Empathy is multidimensional concept, contains different components, and has different definitions [1, 2, 3, 4]. Most scholars focus on three dimensions of empathy, i.e., cognitive component, emotional component and behavioural component, and agree that empathy includes the ability to feel the experiences of others (e.g., patients) (emotional component), an understanding of these experiences from an objective perspective (cognitive component), and a capacity to convey this understanding (behavioural component) [3, 4].

Showing empathy to patients is a principal aspect of health care providers' communication skills [5] and allows nurses to appropriately respond to the needs of patients and their families [6]. Thus, empathy improves the nurse-patient relationship and patient compliance and leads to better management of patient problems, thus promoting patient rehabilitation [7, 8, 9]. Kesbakhi & Rohani [10] indicated that the motivation for empathetic communication should be promoted to improve patients' satisfaction and quality of life. Thus, understanding how empathy is motivated in nurses should be further investigated and could have practical implications for developing empathy-based care.

Motives are intended to propel or cause action and can explain why people choose a specific behaviour [3]. American psychologists Deci & Ryan [11] and Ryan & Deci [12] suggested that motivation is a continuum from nonmotivation to extrinsic motivation to intrinsic motivation. Based on the degree of individual autonomy, the researchers [11, 12] further identified three motivational subsystems within the widely used self-determination theory, i.e., autonomous motivation, controlled motivation and amotivation. Among them, autonomous motivation is associated with better outcomes and considered as the desirable type of motivation [13]. We hypothesize that nurses can experience autonomous motivation and controlled motivation when empathizing with a patient or may even lack empathy motivation for a variety of reasons.

However, research has little explored clinical nurses' empathy motivations in daily working practices worldwide. Thus, in-depth research on nurses' experience of empathy motivation in nursing care has clinical significance. Munhall [14] noted that a qualitative approach is more suitable for identifying hidden or less-recognized perceptions. Therefore, the experiences of nurses' empathetic motivations should be investigated through a qualitative research method.

The present study aims to explore Chinese nurses' experiences with empathy motivation based on the theoretical framework of self-determination theory. This study is part of a larger project (the Conceptual Framework and Evaluation Tool of Nurses' Nurse-Patient Empathy Motivation at Hospitals in China) on the perceptions of empathy by clinical nurses and the tools used to evaluate nurses' empathy motivation.

We used a qualitative design to allow nurses to discuss their motivations for expressing empathy with patients. We identified three categories of empathy motivation, i.e., autonomous motivation, controlled motivation and a lack of empathy motivation, and each had corresponding subcategories. To the best of our knowledge, this study is the first qualitative examination of empathy motivations among clinical nurses.

In this study, the three categories of empathy motivation, i.e., autonomous motivation, controlled motivation and a lack of empathy motivation, were identified based on self-determination theory and found to be consistent with the self-determination theory classification of motivation. Among the subcategories, “personal interest, enjoyment or a sense of value”, “assimilation”, “recognition of the importance of empathy”, “pressures from oneself and others”, “the possibility of tangible or intangible rewards”, “avoidance of adverse effects”, and “a lack of empathy motivation” are consistent with intrinsic motivation, integration regulation, identified regulation, introjected regulation, external regulation, and amotivation of the theory [11, 12]. In addition to these consistencies, nurses' empathetic motivations had a professional specificity that reflected the characteristics of the nursing profession. The interviews showed that love and a sense of devotion motivate the tireless empathy that these nurses have for the patient and their family and this result has not been mentioned in previous theories. This finding may be closely related to the fact that nursing is a helping profession that attracts people with certain personality traits and personal predispositions [18]. As suggested by Lombardo & Eyre [19], most nurses choose the profession under the assumption that they will be assisting patients and providing empathetic care for patients' physical, emotional, psychological and spiritual needs.

A common motivation among clinical nurses for choosing empathy with patients and their families is autonomous motivation. First, the interviews showed that some nurses spontaneously showed patients and their families understanding and care because of interest, enjoyment, a sense of value or pure altruism and asked nothing in return. Among these, pure altruism has not been mentioned in previous theories and reflects the characteristics of the nursing profession. This has been mentioned above. Second, recognition of the importance of empathy is the most frequent motive for choosing empathy. On the one hand, it suggests that nurses' empathy for patients can indeed have the important impacts, such as ensuring a good nurse-patient relationship, that have been confirmed by a large number of studies [6, 7, 8, 9]. On the other hand, it indicates that the psychological needs of nurses affect their empathy with patients. Third, several nurses talked about how they absorbed external values during their work and gradually adopted empathy as their own ideology. This reveals that the environment of the hospital and the department has a certain influence on the empathy motivation of nurses. Furthermore, according to self-determination theory, different motivation types have different effects on related variables. Compared with controlled motivation and amotivation, autonomous motivation is positively correlated with positive aspects of motivation, such as health outcomes [11]. Nursing managers, therefore, should take steps to assist nurses in maintaining a high quality of empathy motivation and select persons with career-required characteristics when recruiting nurses.

Controlled motivation is also a motivation for choosing empathy emphasized by the nurses. Nurses' empathy for the patient is accompanied by a sense of restraint or coercion without autonomy. During the interviews, one nurse explicitly considered that not empathizing with patients from the bottom of one's heart is not a real empathy. Indeed, Momaerts et al. [20] pointed out that “behaviors feigning empathy may appear disingenuous”. Furthermore, according to self-determination theory, different types of empathy motivation can be transformed into each other [11]. Thus, it is necessary for researchers and nursing management personnel to develop strategies for guiding nurses to shift from unmotivated and controlled motivation to autonomous motivation by, for example, repeatedly engaging in autonomously motivating activities [21]. In other words, optimizing the type of empathy motivation is necessary to improve the empathy-based care ability among nurses. In addition, college educators should consider adding empathy motivation to the curriculum to cultivate students' empathy caretaking ability at an early stage.

According to the study, several nurses were described as not attempting to help others or provide empathetic care, regardless of the severity of the patients' condition. These nurses believed that some of their colleagues had become emotionally numb because of experiencing or seeing too much, especially nurses who provided care to cancer patients. As healthcare providers, empathetic and caring nurses experience long-term and frequent exposure to patients' traumatic events, especially those of cancer patients and their family members. However, when the difficulty of such exposure is not acknowledged and the appropriate steps are not taken to manage the situation, such nurses can become victims of the continuing stress of meeting patients' needs; in other words, they can experience psychological distress [22] that leads to compassion fatigue [10, 19, 23]. In addition, there is a shortage of nursing staff in China and nurses experience heavy workloads; thus, time at work is precious. Time pressure has a negative impact on nurses' empathy towards patients and their families since increases the difficulty of expressing empathy [10, 24]. Some nurses working in this environment may even think that being empathetic with patients is a waste of time when they are not treated with trust or respect, which is consistent with the results of other studies [25]. Thus, elements that make nursing empathy more inherently enjoyable and beneficial consequences must first be secured by nurse leaders, and those nursing leaders should then ensure that the working environment allows nurses to satisfy certain innate psychological needs, namely, the need for autonomy [22, 26], to support the development of empathy motivations and thereby improve the nurses' professional competence and performance.

This study had several limitations. Participants were recruited from just four tertiary hospitals in Anhui Province. Because empathetic motivations may vary across different regions and hospital levels, the generalizability of the results to other nursing contexts is limited. In addition, the sample may not represent all nurses working in the above hospitals because the participants were volunteers. Therefore, the nurses participating in our study may have tended to be empathetic. To reduce bias, we asked the participants how their colleagues and leaders thought about empathy motivation.

This study aimed to explore clinical nurses' motivations for empathy within the theoretical framework of self-determination theory and provided an opportunity to understand clinical nurses' reasons for empathizing with patients and their family members. Clinical nurses are motivated to empathize with patients based on a variety of factors and different combinations of motivation types. In addition, the three categories of empathy motivation are consistent with the self-determination theory and reflect the characteristics of nursing professional culture. Nurse management should be encouraged to emphasize to plan effective strategies to provide an empathetic care culture. In other words, strategies to shift from unmotivated and controlled motivation to autonomous motivation should be developed. Also management should focus on factors in the organizational environment that have impacts on motivation experiences.