent t test or ANOVA (Table 2). For burnout, we observed statistically significant differences in different marital conditions(p = .017), which suggested that a plausible reason for the higher burnout score reported by married nurses (32.20 SD 11.87) compared with unmarried nurses (30.17 SD 11.61) could be influenced by the conditions

| Correlation among burnout, coping strategy and empathy
Pearson correlation analysis was performed to test the correlation among the subscales of burnout, coping strategy and empathy, and the results are presented in Table 3. With exception of emotional exhaustion and emotional experience, emotional exhaustion and personal accomplishment, as well as negative coping and personal accomplishment, the correlations among the variables were significant (p < .05). Positive coping style had significantly negative correlations with three subscales of burnout (p < .01), whereas negative copying style had significantly positive correlations with the subscales of emotional exhaustions (p < .01) and depersonalization (p < .01). In addition, the subscales of empathy showed significantly negative correlations with three subscales of burnout (p < .01) with exception of emotional experience and emotional. Empathy was positively associated with positive coping (standard

| D ISCUSS I ON
According to the results, the mean score for personal accomplishment was higher compared with emotional exhaustion and depersonalization. This difference demonstrated that personal accomplishment plays a critical role in job burnout in medical and surgical wards, which was highlighted by Wang, Liu and Wang (2015): they found that decreased personal accomplishment is strongly correlated with nurses' job burnout. This outcome meant that the nurses were not satisfied with their actual work results and had confused and negative attitudes towards the meaning of their work. The repetitive nature of daily nursing work makes it more difficult for nurses to achieve satisfaction and improve their sense of achievement in nursing positions. Additionally, patients in China usually trust physicians more than nurses, which has also contributed to the lowered sense of accomplishment experienced by nurses (Cao, Lu, & Liu, 2010). Meanwhile, about four-fifths of the nurses in the study reported burnout, with 6.06% reporting high burnout. The reported burnout from this study was lower than that of another study conducted in Shanghai (Lu, Ruan, Xing, & Hu, 2015), which has a greater shortage of nurses, a higher social burden on nurses and a faster pace of life.
Our results suggested that married nurses experienced higher job burnout than their unmarried peers. Nurses who are married and have better job experience become the core support in their workplace; they are constantly required to guide and support nursing students and less experienced nurses (Chao, Shih, & Hsu, 2016). As such, they work with more burden and undertake more responsibilities and workload compared with younger and single nurses. Role conflict between work and family has been found to be positively related to burnout (Garcia-Izquierdo & Rios-Risquez, 2012). Moreover, married nurses perform daily nursing work with high proficiency and without any difficulty because of their rich clinical experience. Unchallenging work saps employees' motivation, which causes and low personal accomplishment (Yin, 2015).
The results showed that the mean score of the participants' level of empathy was slightly higher than the median value, which indicated that the nurses' level of empathy was between the middle and higher ranges. This finding could be related to the development of

High Quality Nursing Service, implemented nationally since 2011 in
China. The purpose of this programme was to place patients at the centre of care and strengthen the nurses' skills in basic nursing care (Meng, Li, & Liu, 2018). Therefore, nurses pay more attention to the psychological status of patients and they become more sensitive towards patients' feelings.
Our results demonstrated that both senior RNs and head nurses scored higher in empathy compared with junior RNs and staff nurses. Senior RNs usually have more than ten years of work experience in nursing and the greater work and life experience amassed by senior nurses compared with their junior colleagues give them advanced practical and theoretical knowledge (Humpel & Caputi, 2001). Thus, this advantage enables them to be more sensitive to their patients' behaviour and emotions, leading them to act altruistically, such as meeting and assisting their patients' needs promptly (Humpel & Caputi, 2001). Moreover, head nurses have received more opportunities for psychological training than staff nurses and this places them at an advantage to develop and practice empathy towards patients and their peers through their work. In addition, head nurses, as managers of and role models to the staff nurses, would pay particular attention to their own behaviours (Kalimo et al., 2003) to set an example to the nursing team in demonstrating empathy to patients.

TA B L E 2 (Continued)
In this study, the average work years of permanent nurses was 16.51, higher than that of personnel agency (6.59 years) and con- Our results also showed that senior RNs had higher scores than midlevel and junior RNs in the area of positive coping style. This finding suggests that senior nurses are more inclined to adopt positive coping methods, which may be owing to their extensive work experience, strong job autonomy, good career development prospects and complete social support system. All these factors enable them to deal with their stress at work.
The results revealed the positive correlation between negative coping style and burnout and the negative correlations between positive coping style and burnout and between the level of empathy and burnout. The effects of positive and negative coping strategies on job burnout were consistent with prior findings Xie et al., 2013). Job burnout is an extreme reaction when an individual cannot cope with stress smoothly. It is a condition of emotional exhaustion, and it is an attitude and behaviour under long-term stress. Prolonged high job stress and inappropriate coping strategies can lead to job burnout. Positive coping styles can help people solve problems and reduce the lack of fulfilment at work. In contrast, negative coping styles cannot solve problems but rather lead to worse emotional conditions and cause people to be indifferent and unsympathetic towards others (Xie, Zhang, & Lin, 2005).
High levels of empathy tended to reduce job burnout and vice versa, in line with the findings of Qi, Hou, Gu, and Chang (2011).
Hoffman (2001) (Song, 2015). Moreover, our results suggested that coping style may be an important intervening factor between empathy and burnout. Both positive coping and negative coping were mediators in the correlation between empathy and burnout. Individuals can deal with difficulties by mobilizing different coping styles, which eventually produces different levels of burnout. Nurses with strong empathy are more positive and less negative in responding to stress (Jia，2018). Indeed, individuals with a strong ability to empathize have a stronger perception of social support and psychological resilience (Pang, Zhao, & Su, 2019 However, using negative coping styles to deal with occupational problems will lead to the continuous accumulation of problems, which cannot be effectively resolved and personal abilities will not be improved. Further, continuing to adopt negative coping styles will lead to constant self-denial, lack of personal accomplishment and psychological problems, such as emotional exhaustion and depersonalization (Xie et al., 2013).

| Limitations
This study has a few limitations. First, we used a cross-sectional design, with data being collected at only one point in time. Therefore, the study could not identify the changes and trends over time and as such might provide weak evidence of correlation among burnout, coping strategies and empathy. Second, data were collected only in general surgical and medical wards; thus, the convenience sample may not be representative of the targeted population and the results may be biased. Future studies should be conducted in more areas, such as the emergency department and intensive care unit, to ensure a representative and diverse sample that could more accurately reflect the nursing population. Nonetheless, the effect of the limitations might be diminished by the diverse dimensions included during measurement.

| CON CLUS ION
Nurse burnout was prevalent among nurses in China, and it was associated with coping strategies and empathy. The present findings suggested that enhancing empathy skills and positive coping strategy, and the reduction of negative coping strategy, may lead to a reduction of burnout in nurses. To reduce work-related burnout, hospital administrators, nurse managers and policymakers should provide continued training, education and mentoring for nurses.
Moreover, they need to take action to improve nurses' perception of being supported not only in their work but also by society at large.
These measures may help achieve the goal of increasing job satisfaction for nurses and the quality of patient care provided.

ACK N OWLED G EM ENTS
The authors would like to thank all of the nurses who participated in this study. The authors would also like to acknowledge the deans of the hospitals for assisting with the data collection and for their support.

CO N FLI C T O F I NTE R E S T
The authors declare that they have no competing interests.