{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,22]],"date-time":"2026-10-22T05:39:31Z","timestamp":1792647571911,"version":"4.5.0"},"reference-count":46,"publisher":"Wiley","issue":"1","license":[{"start":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T00:00:00Z","timestamp":1792540800000},"content-version":"vor","delay-in-days":293,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,1,1]],"date-time":"2026-01-01T00:00:00Z","timestamp":1767225600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"funder":[{"DOI":"10.13039\/501100001691","name":"Japan Society for the Promotion of Science","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100001691","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Journal of Nursing Management"],"published-print":{"date-parts":[[2026,1]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Evidence regarding the relationship between empathy and burnout among nurses remains inconsistent. Moral distress may help explain this complexity. Given the associations of moral distress and burnout with turnover intention, it remains insufficiently understood how empathy is linked to these outcomes through multidimensional moral distress, which is a critical concern for nursing management.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Aim<\/jats:title>\n                    <jats:p>This study examined how empathy relates to burnout and turnover intention among nurses, focusing on indirect associations involving multidimensional moral distress and burnout.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      A cross\u2010sectional web\u2010based survey was conducted among Japanese nurses (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u2009412). Empathy was assessed using the Jefferson Scale of Empathy, burnout using the Burnout Assessment Tool, and moral distress using the Measure of Moral Distress for Healthcare Professionals, which captures multiple dimensions of moral distress. Turnover intention was measured using a single\u2010item scale. Mediation and moderation analyses were performed.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>In the primary parallel mediation analysis, with all four moral distress domains considered simultaneously, positive indirect associations involving system\u2010level moral distress were statistically significant for burnout and turnover intention using 95% bootstrap confidence intervals. Supplementary separate\u2010domain sensitivity analyses also identified indirect associations involving clinical\u2010\/patient\u2010level moral distress. The interaction between empathy and burnout in relation to turnover intention was significant. The negative indirect association of empathy with turnover intention through burnout and the positive serial indirect association through system\u2010level moral distress and burnout were both conditional on empathy level.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The opposing indirect associations suggest that empathy should not be viewed as a uniformly protective resource in relation to turnover intention. System\u2010level moral distress showed the most consistent domain\u2010specific pattern across the analyses. The cross\u2010sectional design does not establish temporal or causal relationships.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Implications for Nursing Management<\/jats:title>\n                    <jats:p>Nursing managers may consider staffing adequacy, ethical climate, decision\u2010making autonomy, and organizational support alongside individual\u2010focused approaches to empathy and resilience.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1155\/jonm\/9665722","type":"journal-article","created":{"date-parts":[[2026,10,22]],"date-time":"2026-10-22T05:18:09Z","timestamp":1792646289000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Empathy as a Conditional Resource: System\u2010Level Moral Distress as an Indirect Pathway in the Associations of Empathy with Burnout and Turnover Intention"],"prefix":"10.1155","volume":"2026","author":[{"ORCID":"https:\/\/orcid.org\/0009-0008-4712-746X","authenticated-orcid":false,"given":"Eisho","family":"Yoshikawa","sequence":"first","affiliation":[{"name":"Department of Medical Psychology Nippon Medical School  1-7-1 Kyonan-cho, Musashino Tokyo 180-0023 Japan  nms.ac.jp"},{"name":"Department of Neuropsychiatry Nippon Medical School  1-1-5 Sendagi, Bunkyo Tokyo 113-8602 Japan  nms.ac.jp"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nozomi","family":"Sukigara","sequence":"additional","affiliation":[{"name":"Students Counseling Room Nippon Medical School  1-1-5 Sendagi, Bunkyo Tokyo 113-8602 Japan  nms.ac.jp"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yuko","family":"Kato","sequence":"additional","affiliation":[{"name":"Students Counseling Room Nippon Medical School  1-1-5 Sendagi, Bunkyo Tokyo 113-8602 Japan  nms.ac.jp"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yuzo","family":"Fukuyama","sequence":"additional","affiliation":[{"name":"Department of Nursing Nippon Medical School Tama Nagayama Hospital  1-7-1 Nagayama, Tama City Tokyo 206-8512 Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maya","family":"Fukugawa","sequence":"additional","affiliation":[{"name":"Department of Nursing Nippon Medical School Tama Nagayama Hospital  1-7-1 Nagayama, Tama City Tokyo 206-8512 Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3587-1845","authenticated-orcid":false,"given":"Michihiko","family":"Koeda","sequence":"additional","affiliation":[{"name":"Department of Neuropsychiatry Nippon Medical School Tama Nagayama Hospital  1-7-1 Nagayama, Tama City Tokyo 206-8512 Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7049-1402","authenticated-orcid":false,"given":"Hitomi","family":"Kataoka","sequence":"additional","affiliation":[{"name":"Center for Medical Education and Internationalization Graduate School of Medicine and Faculty of Medicine Kyoto University  Yoshida Konoe-cho, Sakyo-ku Kyoto 606-8501 Japan  kyoto-u.ac.jp"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4590-0120","authenticated-orcid":false,"given":"Amane","family":"Tateno","sequence":"additional","affiliation":[{"name":"Department of Neuropsychiatry Nippon Medical School  1-1-5 Sendagi, Bunkyo Tokyo 113-8602 Japan  nms.ac.jp"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,10,21]]},"reference":[{"key":"e_1_2_13_1_2","volume-title":"State of the World\u2019s Nursing 2020: Investing in Education, Jobs and 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