From Effort to Exhaustion: A Qualitative Study of Compassion Fatigue in elderly healthcare aides based on the Effort-Recovery Theory

From Effort to Exhaustion: A Qualitative Study of Compassion Fatigue in elderly healthcare aides based on the Effort-Recovery Theory | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article From Effort to Exhaustion: A Qualitative Study of Compassion Fatigue in elderly healthcare aides based on the Effort-Recovery Theory Liang Yuqi, Zou Min, Li Cuihua, Zhang Yueling, Ka Meng Ao, Joanne Wai-yee Chung, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7266010/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Aim This qualitative study, guided by the Effort-Recovery Theory (ERT), examines how compassion fatigue (CF) develops in elderly healthcare aides (HCAs) in China. The study focuses on the developmental mechanisms and dynamic trajectory of CF. Background With global population aging, especially in China, where adults aged over 60 reached 310 million (22% of the population) by the end of 2024, HCAs face increasing physical and emotional burdens. Their physical labor includes daily care and emergency response, while their emotional labor involves managing empathy and nonverbal communication with residents who have cognitive impairments. However, existing research on CF has primarily focused on hospital nurses, with limited attention to HCAs’ unique experiences, particularly the dynamic process of CF under China’s sociocultural context. Methods A qualitative descriptive design was adopted, with 13 HCAs recruited from a large long-term care facility in Shanghai through purposive sampling. Data were collected via semi-participant observation and in-depth interviews, and analyzed using directed content analysis. The study adhered to the COREQ checklist to ensure methodological rigor. Results The analysis revealed a four-stage development process of CF. Stage one is Work Demand Overload. This stage involves physical burden, such as intensive labor and fragmented sleep. It also involves psychological burden, such as high cognitive demands and emotional entanglement. Stage two is Compensatory Effort Strategies. These strategies include emotional detachment through surface acting. They also include physiological compensation, for example, caffeine dependence. Another strategy is culturally specific cognitive reframing, such as believing in "karmic merit". Stage three is Insufficient Recovery. Stage three is Insufficient Recovery. Divergent recovery awareness influences this stage, which encompasses active micro-recovery, passive adaptation, and awareness-action disconnection. Structural barriers also contribute, which include institutional resource exclusion and cultural stigma. Stage four is Negative Effects, where CF emerges, which manifests as occupational burnout, secondary traumatization, and declining empathy satisfaction. Conclusion This study confirms that ERT effectively explains CF in HCAs. An imbalance between resource consumption and recovery drives the development of CF. Cultural norms, like the expectation of "family-like care", and institutional constraints make this imbalance worse. The findings address a gap in CF research about HCAs. They also provide a theory base for interventions. These could include optimizing workloads and improving recovery resources. Such steps could support the well-being of HCAs and enhance the quality of care. Figures Figure 1 Figure 2 Background Population ageing is a major global social challenge. By 2050, approximately 22% of the world's population will be over 60 years old[ 1 ]. This demographic change increases the number of older people with disabilities in activities of daily living (ADL). Globally, ADL disability rates among those aged 65 and above typically range from about 10% to over 50%, depending on various factors such as country, age group, and measurement methods[ 2 , 3 ]. Moreover, the global prevalence of dementia is expected to increase from 57.4 million cases in 2019 to 152.8 million cases in 2050, mainly due to population growth and ageing[ 4 ]. These health conditions necessitate an expanded and specialized workforce for care. However, shortages persist: the WHO estimates a projected shortfall of 11 million healthcare aides(HCAs) by 2030[ 5 ]. In China, approximately 310 million individuals (22% of the population) were aged over 60 at the end of 2024[ 6 ]. Smaller family sizes and migration from rural to urban areas have led to an increase in the number of families relying on institutional care, thereby increasing the pressure on HCAs[ 7 ]. HCAs in long-term care settings play a crucial role as they are essential paramedical extensions of registered nurses. They are responsible for fundamental care tasks, such as assisting with mobility, personal hygiene, and feeding[ 8 ]. These tasks free up professional nurses to focus on more complex clinical duties. HCAs, who represent 60%-70% of the long-term care workforce, provide 70%-90% of the direct care to residents[ 9 ]. Although HCAs have more contact with patients than registered nurses, both in time and frequency, they usually have less training and lower professional status. [ 9 , 10 ] HCAs in long-term elderly care face two main types of demands. They are burdened with physically intensive tasks, like bathing, feeding residents, and continuous bedside monitoring. At the same time, they must constantly manage their emotions while providing compassionate care. Both physical and emotional labour are central to their roles, with emotional labour having complex implications for their well-being, job satisfaction, and the quality of care they provide. This dual burden makes them more likely to experience compassion fatigue (CF), which is characterized by emotional, physical, and psychological exhaustion resulting from long-term care for traumatized individuals[ 11 ]. Research indicates that CF is prevalent among this group [ 12 – 14 ], which is closely linked to increased burnout and intentions to turnover [ 14 , 15 ]. In previous research on nurses, CF can negatively impact the quality of care [ 16 , 17 ]. Moreover, the emotional indifference caused by CF may transmit negative feelings through reduced nonverbal interactions (such as rigid expressions and brief language), indirectly exacerbating the depression scores of the elderly[ 18 , 19 ]. In China, 39.45% of elderly care workers report severe CF symptoms, which are linked to job dissatisfaction and a decline in care quality.[ 20 , 21 ] The Effort-Recovery Theory (ERT) explains this phenomenon through the concept of resource depletion. It states that without adequate recovery, such as rest and social support, sustained effort leads to a decline in health[ 22 ]. However, existing CF research primarily focuses on hospital nurses, with few studies examining HCAs in long-term elderly care facilities [ 17 , 23 ]. This specific group has unique occupational characteristics, such as relatively low educational attainment, short training periods despite shouldering the majority of care work, and long-term companionship with older people [ 9 , 10 ]. Additionally, given China's cultural background, there may be differences in the development of CF among Chinese HCAs compared to Western HCAs. Most current research is quantitative, focusing on the static prevalence of CF. There is a lack of qualitative exploration of the dynamic process of CF, which may include workload accumulation, compensatory strategies, and ultimately, resource depletion. Without understanding this process, it is challenging to design effective and targeted interventions. In recent years, China has promoted the pilot implementation of long-term care insurance and the standardization of institutional elderly care. However, the occupational protection of HCAs, such as mandatory rest periods and psychological support, has not been incorporated into the policy framework [ 24 ]. There is a contradiction between the policy's pursuit of "quantity of care" and the neglect of the "sustainable care capabilities" of HCAs[ 25 ]. Therefore, it is crucial to attend to the physical and mental needs of HCAs on time to ensure the steady development of the elderly care industry. Theoretical background This study adopts the Effort-Recovery Theory. It explores how CF develops and uniquely manifests among HCAs in Chinese long-term care settings, within their specific sociocultural context. The study examines the balance between effort and recovery during their daily work from both physical and psychological aspects. It aims to fill gaps in the current literature and theories concerning compassion fatigue in HCAs, offering practical insights for developing culturally sensitive interventions in the future. Meijman and Mulder primarily developed the Effort-Recovery Theory. It states that expending effort at work leads to psychophysiological load reactions, which, if not adequately countered by recovery, can result in adverse health outcomes[ 22 ]. Recovery is conceptualized as a dynamic process. It restores a person’s actual psychophysiological state to the optimal state required for functioning, encompassing both physical and mental aspects. The theory emphasizes the importance of both internal (during work) and external (after work) recovery opportunities, highlighting the role of self-regulation in maintaining well-being [ 26 ]. Prolonged effort without sufficient recovery can lead to sustained physiological activation and chronic health impairment[ 27 ]. ERT has been widely applied in occupational health psychology. It helps explain how work effort and recovery affect employee well-being, engagement, and performance. Studies show that leisure activities promoting relaxation and psychological detachment after work improve next-day vigor and work engagement. Conversely, high-duty off-job activities hinder recovery and contribute to increased fatigue. The theory also links acute stress reactions to long-term health, highlighting the importance of recovery in preventing chronic health impairment[ 27 ]. In practical settings, interventions based on this theory promote proactive recovery strategies. These include activities designed to foster detachment, relaxation, and autonomy, thereby enhancing daily well-being and performance [ 28 ]. The theory has been applied to various occupational groups, including managers, entrepreneurs, and hospitality workers, demonstrating the theory’s relevance across diverse work environments.[ 29 , 30 ] This framework is particularly suitable for understanding CF in China's caregiving context. First, ERT explains how the dual burden of physical tasks and emotional labour drains HCAs’ resources, especially when structural barriers limit their ability to recover. Second, it accounts for culturally specific coping strategies, such as "blessing beliefs," which provide temporary relief but ultimately extend resource depletion. Ultimately, the theory elucidates the recurring cycle of overexertion, compensation, and decline. External factors (such as 24-hour shifts) and internal values (like considering endurance a virtue) work together to trap caregivers in a state of prolonged exhaustion. This model integrates physiological, psychological, and sociocultural factors that contribute to compassion fatigue. Method Study design This study adopted a qualitative descriptive approach to explore the dynamic process by which resource expenditure-recovery imbalance contributes to compassion fatigue among HCAs in long-term care facilities. It adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist[ 31 ]. Study participants and sampling This study was conducted in Shanghai, China, from May 23 to August 31, 2024. A total of 13 HCAs, including 10 women and three men, were invited from a large long-term elderly care facility in Shanghai. The inclusion criteria were: (1) aged ≥ 18 years; (2) HCAs employed in the current long-term care facility for ≥ 3 months. Exclusion criteria comprised: (1) dialect-only speakers with communication barriers; and (2) refusal to participate in interviews. Purposive sampling was used to recruit participants. Predetermined criteria were included to account for the diversity of social demographic factors, such as gender, age, education level, work years, professional titles, and work department, to obtain rich data. A trained research team member conducted participant selection. Invitations were distributed through face-to-face interactions, and during these interactions, researchers explained the study's purpose, confidentiality protocols, and precautions. Participation in the survey was voluntary, and all participants provided written informed consent before their participation. The study continued sampling until data saturation was achieved—defined as no new themes emerging from three consecutive interviews. After initial analysis of 10 participants' data, three additional interviews were conducted to verify saturation. During the research process, two HCAs declined participation due to scheduling conflicts. Ultimately, 13 participants completed the interviews. Determining the interview outline An initial interview guide was drafted through literature review and collaborative team discussions. Following a pilot test with two HCAs (excluded from formal analysis), iterative refinements were implemented, incorporating participant feedback and expert consultations with one long-term care facility director, one head nurse, and two geriatric nursing specialists. After the two pre-interviews, the formal interview outline was adjusted, improved, and finalized. The finalized guide featured simplified terminology, enhanced open-ended questions, and optimized question sequencing to better capture participants' lived experiences. Data collection After obtaining institutional approval and participant informed consent , researchers entered the facility as "trainee nurses" to conduct semi-participant observation and in-depth interviews. The phased approach comprised: (1) Descriptive observation during initial site immersion, including facility layout documentation and initial participant screening; (2) Focused observation where researchers shadowed HCAs during care activities (e.g., assisting with mobility, feeding), with supplementary semi-structured interviews conducted during participant downtime/relaxation time (17:00–19:00) lasting 20–40 minutes; and (3) Selective observation during later stages targeting specific cases based on emerging saturation patterns. All data were captured through contemporaneous field notes, audio recordings, and contextual photographs, with analysis and reflective memos completed within 24 hours post-observation. Data analysis Interview recordings were transcribed verbatim within 24 hours post-interview by one researcher and independently verified by another to ensure accuracy. Inaudible parts or discrepancies were clarified with interviewees promptly. Analysis employed directed content analysis through a five-phase process: developing a literature-derived initial coding framework with operational definitions; immersing in data via line-by-line reading and annotation; refining codes iteratively to incorporate emergent concepts; synthesizing codes into thematic subcategories based on relational patterns; and abstracting core themes capturing compassion fatigue mechanisms. Two researchers independently executed these steps, with final themes established through consensus. Ethical approval This study received ethical clearance from the Medical Ethics Committee of Xinhua Hospital, affiliated with Shanghai Jiao Tong University School of Medicine, and adhered strictly to the principles outlined in the Declaration of Helsinki. Before participation, researchers fully disclosed the study's purpose, methodology, and scope to potential participants. All participants provided written informed consent in accordance with institutional protocols, acknowledging their voluntary status and the right to withdraw without restriction. To ensure confidentiality: Interview data were anonymized using case numbers (e.g., C1, C2) instead of personal identifiers; All recordings and transcripts underwent de-identification processing; No personally identifiable information was retained in research records. Trustworthiness and credibility To ensure methodological rigor, the study employed multiple strategies to enhance trustworthiness and credibility. For credibility, maximum variation sampling (encompassing gender, age, education, tenure, and work setting) was employed, with data collection continuing until saturation was achieved. Any ambiguous interview content was clarified through member checking. Auditability was maintained by having verbatim transcripts verified by two researchers within 24 hours, alongside comprehensive analytical trails (including coding decisions and theme development records). Confirmability was strengthened via independent thematic analysis by two researchers, with discrepancies resolved through consensus discussions to minimize researcher bias. Transferability was enhanced through detailed contextual descriptions of themes and participant characteristics, enabling readers to assess the relevance of findings to other settings. Partial respondent validation was conducted for key findings at the participants’ request. All interview recordings, transcripts, and related materials were encrypted and stored on a password-protected server, accessible only to core team members who had signed confidentiality agreements. Data will be retained for 5 years after project completion (including publication) and then permanently deleted in accordance with regulations and policies. Usage is limited to this research (analysis, reporting, publication), with no third-party disclosure or reuse without the explicit written consent of the interviewees. Personal identifiers are anonymized in all outputs. Results No new topics were found after interviewing the 13 participants. The study sample was from a large long-term elderly care facility in Shanghai., China. The participant’s characteristics are presented in Table 1 . The interviews lasted 35–42 minutes, averaging 32 minutes in length. The participants included 10 women and three men; Of them, all were aged over 45 years (including 4 (30.77%) >55 years); 8 (61.54%) had worked for >5 years; 5 (38.46%) had elementary school education, 6 (46.15%) had middle school education, and 2(15.38%) had high school education; with one care work group leader and the others being regular HCAs. Through a thematic analysis of interview transcripts guided by the Effort-Recovery Theory, we identified four core themes – Work Demand Overload, Compensatory Effort Strategies, Insufficient Recovery, and Negative Effects – comprising 10 subthemes (Fig. 1). These themes collectively represent the dynamic process of compassion fatigue development in HCAs (Fig. 2). Table 1: The demographic characteristics of the participants(n=13) Serial number Gender Age Education background Positions Working years C1 Female 53 Elementary School HCA 3 C2 Female 54 Middle School Group Leader 7 C3 Female 52 High School HCA 5 C4 Male 52 Elementary School HCA 12 C5 Female 54 Middle School HCA 9 C6 Female 58 Elementary School HCA 10 C7 Female 56 Middle School HCA 4 C8 Male 58 Elementary School HCA 4 C9 Female 57 Middle School HCA 5 C10 Female 45 Elementary School HCA 1 C11 Male 54 Middle School HCA 8 C12 Female 46 Middle School HCA 2 C13 Female 54 High School HCA 5 Stage I: Work Demand Overload In the Effort-Recovery Theory (ERT), "work demand" serves as the starting point of resource consumption, referring to the physical, cognitive, and emotional resources individuals expend to accomplish work tasks. This demand comprises external load and informational load within the model; when applied to elderly care contexts, external load manifests as physical labor and environmental stressors for HCAs, while informational load denotes cognitive and emotional resource investments—their combined impact resulting in "dual consumption" unique to HCAs. Physical Burden The subtheme of Physical Burden within the Effort-Recovery Theory refers to resource depletion triggered by external load—specifically, the intensity of physical labor and environmental stressors. Long-term caregivers often endure high-intensity or low-intensity but high-frequency tasks alongside nighttime on-call responsibilities, such as responding to emergency call bells, which can result in chronically overloaded physiological states. In most eldercare facilities, these HCAs maintain prolonged periods of exertion; daytime duties demand full engagement in repetitive basic care tasks such as assisting with feeding, mobility support, bathing, and scheduled repositioning, leading to sustained physical depletion—as articulated by caregivers: C6: " Every single day is just one thing after another. My schedule's packed from sunup to sundown"; C9: " The work ain't exactly back-breaking, but... It's like spinning nonstop every day. Open my eyes and boom – drowning in tasks."; C3: " This grandma weighs over 200 pounds. I mean, I really can't reposition her alone. But you can't exactly expect someone always to be free to lend a hand." Beyond routine care tasks, caregivers must maintain constant vigilance to respond promptly to emergencies such as falls or medical crises, with 24/7 on-call pressure compounding physical exhaustion and psychological strain—as reflected in their accounts: C2: "Night shifts? Forget proper sleep. Ears glued to every rustle from granny and beeping from machines."; C5: "My mind's constantly tied to this room. Even when doing chores next door, I'm itching to check on my elders here."; C4: "What decent sleep? You're wiped from daylight chores, then blaring call bells jolt you awake at night. Lost more than ten pounds since starting this job." Beyond physical burdens from work duties, caregivers' combined work-rest environments impose an additional load. Some long-term caregivers are forced to rest within open-ward patient rooms, where disruptive noise triggers fragmented sleep and prevents deep recovery—exacerbating fatigue accumulation. As expressed in caregiver testimonials: C10: "Honestly, I've never fully relaxed during breaks; nerves remain on constant alert even at night, too tense for deep sleep", while C1 confirmed: "Those machines in the ward? Ventilators whooshing, heart monitors beeping. Drove me nuts at first. Couldn't catch a wink." Psychological Burden In the ERT framework, information load denotes the consumption of cognitive and emotional resources during complex information processing, such as interpreting seniors' emotional states or assessing clinical conditions. This is categorized as Psychological Burden in our study. The uniqueness of geriatric care lies in caregivers' dual responsibilities: providing technical care alongside emotional support, which intensifies this information load. Nursing home residents are predominantly functionally or cognitively impaired individuals who cannot articulate their needs clearly. Consequently, long-term HCAs must infer residents' states through subtle nonverbal cues (e.g., facial expressions, groans). As remarked by C11: "He never complains, but you see it – the spark's gone like tending to a house where the lights are out. " Similarly, C7 noted: "After caring for her for so long, every blink and sigh is engraved in my bones. I know her cravings before she asks." Furthermore, within medical contexts, HCAs often undertake preliminary health assessments of residents, such as monitoring pressure ulcer deterioration or respiratory abnormalities, taking on near-clinical cognitive load and condition assessment responsibilities to some extent. As C1 noted: "Gotta stick to the exact amount of softer food each day. Otherwise, her system will crash faster than you can blink with complications." Similarly, C6 explained: "My ears catch the second the unusual sound shifts in Granny's breathing – that's when you drop everything and call the nurses' station." In long-term care facilities, HCAs frequently provide years or even decades of care for the same resident, leading to profound emotional bonds where the elder becomes like family. This deep empathy bond creates emotional entanglement that's difficult to disengage from. As C13 expressed: "Her family lives far away; I deeply wish they could accompany her more often." C9 similarly noted: "After 8 years caregiving, more kin to me than blood now—any slight change in their condition fills us with urgency." This empathy bond can sometimes lead HCAs to internalize the elder's suffering, resulting in secondary trauma. C2 said: "Sometimes it seems the senior isn't suffering; only we who care for them feel the pain." Stage II: Compensatory Effort Strategies Compensatory effort constitutes a core mechanism within ERT, denoting self-initiated regulatory strategies that individuals activate when resource depletion-recovery imbalances threaten work efficacy. While providing transient relief from occupational strain, sustained application of these strategies risks accelerating irreversible physiological and psychological resource attrition by suppressing recovery needs. Emotional Detachment When caregivers experience prolonged exposure to high emotional demands—such as witnessing elderly patients' suffering or end-of-life scenarios—cumulative empathy strain depletes their emotional resources to near exhaustion. Whilst being mindful that elderly care requires "wholehearted commitment," this professional aspiration becomes unsustainable given their depleted capacity. To bridge this divergence between expected engagement and actual capability, caregivers adopt emotional detachment strategies. This manifests as deliberately minimising deep emotional connections with patients and proceduralising care tasks into checklist-driven routines to conserve empathy resources. Caregiver C4 described this adaptation: "Many situations are beyond my control; all I can do is just to keep them physically clean and comfortable." Similarly, C6 noted: "While feeling upset after caring for one resident, I must immediately switch to cheerful mode by pasting on a fresh smile for the next." Similar strategies include demarcating boundaries between occupational duty and humanistic care to avoid emotional expenditure. As C7 stated: "We sandwiched tight between our professional role and closest caregiver—some conversations are permissible, others aren't; everyone has delineated responsibilities." Crucially, sustained emotional suppression may ultimately induce empathy deterioration and provoke self-worth crises over time . C13 questioned: "Colleagues compare me to a monk—I can't tell this is hard-won inside's calm, or just my heart have turned to a dried-out sponge." while C4 confessed: "Pretty often I feel like I don't amount to much…, no matter how hard I try, they keep getting weaker ， which makes me wonder what's the point of this whole nursing job, honestly." Physiological Compensation Under pressures of physical overload – such as overnight on-call duties and repeated repositioning tasks – alongside chronic sleep deprivation, HCAs resort to physiological compensatory behaviours to forcibly sustain physical functioning. This includes relying on stimulatory substances like coffee or energy drinks, or accelerating work pace to mask fatigue symptoms, as noted by C4: "Sometimes when I don't sleep well at night, I feel totally wiped out the next day. I just have to struggle through till lunch break, then catch a quick nap to recharge." and C7: "When things get crazy busy, the tiredness just vanishes. You don't even think about whether you're exhausted or upset—you push through. What choice is there? The work won't do itself." However, such chronic physiological overextension risks precipitating long-term health deterioration, including impaired immunity and chronic musculoskeletal complaints. Like C8 said: "Honestly, you always have some aches or pains going on. It just comes with the job. " And like C2 mentioned: "Sometimes if I had a poor sleep, the next day my heart starts racing like crazy. Then I have to visit the doctor for meds to calm it down—no choice." Critically, accumulated exhaustion compromises emotional regulation capacity, heightening vulnerability to anxiety or irritable outbursts when responding to residents' needs, as C6 put it: " Daytime, my head's not clear for the inadequate sleep. When the elders need me, it's as if my body won't move right and I can't give them what they deserve. " Cognitive Reframing Some caregivers in our study employed cognitive reframing strategies to mitigate the psychological strain arising from persistent effort-recovery imbalances. This compensatory mechanism functions to maintain psychological equilibrium by redefining the meaning of work or rationalizing stressors. As demonstrated in participant narratives: some attributed occupational hardships to inherent job characteristics, C7 noted: "We’re at the lowest rung of society—this job's hard and heavy, but hey, that’s just part of the deal " Others employed transactional reframing by equating compensation with service provision, simplifying care relationships to fee-for-service exchanges, as explained by C1: "Residents’ families pay us, so That’s the deal to solve their worries and shoulder their burden." Notably, several caregivers reinterpreted pressures as the dedication of "benefiting others is benefiting oneself", C5 stated: "Like they drilled into us at training: This is how you 'stock up good karma' which is gonna pay off for our kids later." Such cognitive repositioning effectively preserved emotional reserves. Stage III: Insufficient Recovery Divergent Recovery Awareness The effectiveness of an individual's recovery is directly constrained by the degree of their awareness of their own physical and mental state and the motivation for regulation. This study found that there was a significant differentiation among HCAs at the level of recovery awareness. Despite limited resources, some HCAs demonstrated active self-regulatory behaviors through adaptive micro-recovery strategies. These included leveraging informal peer networks for emotional catharsis and seizing fragmented downtime for momentary reprieve. As C4 illustrates: "Sometimes when I'm fed up with this awful job, I rant with my work buddies. Sure, it won't fix anything, but getting it off your chest is almost like therapy. " While C13 noted: "When things slow down, I just scroll through short videos, casually watching streamers for relaxation." Such behaviors represent intentional mobilization of residual resources to mitigate acute stress responses, exemplifying micro-recovery strategies within constrained environments. In contrast, some caregivers internalize "fatigue" as a professional norm under the continuous effect of high-intensity work, and even regard it as a manifestation of "sense of responsibility". This cognitive bias weakens its sensitivity to seeking recovery and lacks the motivation for active intervention, leading to a passive adaptive recovery model. HCAs regard physical and mental exhaustion as an inevitable cost of their profession and avoid intervention through rationalization and generalization: C3 states: "Pain and exhaustion just come with the job. Taking care of old folks and sick people—how could it NOT wear you out?" C12 notes: " Never crossed my mind to 'fix' being tired. Almost every care worker is like this, just bear it." And C8 adds: "We're paid to do this. Means we gotta suffer what their own kids won't." Their cognitive adaptation converts strain into symbolic dedication, unintentionally suppressing recovery need. A distinct subgroup demonstrates they can detect abnormal conditions of their own. Still, they neither have an adequate reserve of recovery strategies nor the awareness and action methods to explore recovery approaches actively. As C1 said, "I feel off somehow... but got no clue how to fix it." And C7 mentions "After a while, you just learn to live with it." , which implies a passive acceptance of the problem. While C8 described, "I don't even know what I should do. It's messed up—kinda sad and empty inside—but no idea how to make it right." Their awareness-behavior misalignment creates a state of frustrated inertia, where cognitive clarity fails to translate into restorative activity despite the perceived urgency. Restricted Recovery Resources Insufficient recovery stems not only from individual factors but also critically depends on institutional resource allocation. Our findings reveal systemic gaps between formal resource availability and clinical accessibility. Although elderly care institutions have resources such as staff lounges and psychological counseling rooms, there are many obstacles for contract HCAs when they actually use these resources. For example, psychological counseling services are often prioritized for clinical staff (e.g., nurses, physicians), leaving HCAs marginalized. Similarly, physical rest spaces, though present, remain functionally inaccessible—HCAs report relying on fragmented, on-call rest in clinical areas rather than engaging in meaningful disengagement. As C10 noted, "We got a staff lounge, sure—but I think that’s only for the doctors, nurses, therapists... not us." C1 added, ‘We catnap on chairs in the patients’ rooms. That’s our ‘break’ when the elders nap.’ While C5 notes, 'Working nights?’ We 'sleep' in the wards. Gotta watch the old folks every second—no real shut-eye." Administrative pressures further compound these issues. High caregiver-to-resident ratios and rigid scheduling practices disrupt opportunities for consistent recovery. HCAs describe a constant sense of urgency, with C5 stating, "No time for us to grieve—more elders waiting... Work's piling up! This chronic time scarcity perpetuates inadequate psychophysiological restoration, as HCAs lack the space and time needed to recuperate fully. Outsourced employment models exacerbate these deficits. Third-party agencies often provide superficial psychological support, failing to address the chronic psychosocial burdens faced by HCAs. C4 noted that:” I don’t think the outsourcing agency makes a difference. We complain about issues such as workload and salary. They give you some half-hearted pep talks, but never fix what’s really grinding us down.” Compounding this, cultural stigmatization of mental health support discourages help-seeking behaviors. HCAs internalize the belief that seeking counseling is a sign of weakness, as reflected by C11: “No one admits to needing counseling—only ‘sick’ people do that.” Additionally, geographical separation from family networks reduces familial support, leaving HCAs socially isolated. Paradoxically, despite the potential value of peer support, it remains underutilized. This occurs because there is a shared tendency to normalize suffering among HCAs. As C13 explained, "Well, we're all hurting here – but nobody pipes up 'cause you don't want folk thinking you can't hack it." This silence perpetuates a cycle of unaddressed distress, further hindering recovery. Stage IV: Negative Effects "Negative effects" represent the ultimate outcome of resource imbalance within the Effort-Recovery Model, manifesting in this study as the development of compassion fatigue. This phenomenon is characterized by the degradation of physical and psychological functioning and health impairment among HCAs. These effects not only threaten individual well-being but also directly compromise the quality of care and undermine the sustainability of elderly care systems. Nevertheless, under high-pressure conditions, some HCAs exhibit fragmented resilience through self-initiated strategies that temporarily curb or partially mitigate the spread of adverse effects. Onset of Occupational Burnout Prolonged depletion of emotional resources without adequate recovery leads to the gradual degradation of empathy among HCAs, manifesting as emotional numbness and mechanistic work patterns. This functional degradation is a typical sign of resource depletion in the effort-recovery model, characterized by affective exhaustion, where the emotional response to residents shifts from proactive compassion to mechanical execution. C2 described feeling "Honestly, I'm in full robotic mode now. Just get the tasks done, as quickly as I can," while C7 noted, "Dunno when it happened, but my care feels hollow now. Stopped noticing if residents feel comfortable, try to make all tasks done." This burnout demonstrates the model's core "functional degradation" mechanism: sustained resource depletion forces individuals to lower work standards for basic functionality, consequently diminishing care quality. Mechanistic work is prone to causing negligence or mistakes, C6 reported: "Scary moment on days - my head was mush, nearly missed her choking right in front of me. Could've been... " At the same time, C2 admitted, " Mixed up bed tags somehow. I don't know how I confused the age with the bed number and gave the residents the wrong medication. " However, several HCAs stated that they would adopt practical strategies to maintain care effectiveness amid resource constraints, ensuring basic care quality . For instance, C13 employed a "critical-first" task prioritization approach: "I will focus on the worst off first, proper life and death stuff. The rest thing can wait till I spot a gap." This dynamic resource allocation strategy enables the completion of high-priority care despite limited energy. Similarly, C5 regulated her professional state through selective emotional engagement, noting: "Proper chinwag with the chatty residents can shake off that numbness feeling. Like coming up for air." Such reconstructed emotional bonds serve as vital buffers against job burnout. Triggering of Secondary Traumatization Unresolved empathetic stress accumulates and transforms into traumatic memories, manifesting as intrusive flashbacks, avoidance behaviors, or hyperarousal, which is a direct manifestation of "health damage" in the ERT at the psychological level. Specifically, trauma memory generalization bound to specific occupational scenarios triggers intense emotional reactions, closely linked to the professional characteristic of "normalized life-death issues" in long-term care. For example, C12 stated, "I keep dreaming about spare beds and wake up with a tight chest," while C6 shared, " When I encounter similar scenes, I get nervous and keep asking myself if I did enough." Additionally, it may present as somatization symptoms, where psychological stress is converted into physical discomfort. This indicates that under long-term stress, HCAs maintain their work efficiency by depleting their physical resources, ultimately leading to the disruption of the "balance" and autonomic nervous system disorders. C4 stated: "I've lost a lot of weight and often sweat at night." C10: "Compared to before, I get easily irritated by small things and am particularly emotional." Facing these challenges, HCAs develop different coping strategies to digest or avoid traumatic experiences in their long-term work experience: some maintain emotional connections/ bonds through commemorative coping, attempting to find meaning in caregiving through memory reconstruction. This coping strategy may be related to affirming their professional value. For instance, C2: "I still keep her photos and videos on my phone. I take them out from time to time to remember those days." C13: "When things aren't going well, that old lady pops into my mind. She treated me really well and couldn't stand seeing me tired out." Others adopt avoidance coping to cut off triggers and reduce emotional arousal, reflecting a self-protective mechanism of trauma avoidance. C7 noted:" I deleted the family's contact information, cause just seeing their picture makes me think of the old lady... and all that pain she went through." Notably, memorial coping, while temporarily alleviating emotional emptiness, may strengthen traumatic memories and intensify rumination; avoidance coping, although reducing immediate pain, may lead to emotional isolation in the long term and weaken psychological tolerance to similar situations, forming a vicious cycle of "trauma - avoidance - retraumatization." Decline in Empathy Satisfaction The decline in empathy satisfaction raises questions about HCAs' own value. The decline stems from unreciprocated efforts, such as the deterioration of the elderly's condition and the family's misunderstanding of older people. According to ERT, when individuals perceive an effort-reward imbalance (specifically manifested as uncertainty about care outcomes and insufficient social-emotional feedback), their intrinsic motivation (e.g., career value) gradually disintegrates, leading to reduced self-efficacy and a sense of meaninglessness. As C6 wondered, "Why did an old person who was chatting and laughing just collapse all of a sudden? Did I do something wrong?" and C4 admitted, "I always feel useless. If I'd done better back then, maybe they wouldn’t have passed away." Some even experience a professional identity crisis, as seen in C7's query, "What’s the point of anything I do? She’s still suffering so much. I can’t help her at all." Prolonged exposure to such an imbalance situation forces HCAs to rationalize "emotional numbness.", as in C10's, "After seeing so many old folks pass away, I’ve gotten used to it now." T his "depersonalization" is a key feature of job burnout. It is the external manifestation of HCAs' blunted emotional responsiveness and gradual disintegration of professional identity under high-mortality care contexts. During the study, some HCAs indicated that they reclaim work meaningfulness through other minor details, with value reconstruction manifesting in dual pathways: some maintain professional dignity via internal principle adherence, anchoring value in the ethical significance of care behaviors (e.g., upholding elderly dignity) rather than outcomes like disease progression, as seen in C6's "I make sure to keep her clean every single day. At least that way, when her time comes, she goes with dignity. That's the least I can do." Others rely on external recognition to activate career value, reflecting a dependence on environmental feedback, as C10 shared: "When families say thanks, or doctors and nurses give a compliment... that's when I feel like what I do matters all over again.” The former fosters more enduring psychological resilience, while the latter is more susceptible to fluctuations in external evaluations, and the latter risks unstable self-worth due to evaluative fluctuations, implying a potential occupational psychological risk. Discussion Guided by the Effort-Recovery Theory, this study systematically examines the dynamic mechanism of compassion fatigue evolution among HCAs in elderly long-term care facilities. This mechanism unfolds as a four-stage trajectory: work demand overload → compensatory effort strategies → insufficient recovery → negative effects. Each stage represents a progressive manifestation of the "imbalance between resource consumption and recovery" in ERT. Specifically, work demand overload marks the starting point of resource consumption; compensatory effort strategies act as passive adjustments following the imbalance; insufficient recovery serves as a key mediator of the imbalance; and adverse effects constitute the ultimate outcome of such imbalance. Work demand overload, the starting point of resource depletion, manifests through the dual impact of external load and information load. This is consistent with ERT's core hypothesis that resource "resource consumption starts from the superposition of multiple loads"[22]. External load arises from high-intensity physical labor and institutional pressures. It involves caring for multiple elderly individuals with disabilities simultaneously, performing repetitive physical tasks, and managing 24-hour emergency responses. These demands lead to fragmented sleep and physical symptoms over time [32-34]. Information overload refers to the dual depletion of cognitive and emotional resources. HCAs need to interpret the needs of elderly individuals through nonverbal cues and monitor changes in their clinical condition [18]. Moreover, the "family-like care" professional culture creates a persistent "emotional labor load," draining empathic resources excessively[35, 36]. This challenges nursing’s commitment to holistic care, where emotional engagement is valued yet must balance with sustainable practice. This finding expands the scope of information load as defined by Meijman & Mulder, and aligns with research linking nurses’ emotional labor to compassion fatigue[35, 36]. Additionally, the traditional Chinese value of "respecting one’s own elders and extending this respect to others’ elders" strengthens HCAs’ sense of obligation to emotional investment. When interacting with ERT’s "information load," this cultural norm may accelerate emotional resource depletion compared to Western care contexts[37, 38]. These insights point to practical steps for reducing unreasonable loads, such as optimizing careworker-to-resident ratios— a cornerstone of nursing workforce management—and clarifying boundaries for emotional labor to prevent burnout while preserving compassionate care. The rapid resource depletion caused by this dual load forces HCAs to adopt compensatory strategies to maintain basic work efficacy. Within ERT, these strategies act as both "buffers" and "double-edged swords." Emotional detachment reduces empathy expenditure by "de-emotionalizing" care tasks. Emotional detachment reduces empathy expenditure by "de-emotionalizing" care tasks. This works similarly to the distinction between surface acting and deep acting in emotional labour: when individuals are exhausted, they tend to opt for the simpler strategy of surface acting—merely feigning outward behaviors, rather than genuinely engaging with inner feelings[39]. Rather than investing psychological effort to align their emotions with the demands of compassionate care (as in deep acting), HCAs employing emotional detachment suppress authentic emotional responses, maintaining only the procedural gestures of care. This reduces immediate emotional strain but risks creating a dissonance between outward actions and inner states, which over time may deepen emotional exhaustion and decrease the quality of relational care[40]. This aligns with ERT’s premise that individuals self-regulate to sustain function, but long-term use erodes empathy—supporting the pathway through which emotional suppression leads to health impairment. Physiological compensation offers temporary relief from physical exhaustion. However, it consumes additional resources: sustained activation of the sympathetic nervous system leads to weakened immunity and emotional dysregulation[22]. This directly aligns with ERT’s dynamic model[22], illustrating how prolonged reliance on physiological compensation depletes functional reserves over time. This highlights the need for nursing education to integrate "occupational self-care" training, equipping HCAs with science-backed recovery techniques instead of harmful coping. Cognitive reframing, a culturally adaptive strategy among Chinese HCAs[41], involves three approaches: viewing hardships as inherent to their "bottom-rung" occupation; simplifying care into fee-for-service transactions; and reinterpreting labor as "karmic merit" accumulation for families. These culturally distinct methods, similar to Western cognitive reappraisal, address ERT's cross-cultural theoretical gaps and provide insights for developing contextually relevant nursing ethics frameworks that honor local values while promoting professional dignity [42]. Yet, these strategies accelerate resource depletion by suppressing genuine recovery needs. They highlight an imbalance between "individual compensation" and "systemic support": without institutional backing, individual adjustments ultimately worsen resource depletion. This points to the need for intervention strategies that optimize such approaches—for instance, replacing "overdraft compensation" with "healthy compensation,” a shift that nursing leadership can drive through policy advocacy and workplace restructuring. Sustained resource depletion from compensatory strategies, coupled with inadequate external support, pushes the resource imbalance into a phase of depleted recovery resources—a key mediator of compassion fatigue. This phase emerges from the interplay between varying kinds of individual recovery awareness and structural barriers to external resources, confirming ERT’s core mechanism: insufficient recovery worsens imbalance. Three patterns characterize individual recovery awareness in this study. Firstly, active micro-recovery, an instinctive response to immediate needs, only eases acute stress due to limited resources. This aligns with multiple studies indicating that micro-break activities are associated with enhanced recovery levels, which in turn correlate with higher workplace well-being and reduced work-related stress[43, 44]. This highlights the value of nursing teams designing workflow-tailored structured "micro-break protocols" to integrate brief, purposeful recovery activities into daily routines systematically. Secondly, passive adaptive thinking, shaped by long-term stress, dulls sensitivity to recovery needs and induces emotional numbness toward residents. This, in turn, undermines the HCA-resident relationship, as observed in studies of direct care workers [45]. This phenomenon parallels Maslach’s burnout theory of "depersonalization," which is characterized by a sense of emotional detachment and cynicism toward both one’s work and the individuals being served [46]. Lastly, a disconnect between awareness and action reveals impaired recovery self-efficacy among less educated HCAs. Previous studies have indicated that recovery self-efficacy can mitigate the impact of negative emotions on call center workers[47], underscoring the significance of recovery literacy in this context. External resources are confronted with dual barriers: institutional exclusion and cultural stigma. Uneven resource distribution intensifies recovery challenges at the individual level. This directly contradicts ERT’s core premise: recovery opportunities are crucial to balancing workloads [22]. When HCAs face chronic resource restrictions—such as inadequate rest spaces or less psychological support than other staff—their recovery processes, already fragile due to high workloads, become further impaired[48]. This perpetuates and worsens the imbalance between workload and recovery. Additionally, psychological support under outsourcing models tends to be superficial and fails to meet HCAs’ substantial recovery needs. Meanwhile, a stigmatized view persists: seeking psychological help is seen as a sign of illness. Combined with insufficient family support, this creates a unique "recovery island" phenomenon in East Asian care settings. This aligns with research showing Japanese HCAs face similar barriers to seeking psychological help[8] . These findings point to key priorities for systemic recovery support. Examples include optimizing resource allocation to protect rest rights and easing help-seeking stigma through peer support programs, led by senior HCAs or nurse leaders [49]. When recovery opportunities are persistently insufficient, the effort-recovery imbalance progresses into cumulative dysregulation, ultimately manifesting as compassion fatigue—consistent with ERT's prediction of cumulative functional impairment[22]. Burnout—marked by emotional exhaustion and depersonalization[46]—reflects declining care quality linked to ERT's "functional impairment[22]." This is a critical concern for nursing practice, as burnout is associated with increased medication errors and reduced patient satisfaction [50]. Though caregivers develop strategies to maintain efficacy (reflecting adaptive "resource reallocation"), they cannot reverse burnout. Secondary trauma, arising from unrelieved empathic stress, appears as intrusive flashbacks and physical symptoms, matching the "secondary traumatic stress" model[11, 51]. The paradox of commemorative and avoidant coping worsens harm: the former strengthens "ruminative resource consumption," while the latter creates cycles of "emotional detachment and impaired recovery capacity."[52, 53] Reduced empathic satisfaction, driven by long-term "effort-recovery imbalance," drains intrinsic motivation—showing as shattered self-efficacy and professional identity crises—threatening the sustainability of nursing workforces in aging societies. "Rationalized emotional numbness" aligns with "depersonalization" in Maslach's model[46]. At the same time, dual value reconstruction approaches (sticking to internal principles versus relying on external recognition) reveal cultural adaptability beyond ERT that can inform nursing leadership strategies for rebuilding professional pride. These three adverse outcomes reinforce each other, forming a compassion fatigue cycle. HCAs' natural resilience eases some symptoms but cannot break institutional and cultural barriers; therefore, interventions should combine "systemic intervention + individual empowerment" to stop the cycle—a dual focus central to nursing’s role as both direct care provider and system advocate [54, 55]. In summary, this study confirms the relevance of ERT to compassion fatigue in elderly care through a four-stage dynamic analysis. It enriches cross-cultural occupational health psychology by adding "resource imbalance mechanisms in non-Western contexts" to the model, drawing on insights into cultural factors and emotional labor—with specific nursing implications, as the discipline most directly responsible for translating such mechanisms into frontline practice. Additionally, the four-stage intervention pathway—"reducing workload, optimizing compensation, rebuilding recovery, blocking outcomes"—offers a practical framework to tackle the "compassion fatigue and declining care quality" cycle, directly aligning with nursing’s goal of enhancing both provider well-being and patient outcomes. This framework provides empirical support for sustainable workforce development in China's elderly care system and contributes to nursing science by bridging theory and practice in understudied non-Western care contexts. Conclusion Guided by the Effort-Recovery Theory (ERT), this qualitative study explored the dynamic mechanism of compassion fatigue (CF) among 13 elderly healthcare aides (HCAs) in a Shanghai long-term care facility, identifying a four-stage trajectory: Work Demand Overload (physical/psychological dual burdens), Compensatory Effort Strategies (emotional detachment, physiological compensation, cultural cognitive reframing), Insufficient Recovery (divergent awareness + institutional/cultural barriers), and Negative Effects (burnout, secondary traumatization, reduced empathy satisfaction). These stages reveal how resource consumption-recovery imbalance—exacerbated by Chinese cultural factors (e.g., "family-like care" expectations) and institutional constraints (e.g., uneven resource allocation)—drives HCAs’ CF, addressing gaps in prior nurse-focused or quantitative CF research. The proposed "reducing workload, optimizing compensation, rebuilding recovery, blocking outcomes" intervention framework offers a culturally appropriate tool to improve HCAs’ well-being and care quality, supporting China’s elderly care workforce sustainability and bridging ERT theory with care practice. Declarations Acknowledgements We are grateful to all of our participants for sharing their experiences voluntarily. Author contributions LYQ and ZM collected data and wrote the manuscript. LCH and ZYL were responsible for coordinating the data collection process. LYQ, ZM, LCH, ZYL, and KMA analyzed the data and drafted the manuscript. LYQ, ZM, LCH, ZYL, KMA, JWC, and JLP contributed to the design of the study protocol and the development of the interview guide. JWC and JLP supervised the research process and guided manuscript writing. JWC and JLP should be considered the co-corresponding authors. All authors reviewed and approved the final version of the manuscript. Funding The Construction Project of the“Discipline Peak-Climbing Plan” of Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine(XKPF2024C301). Data availability Due to ethical concerns from the participants' perspective, the datasets generated and/or analyzed during the current study are not publicly available; however, they are available from the corresponding author upon a justifiable request. Ethics approval All methods were carried out in accordance with relevant guidelines and regulations, such as the Declaration of Helsinki. The study received ethical approval from the Ethics Committee of Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (XHEC-NSFC-2025-485). Before starting data collection, written informed consent was obtained. Names were not used in interviews, and the audio and transcript files were tagged with a numbered scheme that was only known to the researcher. Consent for publication Non-applicable. Conflict of interest All authors declare that they have no conflicts of interest. References (2025). National Bureau of Statistics: In 2024, the population aged 60 and above in China exceeded 300 million for the first time. from https://laoling.cctv.com/2025/01/17/ARTI1YQU2WRMlO75bKSmmyLY250117.shtml Yan M, Qin T, Yin P. Disabilities in activities of daily living and in instrumental activities of daily living among older adults in China, 2011–15: a longitudinal cohort study. Lancet. 2019;394. https://doi.org/10.1016/S0140-6736(19)32418-3 . S82.DOI. Lestari SK, Ng N, Kowal P, Santosa A. Diversity in the Factors Associated with ADL-Related Disability among Older People in Six Middle-Income Countries: A Cross-Country Comparison. Int J Environ Res Public Health. 2019;16(8). 10.3390/ijerph16081341 . Nichols E, Steinmetz JD, Vollset SE, Fukutaki K, Chalek J, Abd-Allah F, et al. Estimation of the global prevalence of dementia in 2019 and forecasted prevalence in 2050: an analysis for the Global Burden of Disease Study 2019. Lancet Public Health. 2022;7(2):e105–25. 10.1016/S2468-2667(21)00249-8 . (2019). Health workforce. from https://www.who.int/health-topics/health-workforce#tab=tab_1 Huaxia. (2025). China to promote application of big data, AI in elderly care: minister. from https://english.news.cn/20250309/f87fe9c5a5444ba3b07c52e106ab870e/c.html#:~:text=The%20latest%20data%20showed%20that% 20by%20the%20end,for%20roughly%2022%20percent%20of%20its%20total%20population Zhang N, AGING, MIGRATION, AND GRANDPARENTING IN POST–ONE CHILD POLICY CHINA. Innov Aging. 2023;7:952–3. 10.1093/geroni/igad104.3060 . Matsui T, Oba H, Uchida R, Teraguchi T. Relationships between mental health and styles of help-seeking among care workers in comparison with the general population. Discov Ment Health. 2025;5(1):11. 10.1007/s44192-025-00131-7 . Zysberg L, Band-Winterstein T, Doron I, Shulyaev K, Siegel EO, Kornas-Biela D, et al. The health care aide position in nursing homes: A comparative survey of nurses' and aides' perceptions. Int J Nurs Stud. 2019;94:98–106. 10.1016/j.ijnurstu.2019.03.007 . Just DT, O'Rourke HM, Berta WB, Variath C, Cranley LA. Expanding the Concept of End-of-life Care in Long-term Care: A Scoping Review Exploring the Role of Healthcare Assistants. Int J Older People Nurs. 2021;16(2):e12353. 10.1111/opn.12353 . Sorenson C, Bolick B, Wright K, Hamilton R. Understanding Compassion Fatigue in Healthcare Providers: A Review of Current Literature. J Nurs Scholarsh. 2016;48(5):456–65. 10.1111/jnu.12229 . Rahman A, Duan Y, Estabrooks C, RELATIONSHIP BETWEEN WORKING ENVIRONMENT AND CARE, AIDES’ COMPASSION, FATIGUE, BURNOUT AND COMPASSION SATISFACTION. Innov Aging. 2024;8(Suppl 1):555DOI. 10.1093/geroni/igae098.1814 . Rahman A, Duan Y, Symonds-Brown H, Salma J, Estabrooks CA. Care Aides Compassion Fatigue, Burnout, and Compassion Satisfaction Related to Long-Term Care (LTC) Working Environment. J Appl Gerontol. 2025;7334648251328400DOI. 10.1177/07334648251328400 . Richert M, Burnout. Compassion Satisfaction, and Intent to Quit Among Long-Term Care Nursing Assistants in the Time of COVID-19. Innov Aging. 2021;5(Suppl 1):715DOI. 10.1093/geroni/igab046.2671 . Yu H, Gui L. Compassion fatigue, burnout, and compassion satisfaction among emergency nurses: A path analysis. J Adv Nurs. 2022;78(5):1294–304. 10.1111/jan.15034 . Zhang H, Xia Z, Yu S, Shi H, Meng Y, Dator WL. Interventions for Compassion Fatigue, Burnout, and Secondary Traumatic Stress in Nurses: A Systematic Review and Network Meta-Analysis. Nurs Health Sci. 2025;27(1). 10.1111/nhs 70042 . GÖKoĞLan E, AltuntaŞ S, ÇİÇEk Korkmaz A. Merhamet Yorgunluğunun Hemşirelik Hizmetlerine Etkileri. Bandırma Onyedi Eylül Üniversitesi Sağlık Bilimleri ve Araştırmaları. Dergisi. 2023;5(3):282–9. 10.46413/boneyusbad.1330069 . Lee S, Lee KH. Experience of Long-term Care Workers' Communication with Older Adults with Dementia Focused on Emotional Expression. J Korean Acad Psychiatr Ment Health Nurs. 2018;27(3):264–73. 10.12934/jkpmhn.2018.27.3.264 . Ejem DB, Drentea P, Clay OJ. The effects of caregiver emotional stress on the depressive symptomatology of the care recipient. Aging Ment Health. 2015;19(1):55–62. 10.1080/13607863.2014.915919 . Shi H, Zhao Z, Liu H, Yang R. The Current Status of Social Isolation and the Caregiver Compassion Fatigue in Elderly COPD Patients. Clin Interv Aging. 2025;20:739–50. 10.2147/cia.S504600 . Sitong Yan PL, Kong L, Li M, Mei L. The status of compassion fatigue and its subjective and objective factors among nursing workers in rest home. Mod Prev Med. 2020;47(11):1950–3. 10.20043/j.cnki.mpm.2020.11.010 . Meijman TF, Mulder. G. Psychological aspects of workload. Psychology; 1998. Ash M, Burgess K. Literature Review: Understanding Compassion Fatigue in Nursing. Int J Hum Caring. 2025;29(2):102–9. 10.20467/ijhc-2023-0026 . Haakenstad A, Irvine CMS, Knight M, Bintz C, Aravkin AY, Zheng P, et al. Lancet. 2022;399(10341):2129–54. 10.1016/S0140-6736(22)00532-3 . Measuring the availability of human resources for health and its relationship to universal health coverage for 204 countries and territories from 1990 to 2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet Global H. Health-care workers must be trained and retained. Lancet Global Health. 2023;11(5):e629. 10.1016/S2214-109X(23)00172-9 . Zijlstra FR, Cropley M, Rydstedt LW. From recovery to regulation: an attempt to reconceptualize 'recovery from work'. Stress Health. 2014;30(3):244–52. 10.1002/smi.2604 . Geurts SA, Sonnentag S. Recovery as an explanatory mechanism in the relation between acute stress reactions and chronic health impairment. Scand J Work Environ Health. 2006;6482–92. 10.5271/sjweh.1053 . Clark NM, Dodge JA, Partridge MR, Martinez FJ. Focusing on outcomes: making the most of COPD interventions. Int J Chron Obstruct Pulmon Dis. 2009;4:61–77. Battisti M, Gish JJ, Hatak I, Zhou H. Establishing a Recovery Menu to Increase the Resilience of Entrepreneurs. Br J Manag. 2025;36(1):56–72. https://doi.org/10.1111/1467-8551.12827 . Huang L, Tsai H. The effects of recovery experiences on hotel employees’ subjective well-being, organizational citizenship behavior, and task performance. Int J Hospitality Manage. 2024;121. https://doi.org/10.1016/j.ijhm.2024.103798 . :103798.DOI. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. 10.1093/intqhc/mzm042 . Yang Z, Sun F, Zhao L, Hu T, Lin X, Guo Y. Self-efficacy and well-being in the association between caregiver burden and sleep quality among caregivers of elderly patients having multiple chronic conditions in rural China: a serial multiple mediation analysis. BMC Nurs. 2023;22(1). 10.1186/s12912-023-01587-0 . Darragh AR, Sommerich CM, Lavender SA, Tanner KJ, Vogel K, Campo M. Musculoskeletal Discomfort, Physical Demand, and Caregiving Activities in Informal Caregivers. J Appl Gerontol. 2013;34(6):734–60. 10.1177/0733464813496464 . Seol MJ, Lee BS, Lee S-K. Effects of Labor Intensity and Fatigue on Sleep Quality of Clinical Nurses. J Korean Acad Nurs Adm. 2018;24(4):276. 10.11111/jkana.2018.24.4.276 . Barnett MD, Hays KN, Cantu C. Compassion fatigue, emotional labor, and emotional display among hospice nurses. Death Stud. 2022;46(2):290–6. 10.1080/07481187.2019.1699201 . Chu LC. Effect of compassion fatigue on emotional labor in female nurses: Moderating effect of self-compassion. PLoS ONE. 2024;19(3):e0301101. 10.1371/journal.pone.0301101 . Wu J, Liu M, Ouyang Y, Chi I. Beyond Just Giving Care: Exploring the Role of Culture in Chinese American Personal Care Aides’ Work. J Cross-Cult Gerontol. 2020;35(3):255–72. 10.1007/s10823-020-09404-w . Xiao C, Patrician PA, Montgomery AP, Wang Y, Jablonski R, Markaki A. Filial piety and older adult caregiving among Chinese and Chinese-American families in the United States: a concept analysis. BMC Nurs. 2024;23(1). 10.1186/s12912-024-01789-0 . Shahar B-H, Kalman-Halevi M, Roth G. Emotion regulation and intimacy quality: The consequences of emotional integration, emotional distancing, and suppression. J Social Personal Relationships. 2018;36:3343–61. 10.1177/0265407518816881 . Saei E, Sarshar S, Lee RT. Emotional labor and burnout among nurses in Iran: core self-evaluations as mediator and moderator. Hum Resour Health. 2024;22(1). 10.1186/s12960-024-00896-y . Teuber Z, Schreiber S, Rueth J-E, Lohaus A. Emotion regulation among Chinese and German children and adolescents: a binational comparative study. Curr Psychol. 2022;42(28):24641–55. 10.1007/s12144-022-03578-x . Stover AD, Shulkin J, Lac A, Rapp T. A meta-analysis of cognitive reappraisal and personal resilience. Clin Psychol Rev. 2024;110:102428DOI. 10.1016/j.cpr.2024.102428 . Nie Q, Zhang J, Peng J, Chen X. Daily micro-break activities and workplace well-being: A recovery perspective. Curr Psychol. 2021;42(12):9972–85. 10.1007/s12144-021-02300-7 . Sianoja M, Syrek CJ, de Bloom J, Korpela K, Kinnunen U. Enhancing daily well-being at work through lunchtime park walks and relaxation exercises: Recovery experiences as mediators. J Occup Health Psychol. 2018;23(3):428–42. 10.1037/ocp0000083 . Maffett AJ, Paull DN, Skeel RL, Kraysovic JN, Hatch B, O'Mahony S, et al. Emotion Dysregulation and Workplace Satisfaction in Direct Care Worker Burnout and Abuse Risk. J Am Med Dir Assoc. 2022;23(7):1257–61. https://doi.org/10.1016/j.jamda.2022.03.001 . Maslach C, Jackson SE. The measurement of experienced burnout. J Organizational Behav. 1981;2(2):99–113. https://doi.org/10.1002/job.4030020205 . Park Y, Kim S. Customer mistreatment harms nightly sleep and next-morning recovery: Job control and recovery self-efficacy as cross-level moderators. J Occup Health Psychol. 2019;24(2):256–69. 10.1037/ocp0000128 . Duijs SE, van Wees M, Abma T, Bourik Z, Plak O, Jaspers Y, et al. We just take care after each other: Relational health strategies of nurses and nursing aides working in residential long-term care as a mechanism of in- and exclusion in care teams. Work. 2024;78(4):983–94. 10.3233/wor-220653 . Burke E, Pyle M, Machin K, Varese F, Morrison A. The effects of peer support on empowerment, self-efficacy, and internalized stigma: A narrative synthesis and meta-analysis. Stigma Health. 2019. 10.1037/SAH0000148 . Pappa D, Dafogianni C. Association of Occupational Burnout and Nursing Errors With Patient Safety: A Systemic Review. In: Management Association IR, editor. Research Anthology on Nursing Education and Overcoming Challenges in the Workplace. Hershey, PA, USA: IGI Global Scientific Publishing; 2021. pp. 297–310. Zhang J, Zou J, Wang X, Luo Y, Zhang J, Xiong Z, et al. Clinical nurses' compassion fatigue psychological experience process: a constructivist grounded theory study. BMC Nurs. 2023;22(1):487. 10.1186/s12912-023-01665-3 . Mertens L, Tamm G, Hoorelbeke K. Ruminative thinking styles differentially relate to posttraumatic stress versus growth following trauma exposure. Psychological Trauma: Theory, Research, Practice, and Policy. 2025. 10.1037/tra0001969 MacCann C, Double KS, Clarke IE. Lower Avoidant Coping Mediates the Relationship of Emotional Intelligence With Well-Being and Ill-Being. Front Psychol. 2022;13DOI. 10.3389/fpsyg.2022.835819 . Muhunthan M, Olalia MA, Neretljak S, Ezekiel S, Metersky K. Building resilience in nursing through strategic policy interventions. Int Nurs Rev. 2024;72(3). 10.1111/inr.13068 . Rawlings Cu. Adekunle Oyeyemi Adeniyi u, Chioma Anthonia Okolo u, Oloruntoba Babawarun u, Jeremiah Olawumi Arowoogun u. Psychological resilience in healthcare workers: A review of strategies and intervention. World J Biology Pharm Health Sci. 2024;17(2):387–95. 10.30574/wjbphs.2024.17.2.0088 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 16 Dec, 2025 Reviews received at journal 01 Dec, 2025 Reviews received at journal 23 Oct, 2025 Reviewers agreed at journal 19 Oct, 2025 Reviewers agreed at journal 19 Oct, 2025 Reviewers agreed at journal 15 Oct, 2025 Reviewers invited by journal 09 Oct, 2025 Editor assigned by journal 07 Oct, 2025 Editor invited by journal 12 Sep, 2025 Submission checks completed at journal 11 Sep, 2025 First submitted to journal 11 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7266010","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":531903532,"identity":"902c850d-83f0-4487-9017-178ea808468f","order_by":0,"name":"Liang Yuqi","email":"","orcid":"","institution":"Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Liang","middleName":"","lastName":"Yuqi","suffix":""},{"id":531903533,"identity":"c26c0ab3-ff3c-40d7-83bc-4c19c845540c","order_by":1,"name":"Zou Min","email":"","orcid":"","institution":"Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Zou","middleName":"","lastName":"Min","suffix":""},{"id":531903534,"identity":"1ab3b49b-56af-4647-a3fa-96e097a65e10","order_by":2,"name":"Li Cuihua","email":"","orcid":"","institution":"Shanghai Donghai Senior Nursing Hospital","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Cuihua","suffix":""},{"id":531903535,"identity":"81cce542-e19a-4ef2-a111-a02160b423a7","order_by":3,"name":"Zhang Yueling","email":"","orcid":"","institution":"Shanghai Donghai Senior Nursing Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhang","middleName":"","lastName":"Yueling","suffix":""},{"id":531903536,"identity":"cd199e49-8703-4ec2-afdd-61ba02eacb18","order_by":4,"name":"Ka Meng Ao","email":"","orcid":"","institution":"Kiang Wu Nursing College of Macau","correspondingAuthor":false,"prefix":"","firstName":"Ka","middleName":"Meng","lastName":"Ao","suffix":""},{"id":531903537,"identity":"322325ae-149a-4ee1-8119-72c341ec8e36","order_by":5,"name":"Joanne Wai-yee Chung","email":"","orcid":"","institution":"Kiang Wu Nursing College of Macau","correspondingAuthor":false,"prefix":"","firstName":"Joanne","middleName":"Wai-yee","lastName":"Chung","suffix":""},{"id":531903538,"identity":"da704c65-6f70-4d5f-9f7e-50d457e7352b","order_by":6,"name":"Jiang Liping","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYBACNv7mgw8+/JDg4WdvbHyQUFFDWAufxLFkw5k9FjKSPYcPGzw4c4ywFjmGHDNhHrYKG4MbaWmSD1uYiXAYw7E0xhk8EjwGN3LMKhIb2Bj427sT8Gthbj724IOFBI/kmTdmNxJ3yDBInDm7gZAt6YYgW/iO5wC1nGFjMJDIJaQlx0yah02Ch+FAjllBYhszCVoETqSlMRCnBRLIQL8AA1ki4cwxHoJ+ke8HR2WdPSgqP/6oqJHjb+/FrwUD8JCmfBSMglEwCkYBVgAAw+FKowhXLuwAAAAASUVORK5CYII=","orcid":"","institution":"XinHua Hospital","correspondingAuthor":true,"prefix":"","firstName":"Jiang","middleName":"","lastName":"Liping","suffix":""}],"badges":[],"createdAt":"2025-07-31 23:38:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7266010/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7266010/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":94205238,"identity":"7fc5ed6f-abae-451a-b3df-3e982e5b9945","added_by":"auto","created_at":"2025-10-23 14:33:42","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1778653,"visible":true,"origin":"","legend":"","description":"","filename":"0911FromEfforttoExhaustionAQualitativeStudyofCompassionFatigueinelderlyhealthcareaidesbasedontheeffortrecoverymodel.docx","url":"https://assets-eu.researchsquare.com/files/rs-7266010/v1/3085bb1fa1c3d0e3be79d2b0.docx"},{"id":94204752,"identity":"1da25c1c-f1be-4d73-8893-fe617870a1d9","added_by":"auto","created_at":"2025-10-23 14:25:42","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":9830,"visible":true,"origin":"","legend":"","description":"","filename":"71dbebdda2414a9cbcb5746cc69a24e2.json","url":"https://assets-eu.researchsquare.com/files/rs-7266010/v1/20e496aa39dd8f7d1d0a2ef0.json"},{"id":94204757,"identity":"570ce382-79d1-459b-8f26-ff022f9b3602","added_by":"auto","created_at":"2025-10-23 14:25:42","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":161494,"visible":true,"origin":"","legend":"","description":"","filename":"71dbebdda2414a9cbcb5746cc69a24e21enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7266010/v1/a55522312b38933fb18fb8fb.xml"},{"id":94204754,"identity":"0828218b-2fa6-4982-9d1a-7275543240d3","added_by":"auto","created_at":"2025-10-23 14:25:42","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1507275,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7266010/v1/58c9b35efde13a095759a4cc.png"},{"id":94206062,"identity":"d0466d02-5997-4c6c-9099-236312f05ca1","added_by":"auto","created_at":"2025-10-23 14:41:42","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":30754,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7266010/v1/63e15d6fdf2902284e347269.png"},{"id":94204759,"identity":"30f56928-37f0-4661-9176-ec331421162e","added_by":"auto","created_at":"2025-10-23 14:25:42","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":352265,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7266010/v1/1527f19bfc5647b5f5c7189c.png"},{"id":94204761,"identity":"11e79a9f-8772-4a07-81c7-d15b9b89afd8","added_by":"auto","created_at":"2025-10-23 14:25:43","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":158502,"visible":true,"origin":"","legend":"","description":"","filename":"71dbebdda2414a9cbcb5746cc69a24e21structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7266010/v1/035c775ec31c293cbf74c5ea.xml"},{"id":94205239,"identity":"775152f6-11cf-473a-8b15-3e3245ab8a17","added_by":"auto","created_at":"2025-10-23 14:33:42","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":172841,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7266010/v1/288a8779a31e33421cd4dbe9.html"},{"id":94205236,"identity":"11c4e8f2-9f78-423f-8fc5-f7cb172b05bb","added_by":"auto","created_at":"2025-10-23 14:33:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":133465,"visible":true,"origin":"","legend":"\u003cp\u003eAn imbalance between resource consumption and recovery drives the dynamics of compassion fatigue among HCAs.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7266010/v1/2585b86965369c00728b16c9.png"},{"id":94204753,"identity":"1b0a41e1-b457-4e79-998a-6c970eba3c59","added_by":"auto","created_at":"2025-10-23 14:25:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":247781,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic diagram of the developmental stages of HCAs’ compassion fatigue\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7266010/v1/98326cafa1aaebe05464b225.png"},{"id":94206463,"identity":"66cf3fe2-a1f5-4d11-831a-db7d1699bd22","added_by":"auto","created_at":"2025-10-23 14:49:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1150352,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7266010/v1/6f38079a-e470-4327-b19c-359305511eb8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"From Effort to Exhaustion: A Qualitative Study of Compassion Fatigue in elderly healthcare aides based on the Effort-Recovery Theory","fulltext":[{"header":"Background","content":"\u003cp\u003ePopulation ageing is a major global social challenge. By 2050, approximately 22% of the world's population will be over 60 years old[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This demographic change increases the number of older people with disabilities in activities of daily living (ADL). Globally, ADL disability rates among those aged 65 and above typically range from about 10% to over 50%, depending on various factors such as country, age group, and measurement methods[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Moreover, the global prevalence of dementia is expected to increase from 57.4\u0026nbsp;million cases in 2019 to 152.8\u0026nbsp;million cases in 2050, mainly due to population growth and ageing[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These health conditions necessitate an expanded and specialized workforce for care. However, shortages persist: the WHO estimates a projected shortfall of 11\u0026nbsp;million healthcare aides(HCAs) by 2030[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn China, approximately 310\u0026nbsp;million individuals (22% of the population) were aged over 60 at the end of 2024[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Smaller family sizes and migration from rural to urban areas have led to an increase in the number of families relying on institutional care, thereby increasing the pressure on HCAs[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. HCAs in long-term care settings play a crucial role as they are essential paramedical extensions of registered nurses. They are responsible for fundamental care tasks, such as assisting with mobility, personal hygiene, and feeding[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These tasks free up professional nurses to focus on more complex clinical duties. HCAs, who represent 60%-70% of the long-term care workforce, provide 70%-90% of the direct care to residents[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Although HCAs have more contact with patients than registered nurses, both in time and frequency, they usually have less training and lower professional status. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eHCAs in long-term elderly care face two main types of demands. They are burdened with physically intensive tasks, like bathing, feeding residents, and continuous bedside monitoring. At the same time, they must constantly manage their emotions while providing compassionate care. Both physical and emotional labour are central to their roles, with emotional labour having complex implications for their well-being, job satisfaction, and the quality of care they provide. This dual burden makes them more likely to experience compassion fatigue (CF), which is characterized by emotional, physical, and psychological exhaustion resulting from long-term care for traumatized individuals[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Research indicates that CF is prevalent among this group [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], which is closely linked to increased burnout and intentions to turnover [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In previous research on nurses, CF can negatively impact the quality of care [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Moreover, the emotional indifference caused by CF may transmit negative feelings through reduced nonverbal interactions (such as rigid expressions and brief language), indirectly exacerbating the depression scores of the elderly[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In China, 39.45% of elderly care workers report severe CF symptoms, which are linked to job dissatisfaction and a decline in care quality.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe Effort-Recovery Theory (ERT) explains this phenomenon through the concept of resource depletion. It states that without adequate recovery, such as rest and social support, sustained effort leads to a decline in health[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, existing CF research primarily focuses on hospital nurses, with few studies examining HCAs in long-term elderly care facilities [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This specific group has unique occupational characteristics, such as relatively low educational attainment, short training periods despite shouldering the majority of care work, and long-term companionship with older people [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Additionally, given China's cultural background, there may be differences in the development of CF among Chinese HCAs compared to Western HCAs. Most current research is quantitative, focusing on the static prevalence of CF. There is a lack of qualitative exploration of the dynamic process of CF, which may include workload accumulation, compensatory strategies, and ultimately, resource depletion. Without understanding this process, it is challenging to design effective and targeted interventions.\u003c/p\u003e\u003cp\u003eIn recent years, China has promoted the pilot implementation of long-term care insurance and the standardization of institutional elderly care. However, the occupational protection of HCAs, such as mandatory rest periods and psychological support, has not been incorporated into the policy framework [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. There is a contradiction between the policy's pursuit of \"quantity of care\" and the neglect of the \"sustainable care capabilities\" of HCAs[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Therefore, it is crucial to attend to the physical and mental needs of HCAs on time to ensure the steady development of the elderly care industry.\u003c/p\u003e"},{"header":"Theoretical background","content":"\u003cp\u003eThis study adopts the Effort-Recovery Theory. It explores how CF develops and uniquely manifests among HCAs in Chinese long-term care settings, within their specific sociocultural context. The study examines the balance between effort and recovery during their daily work from both physical and psychological aspects. It aims to fill gaps in the current literature and theories concerning compassion fatigue in HCAs, offering practical insights for developing culturally sensitive interventions in the future.\u003c/p\u003e\u003cp\u003eMeijman and Mulder primarily developed the Effort-Recovery Theory. It states that expending effort at work leads to psychophysiological load reactions, which, if not adequately countered by recovery, can result in adverse health outcomes[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Recovery is conceptualized as a dynamic process. It restores a person\u0026rsquo;s actual psychophysiological state to the optimal state required for functioning, encompassing both physical and mental aspects. The theory emphasizes the importance of both internal (during work) and external (after work) recovery opportunities, highlighting the role of self-regulation in maintaining well-being [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Prolonged effort without sufficient recovery can lead to sustained physiological activation and chronic health impairment[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eERT has been widely applied in occupational health psychology. It helps explain how work effort and recovery affect employee well-being, engagement, and performance. Studies show that leisure activities promoting relaxation and psychological detachment after work improve next-day vigor and work engagement. Conversely, high-duty off-job activities hinder recovery and contribute to increased fatigue. The theory also links acute stress reactions to long-term health, highlighting the importance of recovery in preventing chronic health impairment[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In practical settings, interventions based on this theory promote proactive recovery strategies. These include activities designed to foster detachment, relaxation, and autonomy, thereby enhancing daily well-being and performance [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The theory has been applied to various occupational groups, including managers, entrepreneurs, and hospitality workers, demonstrating the theory\u0026rsquo;s relevance across diverse work environments.[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThis framework is particularly suitable for understanding CF in China's caregiving context. First, ERT explains how the dual burden of physical tasks and emotional labour drains HCAs\u0026rsquo; resources, especially when structural barriers limit their ability to recover. Second, it accounts for culturally specific coping strategies, such as \"blessing beliefs,\" which provide temporary relief but ultimately extend resource depletion. Ultimately, the theory elucidates the recurring cycle of overexertion, compensation, and decline. External factors (such as 24-hour shifts) and internal values (like considering endurance a virtue) work together to trap caregivers in a state of prolonged exhaustion. This model integrates physiological, psychological, and sociocultural factors that contribute to compassion fatigue.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eThis study adopted a qualitative descriptive approach to explore the dynamic process by which resource expenditure-recovery imbalance contributes to compassion fatigue among HCAs in long-term care facilities. It adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eStudy participants and sampling\u003c/h3\u003e\n\u003cp\u003eThis study was conducted in Shanghai, China, from May 23 to August 31, 2024. A total of 13 HCAs, including 10 women and three men, were invited from a large long-term elderly care facility in Shanghai. The inclusion criteria were: (1) aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years; (2) HCAs employed in the current long-term care facility for \u0026ge;\u0026thinsp;3 months. Exclusion criteria comprised: (1) dialect-only speakers with communication barriers; and (2) refusal to participate in interviews. Purposive sampling was used to recruit participants. Predetermined criteria were included to account for the diversity of social demographic factors, such as gender, age, education level, work years, professional titles, and work department, to obtain rich data. A trained research team member conducted participant selection. Invitations were distributed through face-to-face interactions, and during these interactions, researchers explained the study's purpose, confidentiality protocols, and precautions. Participation in the survey was voluntary, and all participants provided written informed consent before their participation. The study continued sampling until data saturation was achieved\u0026mdash;defined as no new themes emerging from three consecutive interviews. After initial analysis of 10 participants' data, three additional interviews were conducted to verify saturation. During the research process, two HCAs declined participation due to scheduling conflicts. Ultimately, 13 participants completed the interviews.\u003c/p\u003e\n\u003ch3\u003eDetermining the interview outline\u003c/h3\u003e\n\u003cp\u003eAn initial interview guide was drafted through literature review and collaborative team discussions. Following a pilot test with two HCAs (excluded from formal analysis), iterative refinements were implemented, incorporating participant feedback and expert consultations with one long-term care facility director, one head nurse, and two geriatric nursing specialists. After the two pre-interviews, the formal interview outline was adjusted, improved, and finalized. The finalized guide featured simplified terminology, enhanced open-ended questions, and optimized question sequencing to better capture participants' lived experiences.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eAfter obtaining institutional approval and \u003cb\u003eparticipant informed consent\u003c/b\u003e, researchers entered the facility as \"trainee nurses\" to conduct semi-participant observation and in-depth interviews. The phased approach comprised: (1) Descriptive observation during initial site immersion, including facility layout documentation and initial participant screening; (2) Focused observation where researchers shadowed HCAs during care activities (e.g., assisting with mobility, feeding), with supplementary semi-structured interviews conducted during participant downtime/relaxation time (17:00\u0026ndash;19:00) lasting 20\u0026ndash;40 minutes; and (3) Selective observation during later stages targeting specific cases based on emerging saturation patterns. All data were captured through contemporaneous field notes, audio recordings, and contextual photographs, with analysis and reflective memos completed within 24 hours post-observation.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eInterview recordings were transcribed verbatim within 24 hours post-interview by one researcher and independently verified by another to ensure accuracy. Inaudible parts or discrepancies were clarified with interviewees promptly. Analysis employed directed content analysis through a five-phase process: developing a literature-derived initial coding framework with operational definitions; immersing in data via line-by-line reading and annotation; refining codes iteratively to incorporate emergent concepts; synthesizing codes into thematic subcategories based on relational patterns; and abstracting core themes capturing compassion fatigue mechanisms. Two researchers independently executed these steps, with final themes established through consensus.\u003c/p\u003e\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethical clearance from the Medical Ethics Committee of Xinhua Hospital, affiliated with Shanghai Jiao Tong University School of Medicine, and adhered strictly to the principles outlined in the Declaration of Helsinki. Before participation, researchers fully disclosed the study\u0026apos;s purpose, methodology, and scope to potential participants. All participants provided written informed consent in accordance with institutional protocols, acknowledging their voluntary status and the right to withdraw without restriction. To ensure confidentiality: Interview data were anonymized using case numbers (e.g., C1, C2) instead of personal identifiers; All recordings and transcripts underwent de-identification processing; No personally identifiable information was retained in research records.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrustworthiness and credibility\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo ensure methodological rigor, the study employed multiple strategies to enhance trustworthiness and credibility. For credibility, maximum variation sampling (encompassing gender, age, education, tenure, and work setting) was employed, with data collection continuing until saturation was achieved. Any ambiguous interview content was clarified through member checking. Auditability was maintained by having verbatim transcripts verified by two researchers within 24 hours, alongside comprehensive analytical trails (including coding decisions and theme development records). Confirmability was strengthened via independent thematic analysis by two researchers, with discrepancies resolved through consensus discussions to minimize researcher bias. Transferability was enhanced through detailed contextual descriptions of themes and participant characteristics, enabling readers to assess the relevance of findings to other settings. Partial respondent validation was conducted for key findings at the participants\u0026rsquo; request. All interview recordings, transcripts, and related materials were encrypted and stored on a password-protected server, accessible only to core team members who had signed confidentiality agreements. Data will be retained for 5 years after project completion (including publication) and then permanently deleted in accordance with regulations and policies. Usage is limited to this research (analysis, reporting, publication), with no third-party disclosure or reuse without the explicit written consent of the interviewees. Personal identifiers are anonymized in all outputs.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eNo new topics were found after interviewing the 13 participants. The study sample was from a large long-term elderly care facility in Shanghai., China. The participant\u0026rsquo;s characteristics are presented in \u003cstrong\u003eTable 1\u003c/strong\u003e. The interviews lasted 35\u0026ndash;42 minutes, averaging 32 minutes in length. The participants included 10 women and three men; Of them, all were aged over 45 years (including 4 (30.77%) \u0026gt;55 years); 8 (61.54%) had worked for \u0026gt;5 years; 5 (38.46%) had elementary school education, 6 (46.15%) had middle school education, and 2(15.38%) had high school education; with one care work group leader and the others being regular HCAs. Through a thematic analysis of interview transcripts guided by the Effort-Recovery Theory, we identified four core themes \u0026ndash; Work Demand Overload, Compensatory Effort Strategies, Insufficient Recovery, and Negative Effects \u0026ndash; comprising 10 subthemes (Fig. 1). These themes collectively represent the dynamic process of compassion fatigue development in HCAs (Fig. 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u0026nbsp;\u003c/strong\u003eThe demographic characteristics of the participants(n=13)\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"676\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.716%;\"\u003e\n \u003cp\u003eSerial number\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2426%;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.76331%;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1479%;\"\u003e\n \u003cp\u003eEducation background\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5266%;\"\u003e\n \u003cp\u003ePositions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6036%;\"\u003e\n \u003cp\u003eWorking years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.716%;\"\u003e\n \u003cp\u003eC1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2426%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.76331%;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1479%;\"\u003e\n \u003cp\u003eElementary School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5266%;\"\u003e\n \u003cp\u003eHCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6036%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.716%;\"\u003e\n \u003cp\u003eC2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2426%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.76331%;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1479%;\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5266%;\"\u003e\n \u003cp\u003eGroup Leader\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6036%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.716%;\"\u003e\n \u003cp\u003eC3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2426%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.76331%;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1479%;\"\u003e\n \u003cp\u003eHigh School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5266%;\"\u003e\n \u003cp\u003eHCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6036%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.716%;\"\u003e\n \u003cp\u003eC4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2426%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.76331%;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1479%;\"\u003e\n \u003cp\u003eElementary School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5266%;\"\u003e\n \u003cp\u003eHCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6036%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.716%;\"\u003e\n \u003cp\u003eC5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2426%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.76331%;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1479%;\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5266%;\"\u003e\n \u003cp\u003eHCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6036%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.716%;\"\u003e\n \u003cp\u003eC6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2426%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.76331%;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1479%;\"\u003e\n \u003cp\u003eElementary School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5266%;\"\u003e\n \u003cp\u003eHCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6036%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.716%;\"\u003e\n \u003cp\u003eC7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2426%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.76331%;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1479%;\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5266%;\"\u003e\n \u003cp\u003eHCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6036%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.716%;\"\u003e\n \u003cp\u003eC8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2426%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.76331%;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1479%;\"\u003e\n \u003cp\u003eElementary School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5266%;\"\u003e\n \u003cp\u003eHCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6036%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.716%;\"\u003e\n \u003cp\u003eC9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2426%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.76331%;\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1479%;\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5266%;\"\u003e\n \u003cp\u003eHCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6036%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.716%;\"\u003e\n \u003cp\u003eC10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2426%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.76331%;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1479%;\"\u003e\n \u003cp\u003eElementary School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5266%;\"\u003e\n \u003cp\u003eHCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6036%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.716%;\"\u003e\n \u003cp\u003eC11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2426%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.76331%;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1479%;\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5266%;\"\u003e\n \u003cp\u003eHCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6036%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.716%;\"\u003e\n \u003cp\u003eC12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2426%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.76331%;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1479%;\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5266%;\"\u003e\n \u003cp\u003eHCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6036%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.716%;\"\u003e\n \u003cp\u003eC13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2426%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.76331%;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1479%;\"\u003e\n \u003cp\u003eHigh School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5266%;\"\u003e\n \u003cp\u003eHCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6036%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStage I: Work Demand Overload\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the Effort-Recovery Theory (ERT), \u0026quot;work demand\u0026quot; serves as the starting point of resource consumption, referring to the physical, cognitive, and emotional resources individuals expend to accomplish work tasks. This demand comprises external load and informational load within the model; when applied to elderly care contexts, external load manifests as physical labor and environmental stressors for HCAs, while informational load denotes cognitive and emotional resource investments\u0026mdash;their combined impact resulting in \u0026quot;dual consumption\u0026quot; unique to HCAs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePhysical Burden\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe subtheme of Physical Burden within the Effort-Recovery Theory refers to resource depletion triggered by external load\u0026mdash;specifically, the intensity of physical labor and environmental stressors. Long-term caregivers often endure high-intensity or low-intensity but high-frequency tasks alongside nighttime on-call responsibilities, such as responding to emergency call bells, which can result in chronically overloaded physiological states. In most eldercare facilities, these HCAs maintain prolonged periods of exertion; daytime duties demand full engagement in repetitive basic care tasks such as assisting with feeding, mobility support, bathing, and scheduled repositioning, leading to sustained physical depletion\u0026mdash;as articulated by caregivers: \u003cem\u003eC6: \u0026quot;\u003c/em\u003e \u003cem\u003eEvery single day is just one thing after another. My schedule\u0026apos;s packed from sunup to sundown\u0026quot;; C9: \u0026quot;\u003c/em\u003e \u003cem\u003eThe work ain\u0026apos;t exactly back-breaking, but... It\u0026apos;s like spinning nonstop every day. Open my eyes and boom \u0026ndash; drowning in tasks.\u0026quot;; C3: \u0026quot;\u003c/em\u003e \u003cem\u003eThis grandma weighs over 200 pounds. I mean, I really can\u0026apos;t reposition her alone. But you can\u0026apos;t exactly expect someone always to be free to lend a hand.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBeyond routine care tasks, caregivers must maintain constant vigilance to respond promptly to emergencies such as falls or medical crises, with 24/7 on-call pressure compounding physical exhaustion and psychological strain\u0026mdash;as reflected in their accounts:\u003cem\u003e\u0026nbsp;C2: \u0026quot;Night shifts? Forget proper sleep. Ears glued to every rustle from granny and beeping from machines.\u0026quot;; C5: \u0026quot;My mind\u0026apos;s constantly tied to this room. Even when doing chores next door, I\u0026apos;m itching to check on my elders here.\u0026quot;; C4: \u0026quot;What decent sleep? You\u0026apos;re wiped from daylight chores, then blaring call bells jolt you awake at night. Lost more than ten pounds since starting this job.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBeyond physical burdens from work duties, caregivers\u0026apos; combined work-rest environments impose an additional load. Some long-term caregivers are forced to rest within open-ward patient rooms, where disruptive noise triggers fragmented sleep and prevents deep recovery\u0026mdash;exacerbating fatigue accumulation. As expressed in caregiver testimonials: \u003cem\u003eC10: \u0026quot;Honestly, I\u0026apos;ve never fully relaxed during breaks; nerves remain on constant alert even at night, too tense for deep sleep\u0026quot;, while C1 confirmed: \u0026quot;Those machines in the ward? Ventilators whooshing, heart monitors beeping. Drove me nuts at first. Couldn\u0026apos;t catch a wink.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePsychological Burden\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the ERT framework, information load denotes the consumption of cognitive and emotional resources during complex information processing, such as interpreting seniors\u0026apos; emotional states or assessing clinical conditions. This is categorized as Psychological Burden in our study. The uniqueness of geriatric care lies in caregivers\u0026apos; dual responsibilities: providing technical care alongside emotional support, which intensifies this information load. Nursing home residents are predominantly functionally or cognitively impaired individuals who cannot articulate their needs clearly. Consequently, long-term HCAs must infer residents\u0026apos; states through subtle nonverbal cues (e.g., facial expressions, groans). \u003cem\u003eAs remarked by C11: \u0026quot;He never complains, but you see it \u0026ndash; the spark\u0026apos;s gone like tending to a house where the lights are out.\u003c/em\u003e \u003cem\u003e\u0026quot; Similarly, C7 noted: \u0026quot;After caring for her for so long, every blink and sigh is engraved in my bones. I know her cravings before she asks.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFurthermore, within medical contexts, HCAs often undertake preliminary health assessments of residents, such as monitoring pressure ulcer deterioration or respiratory abnormalities, taking on near-clinical cognitive load and condition assessment responsibilities to some extent.\u003cem\u003e\u0026nbsp;As C1 noted: \u0026quot;Gotta stick to the exact amount of softer food each day. Otherwise, her system will crash faster than you can blink with complications.\u0026quot; Similarly, C6 explained: \u0026quot;My ears catch the second the unusual sound shifts in Granny\u0026apos;s breathing \u0026ndash; that\u0026apos;s when you drop everything and call the nurses\u0026apos; station.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn long-term care facilities, HCAs frequently provide years or even decades of care for the same resident, leading to profound emotional bonds where the elder becomes like family. This deep empathy bond creates emotional entanglement that\u0026apos;s difficult to disengage from. \u003cem\u003eAs C13 expressed: \u0026quot;Her family lives far away; I deeply wish they could accompany her more often.\u0026quot; C9 similarly noted: \u0026quot;After 8 years caregiving, more kin to me than blood now\u0026mdash;any slight change in their condition fills us with urgency.\u0026quot;\u0026nbsp;\u003c/em\u003eThis empathy bond can sometimes lead HCAs to internalize the elder\u0026apos;s suffering, resulting in secondary trauma.\u003cem\u003e\u0026nbsp;C2 said: \u0026quot;Sometimes it seems the senior isn\u0026apos;t suffering; only we who care for them feel the pain.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStage II: Compensatory Effort Strategies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCompensatory effort constitutes a core mechanism within ERT, denoting self-initiated regulatory strategies that individuals activate when resource depletion-recovery imbalances threaten work efficacy. While providing transient relief from occupational strain, sustained application of these strategies risks accelerating irreversible physiological and psychological resource attrition by suppressing recovery needs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEmotional Detachment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen caregivers experience prolonged exposure to high emotional demands\u0026mdash;such as witnessing elderly patients\u0026apos; suffering or end-of-life scenarios\u0026mdash;cumulative empathy strain depletes their emotional resources to near exhaustion. Whilst being mindful that elderly care requires \u0026quot;wholehearted commitment,\u0026quot; this professional aspiration becomes unsustainable given their depleted capacity. To bridge this divergence between expected engagement and actual capability, caregivers adopt emotional detachment strategies. This manifests as deliberately minimising deep emotional connections with patients and proceduralising care tasks into checklist-driven routines to conserve empathy resources.\u003cem\u003e\u0026nbsp;Caregiver C4 described this adaptation: \u0026quot;Many situations are beyond my control; all I can do is just to keep them physically clean and comfortable.\u0026quot; Similarly, C6 noted: \u0026quot;While feeling upset after caring for one resident, I must immediately switch to cheerful mode by pasting on a fresh smile for the next.\u0026quot;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSimilar strategies include demarcating boundaries between occupational duty and humanistic care to avoid emotional expenditure. \u003cem\u003eAs C7 stated: \u0026quot;We sandwiched tight between our professional role and closest caregiver\u0026mdash;some conversations are permissible, others aren\u0026apos;t; everyone has delineated responsibilities.\u0026quot;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCrucially, sustained emotional suppression may ultimately induce empathy deterioration and provoke self-worth crises over time\u003cem\u003e. C13 questioned: \u0026quot;Colleagues compare me to a monk\u0026mdash;I can\u0026apos;t tell this is hard-won inside\u0026apos;s calm, or just my heart have turned to a dried-out sponge.\u0026quot; while C4 confessed: \u0026quot;Pretty often I feel like I don\u0026apos;t amount to much\u0026hellip;,\u003c/em\u003e \u003cem\u003eno matter how hard I try, they keep getting weaker\u003c/em\u003e\u003cem\u003e，\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003ewhich makes me wonder what\u0026apos;s the point of this whole nursing job, honestly.\u0026quot;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePhysiological Compensation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnder pressures of physical overload \u0026ndash; such as overnight on-call duties and repeated repositioning tasks \u0026ndash; alongside chronic sleep deprivation, HCAs resort to physiological compensatory behaviours to forcibly sustain physical functioning. This includes relying on stimulatory substances like coffee or energy drinks, or accelerating work pace to mask fatigue symptoms, as noted by\u003cem\u003e\u0026nbsp;C4: \u0026quot;Sometimes when I don\u0026apos;t sleep well at night, I feel totally wiped out the next day. I just have to struggle through till lunch break, then catch a quick nap to recharge.\u0026quot; and C7: \u0026quot;When things get crazy busy, the tiredness just vanishes. You don\u0026apos;t even think about whether you\u0026apos;re exhausted or upset\u0026mdash;you push through. What choice is there? The work won\u0026apos;t do itself.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, such chronic physiological overextension risks precipitating long-term health deterioration, including impaired immunity and chronic musculoskeletal complaints.\u003cem\u003e\u0026nbsp;Like C8 said: \u0026quot;Honestly, you always have some aches or pains going on. It just comes with the job. \u0026quot; And like C2 mentioned: \u0026quot;Sometimes if I had a poor sleep, the next day my heart starts racing like crazy. Then I have to visit the doctor for meds to calm it down\u0026mdash;no choice.\u0026quot;\u0026nbsp;\u003c/em\u003eCritically, accumulated exhaustion compromises emotional regulation capacity, heightening vulnerability to anxiety or irritable outbursts when\u003cem\u003e\u0026nbsp;responding to residents\u0026apos; needs, as C6 put it: \u0026quot; Daytime, my head\u0026apos;s not clear for the inadequate sleep. When the elders need me, it\u0026apos;s as if my body won\u0026apos;t move right and I can\u0026apos;t give them what they deserve. \u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCognitive Reframing\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome caregivers in our study employed cognitive reframing strategies to mitigate the psychological strain arising from persistent effort-recovery imbalances. This compensatory mechanism functions to maintain psychological equilibrium by redefining the meaning of work or rationalizing stressors. As demonstrated in participant narratives: some attributed occupational hardships to inherent job characteristics,\u003cem\u003e\u0026nbsp;C7 noted: \u0026quot;We\u0026rsquo;re at the lowest rung of society\u0026mdash;this job\u0026apos;s hard and heavy, but hey, that\u0026rsquo;s just part of the deal \u0026quot;\u003c/em\u003e Others employed transactional reframing by equating compensation with service provision, simplifying care relationships to fee-for-service exchanges, \u003cem\u003eas explained by C1: \u0026quot;Residents\u0026rsquo; families pay us, so\u0026nbsp;\u003c/em\u003eThat\u0026rsquo;s the deal \u003cem\u003eto\u0026nbsp;\u003c/em\u003esolve their worries\u003cem\u003e\u0026nbsp;and shoulder their burden.\u0026quot;\u0026nbsp;\u003c/em\u003eNotably, several caregivers reinterpreted pressures as the dedication of \u0026quot;benefiting others is benefiting oneself\u0026quot;,\u003cem\u003e\u0026nbsp;C5 stated: \u0026quot;Like they drilled into us at training:\u003c/em\u003e \u003cem\u003eThis is how you \u0026apos;stock up good karma\u0026apos; which is gonna pay off for our kids later.\u0026quot;\u003c/em\u003e Such cognitive repositioning effectively preserved emotional reserves.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStage III: Insufficient Recovery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDivergent Recovery Awareness\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe effectiveness of an individual\u0026apos;s recovery is directly constrained by the degree of their awareness of their own physical and mental state and the motivation for regulation. This study found that there was a significant differentiation among HCAs at the level of recovery awareness.\u003c/p\u003e\n\u003cp\u003eDespite limited resources, some HCAs demonstrated active self-regulatory behaviors through adaptive micro-recovery strategies. These included leveraging informal peer networks for emotional catharsis and seizing fragmented downtime for momentary reprieve. \u003cem\u003eAs C4 illustrates: \u0026quot;Sometimes when I\u0026apos;m fed up with this awful job, I rant with my work buddies. Sure, it won\u0026apos;t fix anything, but getting it off your chest is almost like therapy. \u0026quot; While C13 noted: \u0026quot;When things slow down, I just scroll through short videos, casually watching streamers for relaxation.\u0026quot;\u0026nbsp;\u003c/em\u003eSuch behaviors represent intentional mobilization of residual resources to mitigate acute stress responses, exemplifying micro-recovery strategies within constrained environments.\u003c/p\u003e\n\u003cp\u003eIn contrast, some caregivers internalize \u0026quot;fatigue\u0026quot; as a professional norm under the continuous effect of high-intensity work, and even regard it as a manifestation of \u0026quot;sense of responsibility\u0026quot;. This cognitive bias weakens its sensitivity to seeking recovery and lacks the motivation for active intervention, leading to a passive adaptive recovery model. HCAs regard physical and mental exhaustion as an inevitable cost of their profession and avoid intervention through rationalization and generalization: \u003cem\u003eC3 states: \u0026quot;Pain and exhaustion just come with the job. Taking care of old folks and sick people\u0026mdash;how could it NOT wear you out?\u0026quot; C12 notes: \u0026quot;\u003c/em\u003e \u003cem\u003eNever crossed my mind to \u0026apos;fix\u0026apos; being tired. Almost every care worker is like this, just bear it.\u0026quot; And C8 adds: \u0026quot;We\u0026apos;re paid to do this. Means we gotta suffer what their own kids won\u0026apos;t.\u0026quot;\u0026nbsp;\u003c/em\u003eTheir cognitive adaptation converts strain into symbolic dedication, unintentionally suppressing recovery need.\u003c/p\u003e\n\u003cp\u003eA distinct subgroup demonstrates they can detect abnormal conditions of their own. Still, they neither have an adequate reserve of recovery strategies nor the awareness and action methods to explore recovery approaches actively. \u003cem\u003eAs C1 said, \u0026quot;I feel off somehow... but got no clue how to fix it.\u0026quot; And C7 mentions \u0026quot;After a while, you just learn to live with it.\u0026quot;\u003c/em\u003e, which implies a passive acceptance of the problem. \u003cem\u003eWhile C8 described, \u0026quot;I don\u0026apos;t even know what I should do. It\u0026apos;s messed up\u0026mdash;kinda sad and empty inside\u0026mdash;but no idea how to make it right.\u0026quot;\u003c/em\u003e Their awareness-behavior misalignment creates a state of frustrated inertia, where cognitive clarity fails to translate into restorative activity despite the perceived urgency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRestricted Recovery Resources\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInsufficient recovery stems not only from individual factors but also critically depends on institutional resource allocation. Our findings reveal systemic gaps between formal resource availability and clinical accessibility. Although elderly care institutions have resources such as staff lounges and psychological counseling rooms, there are many obstacles for contract HCAs when they actually use these resources. For example, psychological counseling services are often prioritized for clinical staff (e.g., nurses, physicians), leaving HCAs marginalized. Similarly, physical rest spaces, though present, remain functionally inaccessible\u0026mdash;HCAs report relying on fragmented, on-call rest in clinical areas rather than engaging in meaningful disengagement.\u003cem\u003e\u0026nbsp;As C10 noted, \u0026quot;We got a staff lounge, sure\u0026mdash;but I think that\u0026rsquo;s only for the doctors, nurses, therapists... not us.\u0026quot; C1 added, \u0026lsquo;We catnap on chairs in the patients\u0026rsquo; rooms. That\u0026rsquo;s our \u0026lsquo;break\u0026rsquo; when the elders nap.\u0026rsquo; While C5 notes, \u0026apos;Working nights?\u0026rsquo; We \u0026apos;sleep\u0026apos; in the wards. Gotta watch the old folks every second\u0026mdash;no real shut-eye.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdministrative pressures further compound these issues. High caregiver-to-resident ratios and rigid scheduling practices disrupt opportunities for consistent recovery. HCAs describe a constant sense of urgency, \u003cem\u003ewith C5 stating, \u0026quot;No time for us to grieve\u0026mdash;more elders waiting... Work\u0026apos;s piling up!\u003c/em\u003e This chronic time scarcity perpetuates inadequate psychophysiological restoration, as HCAs lack the space and time needed to recuperate fully.\u003c/p\u003e\n\u003cp\u003eOutsourced employment models exacerbate these deficits. Third-party agencies often provide superficial psychological support, failing to address the chronic psychosocial burdens faced by HCAs.\u003cem\u003e\u0026nbsp;C4 noted that:\u0026rdquo; I don\u0026rsquo;t think the outsourcing agency makes a difference. We complain about issues such as workload and salary. They give you some half-hearted pep talks, but never fix what\u0026rsquo;s really grinding us down.\u0026rdquo;\u0026nbsp;\u003c/em\u003eCompounding this, cultural stigmatization of mental health support discourages help-seeking behaviors. HCAs internalize the belief that seeking counseling is a sign of weakness, \u003cem\u003eas reflected by C11: \u0026ldquo;No one admits to needing counseling\u0026mdash;only \u0026lsquo;sick\u0026rsquo; people do that.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdditionally, geographical separation from family networks reduces familial support, leaving HCAs socially isolated. Paradoxically, despite the potential value of peer support, it remains underutilized. This occurs because there is a shared tendency to normalize suffering among HCAs. \u003cem\u003eAs C13 explained, \u0026quot;Well, we\u0026apos;re all hurting here \u0026ndash; but nobody pipes up \u0026apos;cause you don\u0026apos;t want folk thinking you can\u0026apos;t hack it.\u0026quot;\u0026nbsp;\u003c/em\u003eThis silence perpetuates a cycle of unaddressed distress, further hindering recovery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStage IV: Negative Effects\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026quot;Negative effects\u0026quot; represent the ultimate outcome of resource imbalance within the Effort-Recovery Model, manifesting in this study as the development of compassion fatigue. This phenomenon is characterized by the degradation of physical and psychological functioning and health impairment among HCAs. These effects not only threaten individual well-being but also directly compromise the quality of care and undermine the sustainability of elderly care systems. Nevertheless, under high-pressure conditions, some HCAs exhibit fragmented resilience through self-initiated strategies that temporarily curb or partially mitigate the spread of adverse effects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eOnset of Occupational Burnout\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProlonged depletion of emotional resources without adequate recovery leads to the gradual degradation of empathy among\u0026nbsp;HCAs, manifesting as emotional numbness and mechanistic work patterns. This functional degradation is a typical sign of resource depletion in the effort-recovery model, characterized by affective exhaustion, where the emotional response to residents shifts from proactive compassion to mechanical execution.\u003cem\u003e\u0026nbsp;C2 described feeling \u0026quot;Honestly, I\u0026apos;m in full robotic mode now. Just get the tasks done, as quickly as I can,\u0026quot; \u0026nbsp;while C7 noted,\u0026nbsp;\u003c/em\u003e\u003cem\u003e\u0026quot;Dunno when it happened, but my care feels hollow now. Stopped noticing if residents feel comfortable, try to make all tasks done.\u0026quot;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis burnout demonstrates the model\u0026apos;s core \u0026quot;functional degradation\u0026quot; mechanism: sustained resource depletion forces individuals to lower work standards for basic functionality, consequently diminishing care quality. Mechanistic work is prone to causing negligence or mistakes, \u003cem\u003eC6 reported: \u0026quot;Scary moment on days - my head was mush, nearly missed her choking right in front of me. Could\u0026apos;ve been... \u0026quot; At the same time, C2 admitted, \u0026quot;\u003c/em\u003e \u003cem\u003eMixed up bed tags somehow. I don\u0026apos;t know how I confused the age with the bed number and gave the residents the wrong medication. \u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, several\u0026nbsp;HCAs stated that they would adopt practical strategies to maintain care effectiveness amid resource constraints, ensuring basic care quality\u003cem\u003e. For instance, C13 employed a \u0026quot;critical-first\u0026quot; task prioritization approach: \u0026quot;I will focus on the worst off first, proper life and death stuff. The rest thing can wait till I spot a gap.\u0026quot;\u0026nbsp;\u003c/em\u003eThis dynamic resource allocation strategy enables the completion of high-priority care despite limited energy. Similarly, \u003cem\u003eC5 regulated her professional state through selective emotional engagement, noting: \u0026quot;Proper chinwag with the chatty residents can shake off that numbness feeling. Like coming up for air.\u0026quot;\u003c/em\u003e Such reconstructed emotional bonds serve as vital buffers against job burnout.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTriggering of Secondary Traumatization\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnresolved empathetic stress accumulates and transforms into traumatic memories, manifesting as intrusive flashbacks, avoidance behaviors, or hyperarousal, which is a direct manifestation of \u0026quot;health damage\u0026quot; in the ERT at the psychological level. Specifically, trauma memory generalization bound to specific occupational scenarios triggers intense emotional reactions, closely linked to the professional characteristic of \u0026quot;normalized life-death issues\u0026quot; in long-term care. For example, \u003cem\u003eC12 stated, \u0026quot;I keep dreaming about spare beds and wake up with a tight chest,\u0026quot; while C6 shared, \u0026quot; When I encounter similar scenes, I get nervous and keep asking myself if I did enough.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdditionally, it may present as somatization symptoms, where psychological stress is converted into physical discomfort. This indicates that under long-term stress, HCAs maintain their work efficiency by depleting their physical resources, ultimately leading to the disruption of the \u0026quot;balance\u0026quot; and autonomic nervous system disorders.\u003cem\u003e\u0026nbsp;C4 stated: \u0026quot;I\u0026apos;ve lost a lot of weight and often sweat at night.\u0026quot; C10: \u0026quot;Compared to before, I get easily irritated by small things and am particularly emotional.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFacing these challenges, HCAs develop different coping strategies to digest or avoid traumatic experiences in their long-term work experience: some maintain emotional connections/ bonds through commemorative coping, attempting to find meaning in caregiving through memory reconstruction. This coping strategy may be related to affirming their professional value. For instance, \u003cem\u003eC2: \u0026quot;I still keep her photos and videos on my phone. I take them out from time to time to remember those days.\u0026quot; C13: \u0026quot;When things aren\u0026apos;t going well, that old lady pops into my mind. She treated me really well and couldn\u0026apos;t stand seeing me tired out.\u0026quot;\u003c/em\u003e Others adopt avoidance coping to cut off triggers and reduce emotional arousal, reflecting a self-protective mechanism of trauma avoidance. \u003cem\u003eC7 noted:\u0026quot; I deleted the family\u0026apos;s contact information, cause just seeing their picture makes me think of the old lady... and all that pain she went through.\u0026quot;\u0026nbsp;\u003c/em\u003eNotably, memorial coping, while temporarily alleviating emotional emptiness, may strengthen traumatic memories and intensify rumination; avoidance coping, although reducing immediate pain, may lead to emotional isolation in the long term and weaken psychological tolerance to similar situations, forming a vicious cycle of \u0026quot;trauma - avoidance - retraumatization.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDecline in Empathy Satisfaction\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe decline in empathy satisfaction raises questions about HCAs\u0026apos; own value. The decline stems from unreciprocated efforts, such as the deterioration of the elderly\u0026apos;s condition and the family\u0026apos;s misunderstanding of older people. According to ERT, when individuals perceive an effort-reward imbalance (specifically manifested as uncertainty about care outcomes and insufficient social-emotional feedback), their intrinsic motivation (e.g., career value) gradually disintegrates, leading to reduced self-efficacy and a sense of meaninglessness. \u003cem\u003eAs C6 wondered, \u0026quot;Why did an old person who was chatting and laughing just collapse all of a sudden? Did I do something wrong?\u0026quot;\u0026nbsp;\u003c/em\u003eand \u003cem\u003eC4 admitted, \u0026quot;I always feel useless. If I\u0026apos;d done better back then, maybe they wouldn\u0026rsquo;t have passed away.\u0026quot;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome even experience a professional identity crisis, as seen in \u003cem\u003eC7\u0026apos;s query, \u0026quot;What\u0026rsquo;s the point of anything I do? She\u0026rsquo;s still suffering so much. I can\u0026rsquo;t help her at all.\u0026quot;\u0026nbsp;\u003c/em\u003eProlonged exposure to such an imbalance situation forces HCAs to rationalize \u0026quot;emotional numbness.\u0026quot;, \u003cem\u003eas in C10\u0026apos;s, \u0026quot;After seeing so many old folks pass away, I\u0026rsquo;ve gotten used to it now.\u0026quot; T\u003c/em\u003ehis \u0026quot;depersonalization\u0026quot; is a key feature of job burnout. It is the external manifestation of HCAs\u0026apos; blunted emotional responsiveness and gradual disintegration of professional identity under high-mortality care contexts.\u003c/p\u003e\n\u003cp\u003eDuring the study, some HCAs indicated that they reclaim work meaningfulness through other minor details, with value reconstruction manifesting in dual pathways: some maintain professional dignity via internal principle adherence, anchoring value in the ethical significance of care behaviors (e.g., upholding elderly dignity) rather than outcomes like disease progression, as seen in \u003cem\u003eC6\u0026apos;s \u0026nbsp;\u0026quot;I make sure to keep her clean every single day. At least that way, when her time comes, she goes with dignity. That\u0026apos;s the least I can do.\u0026quot;\u0026nbsp;\u003c/em\u003eOthers rely on external recognition to activate career value, reflecting a dependence on environmental feedback, as\u003cem\u003e\u0026nbsp;C10 shared: \u0026quot;When families say thanks, or doctors and nurses give a compliment... that\u0026apos;s when I feel like what I do matters all over again.\u0026rdquo;\u003c/em\u003e The former fosters more enduring psychological resilience, while the latter is more susceptible to fluctuations in external evaluations, and the latter risks unstable self-worth due to evaluative fluctuations, implying a potential occupational psychological risk.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eGuided by the Effort-Recovery Theory, this study systematically examines the dynamic mechanism of compassion fatigue evolution among HCAs in elderly long-term care facilities. This mechanism unfolds as a four-stage trajectory: work demand overload \u0026rarr; compensatory effort strategies \u0026rarr; insufficient recovery \u0026rarr; negative effects. Each stage represents a progressive manifestation of the \u0026quot;imbalance between resource consumption and recovery\u0026quot; in ERT. Specifically, work demand overload marks the starting point of resource consumption; compensatory effort strategies act as passive adjustments following the imbalance; insufficient recovery serves as a key mediator of the imbalance; and adverse effects constitute the ultimate outcome of such imbalance.\u003c/p\u003e\n\u003cp\u003eWork demand overload, the starting point of resource depletion, manifests through the dual impact of external load and information load. This is consistent with ERT\u0026apos;s core hypothesis that resource \u0026quot;resource consumption starts from the superposition of multiple loads\u0026quot;[22]. External load arises from high-intensity physical labor and institutional pressures. It involves caring for multiple elderly individuals with disabilities simultaneously, performing repetitive physical tasks, and managing 24-hour emergency responses. These demands lead to fragmented sleep and physical symptoms over time [32-34]. Information overload refers to the dual depletion of cognitive and emotional resources. HCAs need to interpret the needs of elderly individuals through nonverbal cues and monitor changes in their clinical condition [18]. Moreover, the \u0026quot;family-like care\u0026quot; professional culture creates a persistent \u0026quot;emotional labor load,\u0026quot; draining empathic resources excessively[35, 36]. This challenges nursing\u0026rsquo;s commitment to holistic care, where emotional engagement is valued yet must balance with sustainable practice. This finding expands the scope of information load as defined by Meijman \u0026amp; Mulder, and aligns with research linking nurses\u0026rsquo; emotional labor to compassion fatigue[35, 36].\u003c/p\u003e\n\u003cp\u003eAdditionally, the traditional Chinese value of \u0026quot;respecting one\u0026rsquo;s own elders and extending this respect to others\u0026rsquo; elders\u0026quot; strengthens HCAs\u0026rsquo; sense of obligation to emotional investment. When interacting with ERT\u0026rsquo;s \u0026quot;information load,\u0026quot; this cultural norm may accelerate emotional resource depletion compared to Western care contexts[37, 38]. These insights point to practical steps for reducing unreasonable loads, such as optimizing careworker-to-resident ratios\u0026mdash; a cornerstone of nursing workforce management\u0026mdash;and clarifying boundaries for emotional labor to prevent burnout while preserving compassionate care.\u003c/p\u003e\n\u003cp\u003eThe rapid resource depletion caused by this dual load forces HCAs to adopt compensatory strategies to maintain basic work efficacy. Within ERT, these strategies act as both \u0026quot;buffers\u0026quot; and \u0026quot;double-edged swords.\u0026quot; Emotional detachment reduces empathy expenditure by \u0026quot;de-emotionalizing\u0026quot; care tasks. Emotional detachment reduces empathy expenditure by \u0026quot;de-emotionalizing\u0026quot; care tasks. This works similarly to the distinction between surface acting and deep acting in emotional labour: when individuals are exhausted, they tend to opt for the simpler strategy of surface acting\u0026mdash;merely feigning outward behaviors, rather than genuinely engaging with inner feelings[39]. Rather than investing psychological effort to align their emotions with the demands of compassionate care (as in deep acting), HCAs employing emotional detachment suppress authentic emotional responses, maintaining only the procedural gestures of care. This reduces immediate emotional strain but risks creating a dissonance between outward actions and inner states, which over time may deepen emotional exhaustion and decrease the quality of relational care[40]. This aligns with ERT\u0026rsquo;s premise that individuals self-regulate to sustain function, but long-term use erodes empathy\u0026mdash;supporting the pathway through which emotional suppression leads to health impairment. Physiological compensation offers temporary relief from physical exhaustion. However, it consumes additional resources: sustained activation of the sympathetic nervous system leads to weakened immunity and emotional dysregulation[22]. This directly aligns with ERT\u0026rsquo;s dynamic model[22], illustrating how prolonged reliance on physiological compensation depletes functional reserves over time. This highlights the need for nursing education to integrate \u0026quot;occupational self-care\u0026quot; training, equipping HCAs with science-backed recovery techniques instead of harmful coping. Cognitive reframing, a culturally adaptive strategy among Chinese HCAs[41], involves three approaches: viewing hardships as inherent to their \u0026quot;bottom-rung\u0026quot; occupation; simplifying care into fee-for-service transactions; and reinterpreting labor as \u0026quot;karmic merit\u0026quot; accumulation for families. These culturally distinct methods, similar to Western cognitive reappraisal, address ERT\u0026apos;s cross-cultural theoretical gaps and provide insights for developing contextually relevant nursing ethics frameworks that honor local values while promoting professional dignity [42]. Yet, these strategies accelerate resource depletion by suppressing genuine recovery needs. They highlight an imbalance between \u0026quot;individual compensation\u0026quot; and \u0026quot;systemic support\u0026quot;: without institutional backing, individual adjustments ultimately worsen resource depletion. This points to the need for intervention strategies that optimize such approaches\u0026mdash;for instance, replacing \u0026quot;overdraft compensation\u0026quot; with \u0026quot;healthy compensation,\u0026rdquo; a shift that nursing leadership can drive through policy advocacy and workplace restructuring.\u003c/p\u003e\n\u003cp\u003eSustained resource depletion from compensatory strategies, coupled with inadequate external support, pushes the resource imbalance into a phase of depleted recovery resources\u0026mdash;a key mediator of compassion fatigue. This phase emerges from the interplay between varying kinds of individual recovery awareness and structural barriers to external resources, confirming ERT\u0026rsquo;s core mechanism: insufficient recovery worsens imbalance. Three patterns characterize individual recovery awareness in this study. Firstly, active micro-recovery, an instinctive response to immediate needs, only eases acute stress due to limited resources. This aligns with multiple studies indicating that micro-break activities are associated with enhanced recovery levels, which in turn correlate with higher workplace well-being and reduced work-related stress[43, 44]. This highlights the value of nursing teams designing workflow-tailored structured \u0026quot;micro-break protocols\u0026quot; to integrate brief, purposeful recovery activities into daily routines systematically. Secondly, passive adaptive thinking, shaped by long-term stress, dulls sensitivity to recovery needs and induces emotional numbness toward residents. This, in turn, undermines the HCA-resident relationship, as observed in studies of direct care workers\u0026nbsp;[45]. This phenomenon parallels Maslach\u0026rsquo;s burnout theory of \u0026quot;depersonalization,\u0026quot; which is characterized by a sense of emotional detachment and cynicism toward both one\u0026rsquo;s work and the individuals being served\u0026nbsp;[46]. Lastly, a disconnect between awareness and action reveals impaired recovery self-efficacy among less educated HCAs. Previous studies have indicated that recovery self-efficacy can mitigate the impact of negative emotions on call center workers[47], underscoring the significance of recovery literacy in this context. External resources are confronted with dual barriers: institutional exclusion and cultural stigma. Uneven resource distribution intensifies recovery challenges at the individual level. This directly contradicts ERT\u0026rsquo;s core premise: recovery opportunities are crucial to balancing workloads\u0026nbsp;[22]. When HCAs face chronic resource restrictions\u0026mdash;such as inadequate rest spaces or less psychological support than other staff\u0026mdash;their recovery processes, already fragile due to high workloads, become further impaired[48]. This perpetuates and worsens the imbalance between workload and recovery. Additionally, psychological support under outsourcing models tends to be superficial and fails to meet HCAs\u0026rsquo; substantial recovery needs. Meanwhile, a stigmatized view persists: seeking psychological help is seen as a sign of illness. Combined with insufficient family support, this creates a unique \u0026quot;recovery island\u0026quot; phenomenon in East Asian care settings. This aligns with research showing Japanese HCAs face similar barriers to seeking psychological help[8]\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eThese findings point to key priorities for systemic recovery support. Examples include optimizing resource allocation to protect rest rights and easing help-seeking stigma through peer support programs, led by senior HCAs or nurse leaders\u0026nbsp;[49].\u003c/p\u003e\n\u003cp\u003eWhen recovery opportunities are persistently insufficient, the effort-recovery imbalance progresses into cumulative dysregulation, ultimately manifesting as compassion fatigue\u0026mdash;consistent with ERT\u0026apos;s prediction of cumulative functional impairment[22]. Burnout\u0026mdash;marked by emotional exhaustion and depersonalization[46]\u0026mdash;reflects declining care quality linked to ERT\u0026apos;s \u0026quot;functional impairment[22].\u0026quot; This is a critical concern for nursing practice, as burnout is associated with increased medication errors and reduced patient satisfaction [50]. Though caregivers develop strategies to maintain efficacy (reflecting adaptive \u0026quot;resource reallocation\u0026quot;), they cannot reverse burnout. Secondary trauma, arising from unrelieved empathic stress, appears as intrusive flashbacks and physical symptoms, matching the \u0026quot;secondary traumatic stress\u0026quot; model[11, 51]. The paradox of commemorative and avoidant coping worsens harm: the former strengthens \u0026quot;ruminative resource consumption,\u0026quot; while the latter creates cycles of \u0026quot;emotional detachment and impaired recovery capacity.\u0026quot;[52, 53] Reduced empathic satisfaction, driven by long-term \u0026quot;effort-recovery imbalance,\u0026quot; drains intrinsic motivation\u0026mdash;showing as shattered self-efficacy and professional identity crises\u0026mdash;threatening the sustainability of nursing workforces in aging societies. \u0026quot;Rationalized emotional numbness\u0026quot; aligns with \u0026quot;depersonalization\u0026quot; in Maslach\u0026apos;s model[46]. At the same time, dual value reconstruction approaches (sticking to internal principles versus relying on external recognition) reveal cultural adaptability beyond ERT that can inform nursing leadership strategies for rebuilding professional pride. These three adverse outcomes reinforce each other, forming a compassion fatigue cycle. HCAs\u0026apos; natural resilience eases some symptoms but cannot break institutional and cultural barriers; therefore, interventions should combine \u0026quot;systemic intervention + individual empowerment\u0026quot; to stop the cycle\u0026mdash;a dual focus central to nursing\u0026rsquo;s role as both direct care provider and system advocate [54, 55].\u003c/p\u003e\n\u003cp\u003eIn summary, this study confirms the relevance of ERT to compassion fatigue in elderly care through a four-stage dynamic analysis. It enriches cross-cultural occupational health psychology by adding \u0026quot;resource imbalance mechanisms in non-Western contexts\u0026quot; to the model, drawing on insights into cultural factors and emotional labor\u0026mdash;with specific nursing implications, as the discipline most directly responsible for translating such mechanisms into frontline practice. Additionally, the four-stage intervention pathway\u0026mdash;\u0026quot;reducing workload, optimizing compensation, rebuilding recovery, blocking outcomes\u0026quot;\u0026mdash;offers a practical framework to tackle the \u0026quot;compassion fatigue and declining care quality\u0026quot; cycle, directly aligning with nursing\u0026rsquo;s goal of enhancing both provider well-being and patient outcomes. This framework provides empirical support for sustainable workforce development in China\u0026apos;s elderly care system and contributes to nursing science by bridging theory and practice in understudied non-Western care contexts.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eGuided by the Effort-Recovery Theory (ERT), this qualitative study explored the dynamic mechanism of compassion fatigue (CF) among 13 elderly healthcare aides (HCAs) in a Shanghai long-term care facility, identifying a four-stage trajectory: Work Demand Overload (physical/psychological dual burdens), Compensatory Effort Strategies (emotional detachment, physiological compensation, cultural cognitive reframing), Insufficient Recovery (divergent awareness + institutional/cultural barriers), and Negative Effects (burnout, secondary traumatization, reduced empathy satisfaction). These stages reveal how resource consumption-recovery imbalance\u0026mdash;exacerbated by Chinese cultural factors (e.g., \u0026quot;family-like care\u0026quot; expectations) and institutional constraints (e.g., uneven resource allocation)\u0026mdash;drives HCAs\u0026rsquo; CF, addressing gaps in prior nurse-focused or quantitative CF research. The proposed \u0026quot;reducing workload, optimizing compensation, rebuilding recovery, blocking outcomes\u0026quot; intervention framework offers a culturally appropriate tool to improve HCAs\u0026rsquo; well-being and care quality, supporting China\u0026rsquo;s elderly care workforce sustainability and bridging ERT theory with care practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to all of our participants for sharing their experiences voluntarily.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLYQ and ZM collected data and wrote the manuscript. LCH and ZYL were responsible for coordinating the data collection process. LYQ, ZM, LCH, ZYL, and KMA analyzed the data and drafted the manuscript. LYQ, ZM, LCH, ZYL, KMA, JWC, and JLP contributed to the design of the study protocol and the development of the interview guide. JWC and JLP supervised the research process and guided manuscript writing. JWC and JLP should be considered the co-corresponding authors. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Construction Project of the\u0026ldquo;Discipline Peak-Climbing Plan\u0026rdquo;\u0026nbsp;of Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine(XKPF2024C301).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to ethical concerns from the participants\u0026apos; perspective, the datasets generated and/or analyzed during the current study are not publicly available; however, they are available from the corresponding author upon a justifiable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll methods were carried out in accordance with relevant guidelines and regulations, such as the Declaration of Helsinki. The study received ethical approval from the Ethics Committee of Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (XHEC-NSFC-2025-485). Before starting data collection, written informed consent was obtained. Names were not used in interviews, and the audio and transcript files were tagged with a numbered scheme that was only known to the researcher.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNon-applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare that they have no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003e(2025). National Bureau of Statistics: In 2024, the population aged 60 and above in China exceeded 300 million for the first time. from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://laoling.cctv.com/2025/01/17/ARTI1YQU2WRMlO75bKSmmyLY250117.shtml\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eYan M, Qin T, Yin P. Disabilities in activities of daily living and in instrumental activities of daily living among older adults in China, 2011\u0026ndash;15: a longitudinal cohort study. Lancet. 2019;394. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0140-6736(19)32418-3\u003c/span\u003e\u003c/span\u003e. S82.DOI.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLestari SK, Ng N, Kowal P, Santosa A. Diversity in the Factors Associated with ADL-Related Disability among Older People in Six Middle-Income Countries: A Cross-Country Comparison. Int J Environ Res Public Health. 2019;16(8). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ijerph16081341\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNichols E, Steinmetz JD, Vollset SE, Fukutaki K, Chalek J, Abd-Allah F, et al. Estimation of the global prevalence of dementia in 2019 and forecasted prevalence in 2050: an analysis for the Global Burden of Disease Study 2019. Lancet Public Health. 2022;7(2):e105\u0026ndash;25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2468-2667(21)00249-8\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003e(2019). Health workforce. from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/health-topics/health-workforce#tab=tab_1\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHuaxia. (2025). China to promote application of big data, AI in elderly care: minister. from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://english.news.cn/20250309/f87fe9c5a5444ba3b07c52e106ab870e/c.html#:~:text=The%20latest%20data%20showed%20that%\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e20by%20the%20end,for%20roughly%2022%20percent%20of%20its%20total%20population\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eZhang N, AGING, MIGRATION, AND GRANDPARENTING IN POST\u0026ndash;ONE CHILD POLICY CHINA. Innov Aging. 2023;7:952\u0026ndash;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/geroni/igad104.3060\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMatsui T, Oba H, Uchida R, Teraguchi T. Relationships between mental health and styles of help-seeking among care workers in comparison with the general population. Discov Ment Health. 2025;5(1):11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s44192-025-00131-7\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eZysberg L, Band-Winterstein T, Doron I, Shulyaev K, Siegel EO, Kornas-Biela D, et al. The health care aide position in nursing homes: A comparative survey of nurses\u0026apos; and aides\u0026apos; perceptions. Int J Nurs Stud. 2019;94:98\u0026ndash;106. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijnurstu.2019.03.007\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eJust DT, O\u0026apos;Rourke HM, Berta WB, Variath C, Cranley LA. Expanding the Concept of End-of-life Care in Long-term Care: A Scoping Review Exploring the Role of Healthcare Assistants. Int J Older People Nurs. 2021;16(2):e12353. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/opn.12353\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSorenson C, Bolick B, Wright K, Hamilton R. Understanding Compassion Fatigue in Healthcare Providers: A Review of Current Literature. J Nurs Scholarsh. 2016;48(5):456\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jnu.12229\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRahman A, Duan Y, Estabrooks C, RELATIONSHIP BETWEEN WORKING ENVIRONMENT AND CARE, AIDES\u0026rsquo; COMPASSION, FATIGUE, BURNOUT AND COMPASSION SATISFACTION. Innov Aging. 2024;8(Suppl 1):555DOI. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/geroni/igae098.1814\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRahman A, Duan Y, Symonds-Brown H, Salma J, Estabrooks CA. Care Aides Compassion Fatigue, Burnout, and Compassion Satisfaction Related to Long-Term Care (LTC) Working Environment. J Appl Gerontol. 2025;7334648251328400DOI. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/07334648251328400\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRichert M, Burnout. Compassion Satisfaction, and Intent to Quit Among Long-Term Care Nursing Assistants in the Time of COVID-19. Innov Aging. 2021;5(Suppl 1):715DOI. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/geroni/igab046.2671\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eYu H, Gui L. Compassion fatigue, burnout, and compassion satisfaction among emergency nurses: A path analysis. J Adv Nurs. 2022;78(5):1294\u0026ndash;304. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jan.15034\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eZhang H, Xia Z, Yu S, Shi H, Meng Y, Dator WL. Interventions for Compassion Fatigue, Burnout, and Secondary Traumatic Stress in Nurses: A Systematic Review and Network Meta-Analysis. Nurs Health Sci. 2025;27(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/nhs 70042\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eG\u0026Ouml;KoĞLan E, AltuntaŞ S, \u0026Ccedil;İ\u0026Ccedil;Ek Korkmaz A. Merhamet Yorgunluğunun Hemşirelik Hizmetlerine Etkileri. Bandırma Onyedi Eyl\u0026uuml;l \u0026Uuml;niversitesi Sağlık Bilimleri ve Araştırmaları. Dergisi. 2023;5(3):282\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.46413/boneyusbad.1330069\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLee S, Lee KH. Experience of Long-term Care Workers\u0026apos; Communication with Older Adults with Dementia Focused on Emotional Expression. J Korean Acad Psychiatr Ment Health Nurs. 2018;27(3):264\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.12934/jkpmhn.2018.27.3.264\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eEjem DB, Drentea P, Clay OJ. The effects of caregiver emotional stress on the depressive symptomatology of the care recipient. Aging Ment Health. 2015;19(1):55\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/13607863.2014.915919\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eShi H, Zhao Z, Liu H, Yang R. The Current Status of Social Isolation and the Caregiver Compassion Fatigue in Elderly COPD Patients. Clin Interv Aging. 2025;20:739\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2147/cia.S504600\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSitong Yan PL, Kong L, Li M, Mei L. The status of compassion fatigue and its subjective and objective factors among nursing workers in rest home. Mod Prev Med. 2020;47(11):1950\u0026ndash;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.20043/j.cnki.mpm.2020.11.010\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMeijman TF, Mulder. G. Psychological aspects of workload. Psychology; 1998.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAsh M, Burgess K. Literature Review: Understanding Compassion Fatigue in Nursing. Int J Hum Caring. 2025;29(2):102\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.20467/ijhc-2023-0026\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHaakenstad A, Irvine CMS, Knight M, Bintz C, Aravkin AY, Zheng P, et al. Lancet. 2022;399(10341):2129\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(22)00532-3\u003c/span\u003e\u003c/span\u003e. Measuring the availability of human resources for health and its relationship to universal health coverage for 204 countries and territories from 1990 to 2019: a systematic analysis for the Global Burden of Disease Study 2019.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eThe Lancet Global H. Health-care workers must be trained and retained. Lancet Global Health. 2023;11(5):e629. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2214-109X(23)00172-9\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eZijlstra FR, Cropley M, Rydstedt LW. From recovery to regulation: an attempt to reconceptualize \u0026apos;recovery from work\u0026apos;. Stress Health. 2014;30(3):244\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/smi.2604\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGeurts SA, Sonnentag S. Recovery as an explanatory mechanism in the relation between acute stress reactions and chronic health impairment. Scand J Work Environ Health. 2006;6482\u0026ndash;92. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5271/sjweh.1053\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eClark NM, Dodge JA, Partridge MR, Martinez FJ. Focusing on outcomes: making the most of COPD interventions. Int J Chron Obstruct Pulmon Dis. 2009;4:61\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBattisti M, Gish JJ, Hatak I, Zhou H. Establishing a Recovery Menu to Increase the Resilience of Entrepreneurs. Br J Manag. 2025;36(1):56\u0026ndash;72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/1467-8551.12827\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHuang L, Tsai H. The effects of recovery experiences on hotel employees\u0026rsquo; subjective well-being, organizational citizenship behavior, and task performance. Int J Hospitality Manage. 2024;121. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijhm.2024.103798\u003c/span\u003e\u003c/span\u003e. :103798.DOI.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349\u0026ndash;57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/intqhc/mzm042\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eYang Z, Sun F, Zhao L, Hu T, Lin X, Guo Y. Self-efficacy and well-being in the association between caregiver burden and sleep quality among caregivers of elderly patients having multiple chronic conditions in rural China: a serial multiple mediation analysis. BMC Nurs. 2023;22(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12912-023-01587-0\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDarragh AR, Sommerich CM, Lavender SA, Tanner KJ, Vogel K, Campo M. Musculoskeletal Discomfort, Physical Demand, and Caregiving Activities in Informal Caregivers. J Appl Gerontol. 2013;34(6):734\u0026ndash;60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0733464813496464\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSeol MJ, Lee BS, Lee S-K. Effects of Labor Intensity and Fatigue on Sleep Quality of Clinical Nurses. J Korean Acad Nurs Adm. 2018;24(4):276. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.11111/jkana.2018.24.4.276\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBarnett MD, Hays KN, Cantu C. Compassion fatigue, emotional labor, and emotional display among hospice nurses. Death Stud. 2022;46(2):290\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/07481187.2019.1699201\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eChu LC. Effect of compassion fatigue on emotional labor in female nurses: Moderating effect of self-compassion. PLoS ONE. 2024;19(3):e0301101. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0301101\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eWu J, Liu M, Ouyang Y, Chi I. Beyond Just Giving Care: Exploring the Role of Culture in Chinese American Personal Care Aides\u0026rsquo; Work. J Cross-Cult Gerontol. 2020;35(3):255\u0026ndash;72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10823-020-09404-w\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eXiao C, Patrician PA, Montgomery AP, Wang Y, Jablonski R, Markaki A. Filial piety and older adult caregiving among Chinese and Chinese-American families in the United States: a concept analysis. BMC Nurs. 2024;23(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12912-024-01789-0\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eShahar B-H, Kalman-Halevi M, Roth G. Emotion regulation and intimacy quality: The consequences of emotional integration, emotional distancing, and suppression. J Social Personal Relationships. 2018;36:3343\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0265407518816881\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSaei E, Sarshar S, Lee RT. Emotional labor and burnout among nurses in Iran: core self-evaluations as mediator and moderator. Hum Resour Health. 2024;22(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12960-024-00896-y\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTeuber Z, Schreiber S, Rueth J-E, Lohaus A. Emotion regulation among Chinese and German children and adolescents: a binational comparative study. Curr Psychol. 2022;42(28):24641\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s12144-022-03578-x\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eStover AD, Shulkin J, Lac A, Rapp T. A meta-analysis of cognitive reappraisal and personal resilience. Clin Psychol Rev. 2024;110:102428DOI. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.cpr.2024.102428\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNie Q, Zhang J, Peng J, Chen X. Daily micro-break activities and workplace well-being: A recovery perspective. Curr Psychol. 2021;42(12):9972\u0026ndash;85. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s12144-021-02300-7\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSianoja M, Syrek CJ, de Bloom J, Korpela K, Kinnunen U. Enhancing daily well-being at work through lunchtime park walks and relaxation exercises: Recovery experiences as mediators. J Occup Health Psychol. 2018;23(3):428\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/ocp0000083\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMaffett AJ, Paull DN, Skeel RL, Kraysovic JN, Hatch B, O\u0026apos;Mahony S, et al. Emotion Dysregulation and Workplace Satisfaction in Direct Care Worker Burnout and Abuse Risk. J Am Med Dir Assoc. 2022;23(7):1257\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jamda.2022.03.001\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMaslach C, Jackson SE. The measurement of experienced burnout. J Organizational Behav. 1981;2(2):99\u0026ndash;113. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/job.4030020205\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePark Y, Kim S. Customer mistreatment harms nightly sleep and next-morning recovery: Job control and recovery self-efficacy as cross-level moderators. J Occup Health Psychol. 2019;24(2):256\u0026ndash;69. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/ocp0000128\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDuijs SE, van Wees M, Abma T, Bourik Z, Plak O, Jaspers Y, et al. We just take care after each other: Relational health strategies of nurses and nursing aides working in residential long-term care as a mechanism of in- and exclusion in care teams. Work. 2024;78(4):983\u0026ndash;94. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3233/wor-220653\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBurke E, Pyle M, Machin K, Varese F, Morrison A. The effects of peer support on empowerment, self-efficacy, and internalized stigma: A narrative synthesis and meta-analysis. Stigma Health. 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/SAH0000148\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePappa D, Dafogianni C. Association of Occupational Burnout and Nursing Errors With Patient Safety: A Systemic Review. In: Management Association IR, editor. Research Anthology on Nursing Education and Overcoming Challenges in the Workplace. Hershey, PA, USA: IGI Global Scientific Publishing; 2021. pp. 297\u0026ndash;310.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eZhang J, Zou J, Wang X, Luo Y, Zhang J, Xiong Z, et al. Clinical nurses\u0026apos; compassion fatigue psychological experience process: a constructivist grounded theory study. BMC Nurs. 2023;22(1):487. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12912-023-01665-3\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMertens L, Tamm G, Hoorelbeke K. Ruminative thinking styles differentially relate to posttraumatic stress versus growth following trauma exposure. Psychological Trauma: Theory, Research, Practice, and Policy. 2025.\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/tra0001969\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMacCann C, Double KS, Clarke IE. Lower Avoidant Coping Mediates the Relationship of Emotional Intelligence With Well-Being and Ill-Being. Front Psychol. 2022;13DOI. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpsyg.2022.835819\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMuhunthan M, Olalia MA, Neretljak S, Ezekiel S, Metersky K. Building resilience in nursing through strategic policy interventions. Int Nurs Rev. 2024;72(3). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/inr.13068\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRawlings Cu. Adekunle Oyeyemi Adeniyi u, Chioma Anthonia Okolo u, Oloruntoba Babawarun u, Jeremiah Olawumi Arowoogun u. Psychological resilience in healthcare workers: A review of strategies and intervention. World J Biology Pharm Health Sci. 2024;17(2):387\u0026ndash;95. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.30574/wjbphs.2024.17.2.0088\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7266010/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7266010/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eAim\u003c/h2\u003e\u003cp\u003eThis qualitative study, guided by the Effort-Recovery Theory (ERT), examines how compassion fatigue (CF) develops in elderly healthcare aides (HCAs) in China. The study focuses on the developmental mechanisms and dynamic trajectory of CF.\u003c/p\u003e\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eWith global population aging, especially in China, where adults aged over 60 reached 310\u0026nbsp;million (22% of the population) by the end of 2024, HCAs face increasing physical and emotional burdens. Their physical labor includes daily care and emergency response, while their emotional labor involves managing empathy and nonverbal communication with residents who have cognitive impairments. However, existing research on CF has primarily focused on hospital nurses, with limited attention to HCAs\u0026rsquo; unique experiences, particularly the dynamic process of CF under China\u0026rsquo;s sociocultural context.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA qualitative descriptive design was adopted, with 13 HCAs recruited from a large long-term care facility in Shanghai through purposive sampling. Data were collected via semi-participant observation and in-depth interviews, and analyzed using directed content analysis. The study adhered to the COREQ checklist to ensure methodological rigor.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe analysis revealed a four-stage development process of CF. Stage one is Work Demand Overload. This stage involves physical burden, such as intensive labor and fragmented sleep. It also involves psychological burden, such as high cognitive demands and emotional entanglement. Stage two is Compensatory Effort Strategies. These strategies include emotional detachment through surface acting. They also include physiological compensation, for example, caffeine dependence. Another strategy is culturally specific cognitive reframing, such as believing in \"karmic merit\". Stage three is Insufficient Recovery. Stage three is Insufficient Recovery. Divergent recovery awareness influences this stage, which encompasses active micro-recovery, passive adaptation, and awareness-action disconnection. Structural barriers also contribute, which include institutional resource exclusion and cultural stigma. Stage four is Negative Effects, where CF emerges, which manifests as occupational burnout, secondary traumatization, and declining empathy satisfaction.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThis study confirms that ERT effectively explains CF in HCAs. An imbalance between resource consumption and recovery drives the development of CF. Cultural norms, like the expectation of \"family-like care\", and institutional constraints make this imbalance worse. The findings address a gap in CF research about HCAs. They also provide a theory base for interventions. These could include optimizing workloads and improving recovery resources. Such steps could support the well-being of HCAs and enhance the quality of care.\u003c/p\u003e","manuscriptTitle":"From Effort to Exhaustion: A Qualitative Study of Compassion Fatigue in elderly healthcare aides based on the Effort-Recovery Theory","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-23 14:25:38","doi":"10.21203/rs.3.rs-7266010/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-16T09:19:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-01T07:17:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-23T10:36:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"326155985275265520445068632819668713763","date":"2025-10-19T11:55:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"167549223163095436680525453299783677915","date":"2025-10-19T10:29:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317238354690231521767259720599142495381","date":"2025-10-15T04:24:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-09T15:23:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-07T13:13:15+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-12T09:23:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-11T23:14:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-09-11T23:09:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ea290aa3-23f9-44fa-984b-92e41c4fd074","owner":[],"postedDate":"October 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-30T22:23:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-23 14:25:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7266010","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7266010","identity":"rs-7266010","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}