nursing burnout literature review

• Open access
• Published: 05 June 2020

Burnout in nursing: a theoretical review

• Chiara Dall’Ora 1 ,
• Jane Ball 2 ,
• Maria Reinius 2 &
• Peter Griffiths 1 , 2  

Human Resources for Health volume  18 , Article number:  41 ( 2020 ) Cite this article

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Workforce studies often identify burnout as a nursing ‘outcome’. Yet, burnout itself—what constitutes it, what factors contribute to its development, and what the wider consequences are for individuals, organisations, or their patients—is rarely made explicit. We aimed to provide a comprehensive summary of research that examines theorised relationships between burnout and other variables, in order to determine what is known (and not known) about the causes and consequences of burnout in nursing, and how this relates to theories of burnout.

We searched MEDLINE, CINAHL, and PsycINFO. We included quantitative primary empirical studies (published in English) which examined associations between burnout and work-related factors in the nursing workforce.

Ninety-one papers were identified. The majority ( n = 87) were cross-sectional studies; 39 studies used all three subscales of the Maslach Burnout Inventory (MBI) Scale to measure burnout. As hypothesised by Maslach, we identified high workload, value incongruence, low control over the job, low decision latitude, poor social climate/social support, and low rewards as predictors of burnout. Maslach suggested that turnover, sickness absence, and general health were effects of burnout; however, we identified relationships only with general health and sickness absence. Other factors that were classified as predictors of burnout in the nursing literature were low/inadequate nurse staffing levels, ≥ 12-h shifts, low schedule flexibility, time pressure, high job and psychological demands, low task variety, role conflict, low autonomy, negative nurse-physician relationship, poor supervisor/leader support, poor leadership, negative team relationship, and job insecurity. Among the outcomes of burnout, we found reduced job performance, poor quality of care, poor patient safety, adverse events, patient negative experience, medication errors, infections, patient falls, and intention to leave.

Conclusions

The patterns identified by these studies consistently show that adverse job characteristics—high workload, low staffing levels, long shifts, and low control—are associated with burnout in nursing. The potential consequences for staff and patients are severe. The literature on burnout in nursing partly supports Maslach’s theory, but some areas are insufficiently tested, in particular, the association between burnout and turnover, and relationships were found for some MBI dimensions only.

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Introduction

The past decades have seen a growing research and policy interest around how work organisation characteristics impact upon different outcomes in nursing. Several studies and reviews have considered relationships between work organisation variables and outcomes such as quality of care, patient safety, sickness absence, turnover, and job dissatisfaction [ 1 , 2 , 3 , 4 ]. Burnout is often identified as a nursing ‘outcome’ in workforce studies that seek to understand the effect of context and ‘inputs’ on outcomes in health care environments. Yet, burnout itself—what constitutes it, what factors contribute to its development, and what the wider consequences are for individuals, organisations, or their patients—is not always elucidated in these studies.

The term burnout was introduced by Freudenberger in 1974 when he observed a loss of motivation and reduced commitment among volunteers at a mental health clinic [ 5 ]. It was Maslach who developed a scale, the Maslach Burnout Inventory (MBI), which internationally is the most widely used instrument to measure burnout [ 6 ]. According to Maslach’s conceptualisation, burnout is a response to excessive stress at work, which is characterised by feelings of being emotionally drained and lacking emotional resources—Emotional Exhaustion; by a negative and detached response to other people and loss of idealism—Depersonalisation; and by a decline in feelings of competence and performance at work—reduced Personal Accomplishment [ 7 ].

Maslach theorised that burnout is a state, which occurs as a result of a prolonged mismatch between a person and at least one of the following six dimensions of work [ 7 , 8 , 9 ]:

Workload: excessive workload and demands, so that recovery cannot be achieved.

Control: employees do not have sufficient control over the resources needed to complete or accomplish their job.

Reward: lack of adequate reward for the job done. Rewards can be financial, social, and intrinsic (i.e. the pride one may experience when doing a job).

Community: employees do not perceive a sense of positive connections with their colleagues and managers, leading to frustration and reducing the likelihood of social support.

Fairness: a person perceiving unfairness at the workplace, including inequity of workload and pay.

Values: employees feeling constrained by their job to act against their own values and their aspiration or when they experience conflicts between the organisation’s values.

Maslach theorised these six work characteristics as factors causing burnout and placed deterioration in employees’ health and job performance as outcomes arising from burnout [ 7 ].

Subsequent models of burnout differ from Maslach’s in one of two ways: they do not conceptualise burnout as an exclusively work-related syndrome; they view burnout as a process rather than a state [ 10 ].

The job resources-demands model [ 11 ] builds on the view of burnout as a work-based mismatch but differs from Maslach’s model in that it posits that burnout develops via two separate pathways: excessive job demands leading to exhaustion, and insufficient job resources leading to disengagement. Along with Maslach and Schaufeli, this model sees burnout as the negative pole of a continuum of employee’s well-being, with ‘work engagement’ as the positive pole [ 12 ].

Among those who regard burnout as a process, Cherniss used a longitudinal approach to investigate the development of burnout in early career human services workers. Burnout is presented as a process characterised by negative changes in attitudes and behaviours towards clients that occur over time, often associated with workers’ disillusionment about the ideals that had led them to the job [ 13 ]. Gustavsson and colleagues used this model in examining longitudinal data on early career nurses and found that exhaustion was a first phase in the burnout process, proceeding further only if nurses present dysfunctional coping (i.e. cynicism and disengagement) [ 14 ].

Shirom and colleagues suggested that burnout occurs when individuals exhaust their resources due to long-term exposures to emotionally demanding circumstances in both work and life settings, suggesting that burnout is not exclusively an occupational syndrome [ 15 , 16 ].

This review aims to identify research that has examined theorised relationships with burnout, in order to determine what is known (and not known) about the factors associated with burnout in nursing and to determine the extent to which studies have been underpinned by, and/or have supported or refuted, theories of burnout.

This was a theoretical review conducted according to the methodology outlined by Campbell et al. and Pare et al. [ 17 , 18 ]. Theoretical reviews draw on empirical studies to understand a concept from a theoretical perspective and highlight knowledge gaps. Theoretical reviews are systematic in terms of searching and inclusion/exclusion criteria and do not include a formal appraisal of quality. They have been previously used in nursing, but not focussing on burnout [ 19 ]. While no reporting guideline for theoretical reviews currently exists, the PRISMA-ScR was deemed to be suitable, with some modifications, to enhance the transparency of reporting for the purposes of this review. The checklist, which can be found as Additional file 2 , has been modified as follows:

Checklist title has been modified to indicate that the checklist has been adapted for theoretical reviews.

Introduction (item 3) has been modified to reflect that the review questions lend themselves to a theoretical review approach.

Selection of sources of evidence (item 9) has been modified to state the process for selecting sources of evidence in the theoretical review.

Limitations (item 20) has been amended to discuss the limitations of the theoretical review process.

Funding (item 22) has been amended to describe sources of funding and the role of funders in the theoretical review.

All changes from the original version have been highlighted.

Literature search

A systematic search of empirical studies examining burnout in nursing published in journal articles since 1975 was performed in May 2019, using MEDLINE, CINAHL, and PsycINFO. The main search terms were ‘burnout’ and ‘nursing’, using both free-search terms and indexed terms, synonyms, and abbreviations. The full search and the total number of papers identified are in Additional file 1 .

We included papers written in English that measured the association between burnout and work-related factors or outcomes in all types of nurses or nursing assistants working in a healthcare setting, including hospitals, care homes, primary care, the community, and ambulance services. Because there are different theories of burnout, we did not restrict the definition of burnout according to any specific theory. Burnout is a work-related phenomenon [ 8 ], so we excluded studies focussing exclusively on personal factors (e.g. gender, age). Our aim was to identify theorised relationships; therefore, we excluded studies which were only comparing the levels of burnout among different settings (e.g. in cancer services vs emergency departments). We excluded literature reviews, commentaries, and editorials.

Data extraction and quality appraisal

The following data were extracted from included studies: country, setting, sample size, staff group, measure of burnout, variables the relationship with burnout was tested against, and findings against the hypothesised relationships. One reviewer (MEB) extracted data from all the studies, with CDO and JEB extracting 10 studies each to check for agreement in data extraction. In line with the theoretical review methodology, we did not formally assess the quality of studies [ 19 ]. However, in Additional file 3 , we have summarised the key aspects of quality for each study, covering generalisability (e.g. a multisite study with more than 500 participants); risk of bias from common methods variance (e.g. burnout and correlates assessed with the same survey. This bias arises when there is a shared (common) variance because of the common method rather than a true (causal) association between variables); evidence of clustering (e.g. nurses nested in wards, wards nested in hospitals); and evidence of statistical adjustment (e.g. the association between burnout and correlates has been adjusted to control for potentially influencing variables). It should be noted that cells are shaded in green when the above-mentioned quality standards have been met, and in red when they have not. In the ‘Discussion’ section, we offer a reflection on the common limitations of research in the field and present a graphic summary of the ‘strength of evidence’ in Fig. 1 .

Graphical representation of strength of relationships with burnout

Data synthesis

Due to the breadth of the evidence, we summarised extracted data by identifying common categories through a coding frame. The starting point of the coding frame was the burnout multidimensional theory outlined by Maslach [ 7 ]. We then considered whether the studies’ variables fit into Maslach’s categorisation, and where they did not, we created new categories. We identified nine broad categories: (1) Areas of Worklife; (2) Workload and Staffing Levels; (3) Job Control, Reward, Values, Fairness, and Community; (4) Shift Work and Working Patterns; (5) Psychological Demands and Job Complexity; (6) Support Factors: Working Relationships and Leadership; (7) Work Environment and Hospital Characteristics; (8) Staff Outcomes and Job Performance; and (9) Patient Care and Outcomes. In the literature, categories 1–7 were treated as predictors of burnout and categories 8 and 9 as outcomes, with the exception of missed care and job satisfaction which were treated both as predictors and outcomes.

When the coding frame was finalised, CDO and MLR applied it to all studies. Where there was disagreement, a third reviewer (JEB) made the final decision.

The database search yielded 12 248 studies, of which 11 870 were rapidly excluded as either duplicates or titles and/or abstract not meeting the inclusion criteria. Of the 368 studies accessed in full text, 277 were excluded, and 91 studies were included in the review. Figure 2 presents a flow chart of the study selection.

Study selection flow chart

The 91 studies identified covered 28 countries; four studies included multiple countries, and in one, the country was not reported. Most were from North America ( n = 35), Europe ( n = 28), and Asia ( n = 18).

The majority had cross-sectional designs ( n = 87, 97%); of these, 84 were entirely survey-based. Three studies were longitudinal. Most studies were undertaken in hospitals ( n = 82). Eight studies surveyed nurses at a national level, regardless of their work setting.

Sample sizes ranged from hundreds of hospitals (max = 927) with hundreds of thousands of nurses (max = 326 750) [ 20 ] to small single-site studies with the smallest sample being 73 nurses [ 21 ] (see Additional file 3 ).

The relationships examined are summarised in Table 1 .

Measures of burnout

Most studies used the Maslach Burnout Inventory Scale ( n = 81), which comprises three subscales reflecting the theoretical model: Emotional Exhaustion, Depersonalisation, and reduced Personal Accomplishment. However, less than half (47%, n = 39) of the papers measured and reported results with all three subscales. Twenty-three papers used the Emotional Exhaustion subscale only, and 11 papers used the Emotional Exhaustion and Depersonalisation subscales. In nine studies, the three MBI subscales were summed up to provide a composite score of burnout, despite Maslach and colleagues advising against such an approach [ 22 ].

Five studies used the Copenhagen Burnout Inventory (CBI) [ 23 ]. This scale consists of three dimensions of burnout: personal, work-related, and client-related. Two studies used the Malach-Pines Scale [ 24 ], and one used the burnout subscale of the Professional Quality of Life Measure (ProQoL5) scale, which posits burnout as an element of compassion fatigue [ 25 ]. Two studies used idiosyncratic measures of burnout based on items from other instruments [ 20 , 26 ].

Factors examined in relation to burnout: an overview

The studies which tested the relationships between burnout and Maslach’s six areas of worklife—workload, control, reward, community, fairness, and values—typically supported Maslach’s theory that these areas are predictors of burnout. However, some evidence is based only on certain MBI dimensions. High scores on the Areas of Worklife Scale [ 27 ] (indicating a higher degree of congruence between the job and the respondent) were associated with less likelihood of burnout, either directly [ 28 , 29 ] or through high occupational coping self-efficacy [ 30 ] and presence of civility norms and co-worker incivility [ 31 ].

The majority of studies looking at job characteristics hypothesised by the Maslach model considered workload ( n = 31) and job control and reward ( n = 10). While only a few studies ( n = 9) explicitly examined the hypothesised relationships between burnout and community, fairness, or values, we identified 39 studies that covered ‘supportive factors’ including relationships with colleagues and leadership.

A large number of studies included factors that fall outside of the Maslach model. Six main areas were identified:

Working patterns and shifts working ( n = 15)

Features inherent in the job such as psychological demand and complexity ( n = 24)

Job support from working relationships and leadership ( n = 39)

Hospital or environmental characteristics ( n = 28)

Staff outcomes and job performance ( n = 33)

Patient outcomes ( n = 17)

Individual attributes (personal or professional) ( n = 16)

Workload and staffing levels

Workload and characteristics of jobs that contribute to workload, such as staffing levels, were the most frequently examined factor in relation to burnout. Thirty studies found an association between high workload and burnout.

Of these, 13 studies looked specifically at measures of workload as a predictor of burnout. Workload was associated with Emotional Exhaustion in five studies [ 32 , 33 , 34 , 35 , 36 ], with some studies also reporting a relationship with Depersonalisation, and others Cynicism. Janssen reported that ‘mental work overload’ predicted Emotional Exhaustion [ 37 ]. Three studies concluded that workload is associated with both Emotional Exhaustion and Depersonalisation [ 38 , 39 , 40 ]. Kitaoka-Higashiguchi tested a model of burnout and found that heavy workload predicted Emotional Exhaustion, which in turn predicted Cynicism [ 41 ]. This was also observed in a larger study by Greengrass et al. who found that high workload was associated with Emotional Exhaustion, which consequently predicted Cynicism [ 42 ]. One study reported no association between workload and burnout components [ 43 ], and one study found an association between manageable workload and a composite burnout score [ 44 ].

Further 15 studies looked specifically at nurse staffing levels, and most reported that when nurses were caring for a higher number of patients or were reporting staffing inadequacy, they were more likely to experience burnout. No studies found an association between better staffing levels and burnout.

While three studies did not find a significant association with staffing levels [ 32 , 45 , 46 ], three studies found that higher patient-to-nurse ratios were associated with Emotional Exhaustion [ 47 , 48 , 49 ], and in one study, higher patient-to-nurse-ratios were associated with Emotional Exhaustion, Depersonalisation, and Personal Accomplishment [ 50 ]. One study concluded that Emotional Exhaustion mediated the relationship between patient-to-nurse ratios and patient safety [ 51 ]. Akman and colleagues found that the lower the number of patients nurses were responsible for, the lower the burnout composite score [ 52 ]. Similar results were highlighted by Faller and colleagues [ 53 ]. Lower RN hours per patient day were associated with burnout in a study by Thompson [ 20 ].

When newly qualified RNs reported being short-staffed, they were more likely to report Emotional Exhaustion and Cynicism 1 year later [ 54 ]. In a further study, low staffing adequacy was associated with Emotional Exhaustion [ 55 ]. Similarly, Leineweber and colleagues found that poor staff adequacy was associated with Emotional Exhaustion, Depersonalisation, and Personal Accomplishment [ 56 ]. Leiter and Spence Laschinger explored the relationship between staffing adequacy and all MBI subscales and found that Emotional Exhaustion mediated the relationship between staffing adequacy and Depersonalisation [ 57 ]. Time pressure was investigated in three studies, which all concluded that reported time pressure was associated with Emotional Exhaustion [ 58 , 59 , 60 ].

In summary, there is evidence that high workload is associated with Emotional Exhaustion, nurse staffing levels are associated with burnout, and time pressure is associated with Emotional Exhaustion.

Job control, reward, values, fairness, and community

Having control over the job was examined in seven studies. Galletta et al. found that low job control was associated with all MBI subscales [ 40 ], as did Gandi et al. [ 61 ]. Leiter and Maslach found that control predicted fairness, reward, and community, and in turn, fairness predicted values, and values predicted all MBI subscales [ 35 ]. Low control predicted Emotional Exhaustion only for nurses working the day shift [ 62 ], and Emotional Exhaustion was significantly related to control over practice setting [ 63 ]; two studies reported no effect of job control on burnout [ 44 , 64 ].

Reward predicted Cynicism [ 35 ] and burnout on a composite score [ 44 ]. Shamian and colleagues found that a higher score in the effort and reward imbalance scale was associated with Emotional Exhaustion, and higher scores in the effort and reward imbalance scale were associated with burnout measured by the CBI [ 65 ].

Value congruence refers to a match between the requirements of the job and people’s personal principles [ 7 ]. Value conflicts were related with a composite score of burnout [ 44 ], and one study concluded that nurses with a high value congruence reported lower Emotional Exhaustion than those with a low value congruence, and nurses with a low value congruence experienced more severe Depersonalisation than nurses with a high value congruence [ 66 ]. Low value congruence was a predictor of all three MBI dimensions [ 35 ] and of burnout measured with the Malach-Pines Burnout Scale [ 67 ]. Two studies considered social capital, defined as a social structure that benefits its members including trust, reciprocity, and a set of shared values, and they both concluded that lower social capital in the hospital-predicted Emotional Exhaustion [ 33 , 36 ]. A single study showed fairness predicted values, which in turn predicted all MBI Scales [ 35 ]. Two studies looked at community, and one found that community predicts a composite score of burnout [ 44 ], while the other found no relationships [ 35 ].

While not directly expressed in the terms described by Maslach, other studies demonstrate associations with possible causal factors, many of which are reflected in Maslach’s theory.

In summary, there is evidence that control over the job is associated with reduced burnout, and value congruence is associated with reduced Emotional Exhaustion and Depersonalisation.

Working patterns and shift work

Shift work and working patterns variables were considered by 15 studies. Overall, there was mixed evidence on the relationship between night work, number of hours worked per week, and burnout, with more conclusive results regarding the association between long shifts and burnout, and the potential protective effect of schedule flexibility.

Working night shifts was associated with burnout (composite score) [ 68 ] and Emotional Exhaustion [ 62 ], but the relationship was not significant in two studies [ 69 , 70 ]. Working on permanent as opposed to rotating shift patterns did not impact burnout [ 71 ], but working irregular shifts did impact a composite burnout score [ 72 ]. When nurses reported working a higher number of shifts, they were more likely to report higher burnout composite scores [ 68 ], but results did not generalise in a further study [ 69 ]. One study found working that overtime was associated with composite MBI score [ 73 ]. On-call requirement was not significantly associated with any MBI dimensions [ 71 ].

The number of hours worked per week was not a significant predictor of burnout according to two studies [ 25 , 53 ], but having a higher number of weekly hours was associated with Emotional Exhaustion and Depersonalisation in one study [ 70 ]. Long shifts of 12 h or more were associated with all MBI subscales [ 74 ] and with Emotional Exhaustion [ 49 , 75 ]. A study using the ProQoL5 burnout scale found that shorter shifts were protective of burnout [ 25 ].

Having higher schedule flexibility was protective of Emotional Exhaustion [ 46 ], and so was the ability to schedule days off for a burnout composite score [ 76 ]. Having more than 8 days off per month was associated with lower burnout [ 69 ]. Stone et al. found that a positive scheduling climate was protective of Emotional Exhaustion only [ 77 ].

In summary, we found an association between ≥ 12-h shifts and Emotional Exhaustion and between schedule flexibility and reduced Emotional Exhaustion.

Psychological demands and job complexity

There is evidence from 24 studies that job demands and aspects intrinsic to the job, including role conflict, autonomy, and task variety, are associated with some burnout dimensions.

Eight studies considered psychological demands. The higher the psychological demands, the higher the likelihood of experiencing all burnout dimensions [ 72 ], and high psychological demands were associated with higher odds of Emotional Exhaustion [ 62 , 78 ]. Emotional demands, in terms of hindrances, had an effect on burnout [ 67 ]. One study reported that job demands, measured with the Effort-Reward Imbalance Questionnaire, were correlated with all burnout dimensions [ 79 ], and similarly, Garcia-Sierra et al. found that demands predict burnout, measured with a composite scale of Emotional Exhaustion and Cynicism [ 80 ]. According to one study, job demands were not associated with burnout [ 73 ], and Rouxel et al. concluded that the higher the job demands, the higher the impact on both Emotional Exhaustion and Depersonalisation [ 64 ].

Four studies looked at task nature and variety, quality of job content, in terms of skill variety, skill discretion, task identity, task significance, influenced Emotional Exhaustion through intrinsic work motivation [ 37 ]. Skill variety and task significance were related to Emotional Exhaustion; task significance was also related to Personal Accomplishment [ 60 ]. Having no administrative tasks in the job was associated with a reduced likelihood to experience Depersonalisation [ 71 ]. Higher task clarity was associated with reduced levels of Emotional Exhaustion and increased Personal Accomplishment [ 58 ].

Patient characteristics/requirements were investigated in four papers. When nurses were caring for suffering patients and patients who had multiple requirements, they were more likely to experience Emotional Exhaustion and Cynicism. Similarly, caring for a dying patient and having a high number of decisions to forego life-sustaining treatments were associated with a higher likelihood of burnout (measured with a composite score) [ 76 ]. Stress resulting from patient care was associated with a composite burnout score [ 73 ]. Patient violence also had an impact on burnout, measured with CBI [ 81 ], as did conflict with patients [ 76 ].

Role conflict is a situation in which contradictory, competing, or incompatible expectations are placed on an individual by two or more roles held at the same time. Role conflict predicted Emotional Exhaustion [ 41 ], and so it did in a study by Konstantinou et al., who found that role conflict was associated with Emotional Exhaustion and Depersonalisation [ 34 ]; Levert and colleagues reported that role conflict correlated with Emotional Exhaustion, Depersonalisation, and Personal Accomplishment. They also considered role ambiguity, which correlated with Emotional Exhaustion and Depersonalisation, but not Personal Accomplishment [ 39 ]. Andela et al. investigated the impact of emotional dissonance, defined as the mismatch between the emotions that are felt and the emotions required to be displayed by organisations. They reported that emotional dissonance is a mediator between job aspects (i.e. workload, patient characteristics, and team issues) and Emotional Exhaustion and Cynicism. Rouxel et al. found that perceived negative display rules were associated with Emotional Exhaustion [ 64 ].

Autonomy related to Emotional Exhaustion and Depersonalisation [ 60 ], and in another study, it only related to Depersonalisation [ 43 ]. Low autonomy impacted Emotional Exhaustion via organisational trust [ 82 ]. Autonomy correlated with burnout [ 67 ]. There was no effect of autonomy on burnout according to two studies [ 58 , 63 ]. Low decision-making at the ward level was associated with all MBI subscales [ 77 ]. Decision latitude impacted Personal Accomplishment only [ 36 ], and in one study, it was found to be related to Emotional Exhaustion [ 78 ]. High decision latitude was associated with Personal Accomplishment [ 41 ] and low Emotional Exhaustion [ 33 ].

Overall, high job and psychological demands were associated with Emotional Exhaustion, as was role conflict. Patient complexity was associated with burnout, while task variety, autonomy, and decision latitude were protective of burnout.

Working relationships and leadership

Overall, evidence from 39 studies supports that having positive support factors and working relationships in place, including positive relationships with physicians, support from the leader, positive leadership style, and teamwork, might play a protective role towards burnout.

The quality of the relationship with physicians was investigated by 12 studies. In two studies, having negative relationships with physicians was associated with all MBI dimensions [ 77 , 83 ]; quality of nurse-physician relationship was associated with Emotional Exhaustion and Depersonalisation, but not PA [ 50 ]. Two studies found an association with Emotional Exhaustion only [ 55 , 84 ], and one concluded that quality of relationship with physicians indirectly supported PA [ 36 ]. This was also found by Leiter and Laschinger, who found that positive nurse-physician collaborations predicted Personal Accomplishment [ 57 , 85 ]. When burnout was measured with composite scores of MBI and a not validated scale, two studies reported an association with nurse-physician relationship [ 20 , 76 ], and two studies found no associations [ 56 , 63 ].

Having support from the supervisor or leader was considered in 12 studies, which found relationships with different MBI dimensions. A relationship between low support from nurse managers and all MBI subscales was observed in one study [ 77 ], while two studies reported it is a protective factor from Emotional Exhaustion only [ 58 , 83 ], and one that it was also associated with Depersonalisation [ 86 ]. Kitaoka-Higashiguchi reported an association only with Cynicism [ 41 ], and Jansen et al. found it was only associated with Depersonalisation and Personal Accomplishment [ 60 ]. Van Bogaert and colleagues found that support from managers predicted low Emotional Exhaustion and high Personal Accomplishment [ 84 ], but in a later study, it only predicted high Personal Accomplishment [ 36 ]. Regarding the relationship with the manager, it had a direct effect on Depersonalisation, and it moderated the effect of time pressure on Emotional Exhaustion and Depersonalisation [ 59 ]; a protective effect of a quality relationship with the head nurse on a composite burnout score was also reported [ 76 ]. Two studies using different burnout scales found an association between manager support and reduced burnout [ 25 , 67 ]. Low trust in the leader showed a negative impact on burnout, measured with a composite score [ 87 ]. Two further studies focused on the perceived nurse manager’s ability: authors found that it was related to Emotional Exhaustion [ 46 ], and Emotional Exhaustion and Personal Accomplishment [ 50 ].

Fourteen studies looked at the leadership style and found that it affects burnout through different pathways and mechanisms. Boamah et al. found that authentic leadership—described as leaders who have high self-awareness, balanced processing, an internalised moral perspective, and transparency—predicted higher empowerment, which in turn predicted lower levels of Emotional Exhaustion and Cynicism a year later [ 54 ]. Authentic leadership had a negative direct effect on workplace bullying, which in turn had a direct positive effect on Emotional Exhaustion [ 88 ]. Effective leadership predicted staffing adequacy, which in turn predicted Emotional Exhaustion [ 57 , 85 ]. Authentic leadership predicted all areas of worklife, which in turn predicted all MBI dimensions of burnout [ 30 ], and a similar pathway was identified by Laschiner and Read, although authentic leadership impacted Emotional Exhaustion only and it was also through civility norms and co-worker incivility [ 31 ]. Emotional Exhaustion mediated the relationship between authentic leadership and intention to leave the job [ 89 ]. ‘Leader empowering behaviour’ had an indirect effect on Emotional Exhaustion through structural empowerment [ 29 ], and empowering leadership predicted trust in the leader, which in turn was associated with burnout composite score [ 87 ]. Active management-by-exception was beneficial for Depersonalisation and Personal Accomplishment, passive laissez-faire leadership negatively affected Emotional Exhaustion and Personal Accomplishment, and rewarding transformational leadership protected from Depersonalisation [ 90 ]. Contrary to this, Madathil et al. found that transformational leadership protected against Emotional Exhaustion, but not Depersonalisation, and promoted Personal Accomplishment [ 43 ]. Transformational leadership predicted positive work environments, which in turn predicted lower burnout (composite score) [ 44 ]. Positive leadership affected Emotional Exhaustion and Depersonalisation [ 56 ] and burnout measured with a non-validated scale [ 20 ].

Teamwork and social support were also explored. Co-worker cohesion was only related to Depersonalisation [ 58 ]; team collaboration problems predicted negative scores on all MBI subscales [ 38 ], and workplace support protected from Emotional Exhaustion [ 72 ]. Similarly, support received from peers had a protective effect on Emotional Exhaustion [ 60 ]. Collegial support was related to Emotional Exhaustion and Personal Accomplishment [ 39 ], and colleague support protected from burnout [ 67 ]. Interpersonal conflict affected Emotional Exhaustion through role conflict, but co-worker support had no effect on any burnout dimensions [ 41 ], and similarly, co-worker incivility predicted Emotional Exhaustion [ 31 ], and so did bullying [ 88 ]. Poor team communication was associated with all MBI dimensions [ 40 ], staff issues predicted burnout measured with a composite score [ 73 ], and so did verbal violence from colleagues [ 68 ]. One study found that seeking social support was not associated with any of the burnout dimensions, while another study found that low social support predicted Emotional Exhaustion [ 37 ], and social support was associated with lower Emotional Exhaustion and higher Personal Accomplishment [ 21 ]. Vidotti et al. found an association between low social support and all MBI dimensions [ 62 ].

Work environment and hospital characteristics

Eleven studies were considering the work environment measured with the PES-NWI scale [ 91 ], where higher scores indicate positive work environments. Five studies comprising diverse samples and settings concluded that the better rated the work environment, the lower the likelihood of experiencing Emotional Exhaustion [ 32 , 47 , 49 , 51 , 92 ], and four studies found the same relationship, but on both Emotional Exhaustion and Depersonalisation [ 50 , 66 , 93 , 94 ]; only one study concluded there is an association between work environment and all MBI dimensions [ 95 ]. Negative work environments affected burnout (measured with a composite score) via job dissatisfaction [ 96 ]. One study looked at organisational characteristics on a single scale and found that a higher rating of organisational characteristics predicted lower Emotional Exhaustion [ 82 ]. Environmental uncertainty was related to all MBI dimensions [ 86 ].

Structural empowerment was also considered in relation to burnout: high structural empowerment led to lower Emotional Exhaustion and Cynicism via staffing levels and worklife interference [ 54 ]; in a study using a similar methodology, structural empowerment affected Emotional Exhaustion via Areas of Worklife [ 29 ]. The relationship between Emotional Exhaustion and Cynicism was moderated by organisational empowerment [ 40 ], and organisational support had a protective effect on burnout [ 67 ]. Hospital management and organisational support had a direct effect on Emotional Exhaustion and Personal Accomplishment [ 84 ]. Trust in the organisation predicted lower levels of Emotional Exhaustion [ 82 ] and of burnout measured with a composite MBI score [ 87 ].

Three studies considered whether policy involvement had an effect on burnout. Two studies on the same sample found that having the opportunity to participate in policy decisions was associated with reduced burnout (all subscales) [ 57 , 85 ], and one study did not report results for the association [ 20 ]. Emotional Exhaustion mediated the relationship between nurses’ participation in hospital affairs and their intention to leave the job [ 97 ]; a further study did not found an association between participation in hospital affairs and Emotional Exhaustion, but only with Personal Accomplishment [ 50 ]. Lastly, one study investigated participation in research groups and concluded it was associated with reduced burnout measured with a composite score [ 76 ].

There was an association between opportunity for career advancement and all MBI dimensions [ 77 ]; however, another study found that having promotion opportunities was not related to burnout [ 79 ]. Moloney et al. found that professional development was not related to burnout [ 67 ]. Two studies considered pay. In one study, no effect was found on any MBI dimension [ 73 ], and a very small study ( n = 78 nurses) reported an effect of satisfaction with pay on Emotional Exhaustion and Depersonalisation [ 34 ]. Job insecurity predicted Depersonalisation and PA [ 79 ].

When the hospital adopted nursing models of care rather than medical models of care, nurses were more likely to report high levels of Personal Accomplishment [ 57 , 85 ]. However, another study found no significant relationship [ 20 ]. Regarding ward and hospital type, Aiken and Sloane found that RNs working in specialised AIDS units reported lower levels of Emotional Exhaustion [ 98 ]; however, ward type was not found to be significantly associated with burnout in a study on temporary nurses [ 53 ]. Working in different ward settings was not associated with burnout, but working in hospitals as opposed to in primary care was associated with lower Emotional Exhaustion [ 71 ]. Working in a small hospital was associated with a lower likelihood of Emotional Exhaustion, when compared to working in a community hospital [ 63 ]. Faller’s study also concluded that working in California was a significant predictor of reduced burnout.

When the hospitals’ investment in the quality of care was considered, one study found that having foundations for quality of care was associated with reduced Emotional Exhaustion only [ 50 ], but in another study, foundations for quality of care were associated with all MBI dimensions [ 83 ]. Working in a Magnet hospital was not associated with burnout [ 53 ].

In summary, having a positive work environment (generally work environments scoring higher on the PES-NWI scale) was associated with reduced Emotional Exhaustion, and so was higher structural empowerment. However, none of the organisational characteristics at the hospital level was consistently associated with burnout.

Staff outcomes and job performance

Nineteen studies considered the impact of burnout on intention to leave. Two studies found that Emotional Exhaustion and Cynicism had a direct effect on turnover intentions [ 28 , 99 ], and four studies reported that only Emotional Exhaustion affected intentions to leave the job [ 21 , 32 , 37 , 100 ], with one of these indicating that Emotional Exhaustion affected also intention to leave the organisation [ 32 ], but one study did not replicate such findings [ 101 ] and concluded that only Cynicism was associated with intention to leave the job and nursing. Similarly, one study found that Cynicism was directly related to intention to leave [ 35 ]. A further study found that Emotional Exhaustion affected turnover intentions via job satisfaction [ 88 ], and one article reported that Emotional Exhaustion mediated the effect of authentic leadership on intention to leave [ 89 ]. Emotional Exhaustion was a mediator between nurses’ involvement with decisions and intention to leave the organisation [ 97 ]. Burnout measured on a composite score was associated with a higher intention to leave [ 96 ]. Laeeque et al. reported that burnout, captured with CBI, related to intention to leave [ 81 ]; Estryn-Behar et al. used the same scale to measure burnout and found that high burnout was associated with higher intention to leave in all countries, except for Slovakia [ 102 ]. Burnout, measured with the Malach-Pines Scale, was associated with intention to quit, and stronger associations were found for nurses who had higher perceptions of organisational politics [ 103 ]. Burnout (Malach-Pines Scale) predicted both the intention to leave the job and nursing [ 67 ]. Three studies investigated the relationship between burnout and intention to leave; one of these aggregated all job outcomes in a single variable (i.e. job satisfaction, intention to leave the hospital, applied for another job, and intention to leave nursing) and reported that Depersonalisation and Personal Accomplishment predict job outcomes [ 84 ]; they replicated a similar approach and found the same associations [ 36 ]. They later found that all MBI dimensions were associated with leaving the nursing profession [ 104 ]. Only one study in a sample of 106 nurses from one hospital found an association between Depersonalisation and turnover within 2 years [ 105 ].

Two studies looked at the effect of burnout on job performance: one found a negative association between burnout (measured with CBI) and both task performance and contextual performance [ 106 ]. Only Emotional Exhaustion was associated with self-rated and supervisor-rated job performance of 73 RNs [ 21 ]. Missed care was investigated in three studies, and it was found to be both predictor of Emotional Exhaustion [ 32 ], an outcome of burnout [ 20 , 103 ].

Four studies considered sickness absence. When RNs had high levels of Emotional Exhaustion, they were more likely to experience short-term sickness absence (i.e. 1–10 days of absence), which was obtained from hospital administrative records. Similarly, Emotional Exhaustion was associated with seven or more days of absence in a longitudinal study [ 105 ]. Emotional Exhaustion was significantly associated with reported mental health absenteeism, but not reported physical health absenteeism, and sickness absence from administrative records [ 21 ]. One study did not find any meaningful relationships between burnout and absenteeism [ 107 ].

Emotional Exhaustion was a significant predictor of general health [ 73 ], and in a further study, both Emotional Exhaustion and Personal Accomplishment were associated with perceived health [ 70 ]. Final-year nursing students who experienced health issues were more likely to develop high burnout when entering the profession [ 26 ]. When quality of sleep was treated both as a predictor and outcome of burnout, relationships were found in both instances [ 106 ].

Focussing on mental health, one study found that burnout predicted mental health problems for newly qualified nurses [ 30 ], and Emotional Exhaustion and Cynicism predicted somatisation [ 42 ]. Depressive symptoms were predictive of Emotional Exhaustion and Depersonalisation, considering therefore depression as a predictor of burnout [ 108 ]. Rudman and Gustavsson also found that having depressive mood and depressive episodes were common features of newly qualified nurses who developed or got worse levels of burnout throughout their first years in the profession [ 26 ]. Tourigny et al. considered depression as a predictor and found it was significantly related to Emotional Exhaustion [ 107 ].

Eleven studies considered job satisfaction: of these, three treated job satisfaction as a predictor of burnout and concluded that higher levels of job satisfaction were associated with a lower level of composite burnout scores [ 52 , 96 ] and all MBI dimensions [ 94 ]. According to two studies, Emotional Exhaustion and Cynicism predicted job dissatisfaction [ 54 , 101 ], while four studies reported that Emotional Exhaustion only was associated with increased odds to report job dissatisfaction [ 73 , 82 , 88 , 100 ]; one study reported that Cynicism only was associated with job dissatisfaction [ 99 ]. Rouxel et al. did not find support in their hypothesised model that Emotional Exhaustion and Depersonalisation predicted job satisfaction [ 64 ].

In summary, considering 39 studies, there is conflicting evidence on the direction of the relationship between burnout and missed care, mental health, and job satisfaction. An association between burnout and intention to leave was found, although only one small study reported an association between burnout and turnover. A moderate relationship was found for the effect of burnout on sickness absence, job performance, and general health.

Patient care and outcomes

Among the patient outcomes of burnout, quality of care was investigated by eight studies. Two studies in diverse samples and settings reported that high Emotional Exhaustion, high Depersonalisation, and low Personal Accomplishment were associated with poor quality of care [ 109 , 110 ], but one study found that only Personal Accomplishment was related to better quality of care at the last shift [ 104 ]; Emotional Exhaustion and Cynicism predict low quality of care [ 54 ]; two articles reported that Emotional Exhaustion predicts poor nurse ratings of quality of care [ 82 , 84 ]. A high burnout composite score predicted poor nurse-assessed quality of care [ 96 ]. In one instance, no associations were found between any of the burnout dimensions and quality of care [ 36 ].

Five studies considered aspects of patient safety: burnout was correlated with negative patient safety climate [ 111 ]. Emotional Exhaustion and Depersonalisation were both associated with negative patient safety grades and safety perceptions [ 112 ], and burnout fully mediated the relationship between depression and individual-level safety perceptions and work area/unit level safety perceptions [ 108 ]. Emotional Exhaustion mediated the relationship between workload and patient safety [ 51 ], and a higher composite burnout score was associated with lower patient safety ratings [ 113 ].

Regarding adverse events, high DEP and low Personal Accomplishment predicted a higher rate of adverse events [ 85 ], but in another study, only Emotional Exhaustion predicted adverse events [ 51 ]. When nurses were experiencing high levels of Emotional Exhaustion, they were less likely to report near misses and adverse events, and when they were experiencing high levels of Depersonalisation, they were less likely to report near misses [ 112 ].

All three MBI dimensions predicted medication errors in one study [ 109 ], but Van Bogaert et al. found that only high levels of Depersonalisation were associated with medication errors [ 104 ]. High scores in Emotional Exhaustion and Depersonalisation predicted infections [ 109 ]. Cimiotti et al. found that Emotional Exhaustion was associated with catheter-associated urinary tract infections and surgical site infections [ 114 ], while in another study, Depersonalisation was associated with nosocomial infections [ 104 ]. Lastly, patient falls were also explored, and Depersonalisation and low Personal Accomplishment were significant predictors in one study [ 109 ], while in a further study, only Depersonalisation was associated with patient falls [ 104 ]. There was no association between burnout and hospital-acquired pressure ulcers [ 20 ].

Considering patient experience, Vahey et al. concluded that higher Emotional Exhaustion and low Personal Accomplishment levels were associated with patient dissatisfaction [ 93 ], and Van Bogaert et al. found that Emotional Exhaustion was related to patient and family verbal abuse, and Depersonalisation was related to both patient and family verbal abuse and patient and family complaints [ 104 ].

In summary, evidence deriving from 17 studies points to a negative effect of burnout on quality of care, patient safety, adverse events, error reporting, medication error, infections, patient falls, patient dissatisfaction, and family complaints, but not on pressure ulcers.

Individual characteristics

In total, 16 studies, which had examined work characteristics related to burnout, also considered the relationship between characteristics of the individual and burnout. Relationships were tested on demographic variables, including gender, age, and family status; on personality aspects; on work-life interference; and on professional attributes including length of experience and educational level. Because our focus on burnout is as a job-related phenomenon, we have not reported results of these studies into detail, but overall evidence on demographic and personality factors was inconclusive, and having family issues and high work-life interference was associated with different burnout dimensions. Being younger and not having a bachelor’s degree were found to be associated with a higher incidence of burnout.

This review aimed to identify research that had examined theorised relationships with burnout, in order to determine what is known (and not known) about the factors associated with burnout in nursing and to determine the extent to which studies have been underpinned by, and/or have supported or refuted, theories of burnout. We found that the associations hypothesised by Maslach’s theory between mismatches in areas of worklife and burnout were generally supported.

Research consistently found that adverse job characteristics—high workload, low staffing levels, long shifts, low control, low schedule flexibility, time pressure, high job and psychological demands, low task variety, role conflict, low autonomy, negative nurse-physician relationship, poor supervisor/leader support, poor leadership, negative team relationship, and job insecurity—were associated with burnout in nursing.

However few studies used all three MBI subscales in the way intended, and nine used different approaches to measuring burnout.

The field has been dominated by cross-sectional studies that seek to identify associations with one or two factors, rarely going beyond establishing correlation. Most studies were limited by their cross-sectional nature, the use of different or incorrectly applied burnout measures, the use of common methods (i.e. survey to capture both burnout and correlates), and omitted variables in the models. The 91 studies reviewed, while highlighting the importance of burnout as a feature affecting nurses and patient care, have generally lacked a theoretical approach, or identified mechanisms to test and develop a theory on the causes and consequences of burnout, but were limited in their testing of likely mechanisms due to cross-sectional and observational designs.

For example, 19 studies showed relationships between burnout and job satisfaction, missed care, and mental health. But while some studies treated these as predictors of burnout, others handled as outcomes of burnout. This highlights a further issue that characterises the burnout literature in nursing: the simultaneity bias, due to the cross-sectional nature of the evidence. The inability to establish a temporal link means limits the inference of causality [ 115 ]. Thus, a factor such as ‘missed care’ could lead to a growing sense of compromise and ‘crushed ideals’ in nurses [ 116 ], which causes burnout. Equally, it could be that job performance of nurses experiencing burnout is reduced, leading to increased levels of ‘missed care’. Both are plausible in relation to Maslach’s original theory of burnout, but research is insufficient to determine which is most likely, and thereby develop the theory.

To help address this, three areas of development within research are proposed. Future research adopting longitudinal designs that follow individuals over time would improve the potential to understand the direction of the relationships observed. Research using Maslach’s theory should use and report all three MBI dimensions; where only the Emotional Exhaustion subscale is used, this should be explicit and it should not be treated as being synonymous to burnout. Finally, to move our theoretical understanding of burnout forward, research needs to prioritise the use of empirical data on employee behaviours (such as absenteeism, turnover) rather than self-report intentions or predictions.

Addressing these gaps would provide better evidence of the nature of burnout in nursing, what causes it and its potential consequences, helping to develop evidence-based solutions and motivate work-place change. With better insight, health care organisations can set about reducing the negative consequences of having patient care provided by staff whose work has led them to become emotionally exhausted, detached, and less able to do the job, that is, burnout.

Limitations

Our theoretical review of the literature aimed to summarise information from a large quantity of studies; this meant that we had to report studies without describing their context in the text and also without providing estimates (i.e. ORs and 95% CIs). In appraising studies, we did not apply a formal quality appraisal instrument, although we noted key omissions of important details. However, the results of the review serve to illustrate the variety of factors that may influence/result from burnout and demonstrate where information is missing. We did not consider personality and other individual variables when extracting data from studies. However, Maslach and Leiter recently reiterated that although some connections have been made between burnout and personality characteristics, the evidence firmly points towards work characteristics as the primary drivers of burnout [ 8 ].

While we used a reproducible search strategy searching MEDLINE, CINAHL, and PsycINFO, it is possible that there are studies indexed elsewhere and we did not identify them, and we did not include grey literature. It seems unlikely that these exist in sufficient quantity to substantively change our conclusions.

Patterns identified across 91 studies consistently show that adverse job characteristics are associated with burnout in nursing. The potential consequences for staff and patients are severe. Maslach’s theory offers a plausible mechanism to explain the associations observed. However incomplete measurement of burnout and limited research on some relationships means that the causes and consequences of burnout cannot be reliably identified and distinguished, which makes it difficult to use the evidence to design interventions to reduce burnout.

Availability of data and materials

Not applicable

Abbreviations

• Maslach Burnout Inventory

Copenhagen Burnout Inventory

Professional Quality of Life Measure

Dall’Ora C, Ball J, Recio-Saucedo A, Griffiths P. Characteristics of shift work and their impact on employee performance and wellbeing: a literature review. Int J Nurs Stud. 2016;57:12–27.

Article   PubMed   Google Scholar  

Griffiths P, Ball J, Drennan J, Dall’Ora C, Jones J, Maruotti A, et al. Nurse staffing and patient outcomes: Strengths and limitations of the evidence to inform policy and practice. A review and discussion paper based on evidence reviewed for the National Institute for Health and Care Excellence Safe Staffing guideline development. Int J Nurs Stud. 2016;63:213–25.

Cummings GG, MacGregor T, Davey M, Lee H, Wong CA, Lo E, et al. Leadership styles and outcome patterns for the nursing workforce and work environment: a systematic review. Int J Nurs Stud. 2010;47(3):363–85.

Rafferty AM, Ball J, Aiken LH. Are teamwork and professional autonomy compatible, and do they result in improved hospital care? Qual Health Care. 2001;10(suppl 2):ii32-iii7.

Freudenberger HJ. Staff burn-out. J Soc Issues. 1974;30(1):159–65.

Article   Google Scholar  

Maslach C, Jackson SE. The measurement of experienced burnout. J Occup Behav. 1981;2(2):99–113.

Maslach C. A Multidimensional theory of burnout. In: Cooper CL, editor. Theories of Organizational Stress Oxford University Press Inc.; 1999.

Maslach C, Leiter M. Burnout. Fink G, editor. London, UK: Academic Press; 2016. 351-7 p.

Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52(1):397–422.

Article   CAS   PubMed   Google Scholar  

Ekstedt M. Burnout and sleep: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2005.

Google Scholar  

Demerouti E, Bakker AB, Nachreiner F, Schaufeli WB. The job demands-resources model of burnout. J Appl Psychol. 2001;86(3):499.

Schaufeli WB, Leiter MP, Maslach C. Burnout: 35 years of research and practice. Career Dev Int. 2009;14(2-3):204–20.

Cherniss C. Burnout in new professionals: a long-term follow-up study. J Health Hum Resour Adm. 1989;12(1):11–24.

Gustavsson JP, Hallsten L, Rudman A. Early career burnout among nurses: modelling a hypothesized process using an item response approach. Int J Nurs Stud. 2010;47(7):864–75.

Shirom A. Job-related burnout: a review. Handbook of occupational health psychology. Washington, DC, US: American Psychological Association; 2003. p. 245-264.

Melamed S, Kushnir T, Shirom A. Burnout and risk factors for cardiovascular diseases. Behav Med. 1992;18(2):53–60.

Campbell M, Egan M, Lorenc T, Bond L, Popham F, Fenton C, et al. Considering methodological options for reviews of theory: illustrated by a review of theories linking income and health. Syst Rev. 2014;3(1):114.

Article   PubMed   PubMed Central   Google Scholar  

Pare G, Trudel MC, Jaana M, Kitsiou S. Synthesizing information systems knowledge: a typology of literature reviews. Inf Manag. 2015;52(2):183–99.

Lavoie P, Michaud C, Bélisle M, Boyer L, Gosselin É, Grondin M, et al. Learning theories and tools for the assessment of core nursing competencies in simulation: a theoretical review. J Adv Nurs. 2018;74(2):239–50.

Thompson D. The examination of practice environment, burnout, and missed care on pressure ulcer prevalence rates using a complexity science framework: University of Kansas; 2014.

Parker PA, Kulik JA. Burnout, self- and supervisor-rated job performance, and absenteeism among nurses. J Behav Med. 1995;18(6):581–99.

Maslach C, Jackson SE, Leiter M. Maslach burnout inventory manual. 3rd ed. ed: Mind Garden, Inc.; 2010.

Kristensen TS, Borritz M, Villadsen E, Christensen KB. The Copenhagen Burnout Inventory: a new tool for the assessment of burnout. Work Stress. 2005;19(3):192–207.

Malach-Pines A. The burnout measure, short version. Int J Stress Manag. 2005;12(1):78–88.

Hunsaker S, Chen HC, Maughan D, Heaston S. Factors that influence the development of compassion fatigue, burnout, and compassion satisfaction in emergency department nurses. J Nurs Scholarsh. 2015;47(2):186–94.

Rudman A, Gustavsson JP. Early-career burnout among new graduate nurses: a prospective observational study of intra-individual change trajectories. Int J Nurs Stud. 2011;48(3):292–306.

Leiter MP, Maslach C. Areas of worklife survey manual. Centre for Organizational Research and Development, Acadia University, Wolfville. 2006.

Boamah SA, Laschinger H. The influence of areas of worklife fit and work-life interference on burnout and turnover intentions among new graduate nurses. J Nurs Manag. 2016;24(2):E164–74.

Greco P, Laschinger HK, Wong C. Leader empowering behaviours, staff nurse empowerment and work engagement/burnout. Nurs Leadersh (Tor Ont). 2006;19(4):41–56.

Laschinger HK, Borgogni L, Consiglio C, Read E. The effects of authentic leadership, six areas of worklife, and occupational coping self-efficacy on new graduate nurses’ burnout and mental health: a cross-sectional study. Int J Nurs Stud. 2015;52(6):1080–9.

Laschinger HK, Read EA. The effect of authentic leadership, person-job fit, and civility norms on new graduate nurses’ experiences of coworker incivility and burnout. J Nurs Adm. 2016;46(11):574–80.

Flynn L, Thomas-Hawkins C, Clarke SP. Organizational traits, care processes, and burnout among chronic hemodialysis nurses. West J Nurs Res. 2009;31(5):569–82.

Kowalski C, Ommen O, Driller E, Ernstmann N, Wirtz MA, Kohler T, et al. Burnout in nurses - the relationship between social capital in hospitals and emotional exhaustion. J Clin Nurs. 2010;19(11-12):1654–63.

Konstantinou AK, Bonotis K, Sokratous M, Siokas V, Dardiotis E. Burnout evaluation and potential predictors in a Greek cohort of mental health nurses. Arch Psychiatr Nurs. 2018;32(3):449–56.

Leiter MP, Maslach C. Nurse turnover: the mediating role of burnout. J Nurs Manag. 2009;17(3):331–9.

Van Bogaert P, Kowalski C, Weeks SM, Van Heusden D, Clarke SP. The relationship between nurse practice environment, nurse work characteristics, burnout and job outcome and quality of nursing care: a cross-sectional survey. Int J Nurs Stud. 2013;50(12):1667–77.

Janssen PP, Jonge JD, Bakker AB. Specific determinants of intrinsic work motivation, burnout and turnover intentions: a study among nurses. J Adv Nurs. 1999;29(6):1360–9.

Andela M, Truchot D, Van der Doef M. Job stressors and burnout in hospitals: the mediating role of emotional dissonance. Int J Stress Manag. 2016;23(3):298–317.

Levert T, Lucas M, Ortlepp K. Burnout in psychiatric nurses: contributions of the work environment and a Sense of Coherence. S Afr J Psychol. 2000;30(2):36–43.

Galletta M, Portoghese I, Ciuffi M, Sancassiani F, Aloja E, Campagna M. Working and environmental factors on job burnout: a cross-sectional study among nurses. Clin Pract Epidemiol Ment Health. 2016;12:132–41.

Kitaoka-Higashiguchi K. Burnout as a developmental process among Japanese nurses: investigation of Leiter’s model. Jpn J Nurs Sci. 2005;2(1):9–16.

Greenglass ER, Burke RJ, Fiksenbaum L. Workload and burnout in nurses. J Community Appl Soc Psychol. 2001;11(3):211–5.

Madathil R, Heck NC, Schuldberg D. Burnout in psychiatric nursing: examining the interplay of autonomy, leadership style, and depressive symptoms. Arch Psychiatr Nurs. 2014;28(3):160–6.

Lewis HS, Cunningham CJ. Linking nurse leadership and work characteristics to nurse burnout and engagement. Nurs Res. 2016;65(1):13–23.

Lu M, Ruan H, Xing W, Hu Y. Nurse burnout in China: a questionnaire survey on staffing, job satisfaction, and quality of care. J Nurs Manag. 2015;23(4):440–7.

Dhaini SR, Denhaerynck K, Bachnick S, Schwendimann R, Schubert M, De Geest S, et al. Work schedule flexibility is associated with emotional exhaustion among registered nurses in Swiss hospitals: a cross-sectional study. Int J Nurs Stud. 2018;82:99–105.

Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of hospital care environment on patient mortality and nurse outcomes. J Nurs Adm. 2008;38(5):223–9.

Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987–93.

Zhou W, He G, Wang H, He Y, Yuan Q, Liu D. Job dissatisfaction and burnout of nurses in Hunan, China: A cross-sectional survey. Nurs Health Sci. 2015;17(4):444–50.

Hanrahan NP, Aiken LH, McClaine L, Hanlon AL. Relationship between psychiatric nurse work environments and nurse burnout in acute care general hospitals. Issues Ment Health Nurs. 2010;31(3):198–207.

Liu X, Zheng J, Liu K, Baggs JG, Liu J, Wu Y, et al. Hospital nursing organizational factors, nursing care left undone, and nurse burnout as predictors of patient safety: a structural equation modeling analysis. Int J Nurs Stud. 2018;86:82–9.

Akman O, Ozturk C, Bektas M, Ayar D, Armstrong MA. Job satisfaction and burnout among paediatric nurses. J Nurs Manag. 2016;24(7):923–33.

Faller MS, Gates MG, Georges JM, Connelly CD. Work-related burnout, job satisfaction, intent to leave, and nurse-assessed quality of care among travel nurses. J Nurs Adm. 2011;41(2):71–7.

Boamah SA, Read EA, Spence Laschinger HK. Factors influencing new graduate nurse burnout development, job satisfaction and patient care quality: a time-lagged study. J Adv Nurs. 2017;73(5):1182–95.

Kanai-Pak M, Aiken LH, Sloane DM, Poghosyan L. Poor work environments and nurse inexperience are associated with burnout, job dissatisfaction and quality deficits in Japanese hospitals. J Clin Nurs. 2008;17(24):3324–9.

Leineweber C, Westerlund H, Chungkham HS, Lindqvist R, Runesdotter S, Tishelman C. Nurses’ practice environment and work-family conflict in relation to burn out: a multilevel modelling approach. PLoS One. 2014;9(5):e96991.

Article   PubMed   PubMed Central   CAS   Google Scholar  

Leiter MP, Spence Laschinger HK. Relationships of work and practice environment to professional burnout: testing a causal model. Nurs Res. 2006;55(2):137–46.

Adali E, Priami M, Evagelou H, Mougia V, Ifanti M, Alevizopoulos G. Burnout in psychiatric nursing personnel in Greek hospitals. European Journal of Psychiatry. 2003;17(3):173–81.

Cao X, Naruse T. Effect of time pressure on the burnout of home-visiting nurses: the moderating role of relational coordination with nursing managers. Jpn J Nurs Sci. 2019;16(2):221–31.

Jansen PG, Kerkstra A, Abu-Saad HH, van der Zee J. The effects of job characteristics and individual characteristics on job satisfaction and burnout in community nursing. Int J Nurs Stud. 1996;33(4):407–21.

Gandi JC, Wai PS, Karick H, Dagona ZK. The role of stress and level of burnout in job performance among nurses. Ment Health Fam Med. 2011;8(3):181–94.

PubMed   PubMed Central   Google Scholar  

Vidotti V, Ribeiro RP, Galdino MJQ, Martins JT. Burnout syndrome and shift work among the nursing staff. Rev Lat Am Enfermagem. 2018;26:e3022.

Shamian J, Kerr MS, Laschinger HK, Thomson D. A hospital-level analysis of the work environment and workforce health indicators for registered nurses in Ontario’s acute-care hospitals. Can J Nurs Res. 2002;33(4):35–50.

CAS   PubMed   Google Scholar  

Rouxel G, Michinov E, Dodeler V. The influence of work characteristics, emotional display rules and affectivity on burnout and job satisfaction: a survey among geriatric care workers. Int J Nurs Stud. 2016;62:81–9.

Colindres CV, Bryce E, Coral-Rosero P, Ramos-Soto RM, Bonilla F, Yassi A. Effect of effort-reward imbalance and burnout on infection control among Ecuadorian nurses. Int Nurs Rev. 2018;65(2):190–9.

Shao J, Tang L, Wang X, Qiu R, Zhang Y, Jia Y, et al. Nursing work environment, value congruence and their relationships with nurses’ work outcomes. J Nurs Manag. 2018;26(8):1091–9.

Moloney W, Boxall P, Parsons M, Cheung G. Factors predicting registered nurses’ intentions to leave their organization and profession: a job demands-resources framework. J Adv Nurs. 2018;74(4):864–75.

Anwar MM, Elareed HR. Burnout among Egyptian nurses. Journal of Public Health-Heidelberg. 2017;25(6):693–7.

Wisetborisut A, Angkurawaranon C, Jiraporncharoen W, Uaphanthasath R, Wiwatanadate P. Shift work and burnout among health care workers. Occup Med (Lond). 2014;64(4):279–86.

Article   CAS   Google Scholar  

Ilhan MN, Durukan E, Taner E, Maral I, Bumin MA. Burnout and its correlates among nursing staff: questionnaire survey. J Adv Nurs. 2008;61(1):100–6.

Canadas-De la Fuente GA, Vargas C, San Luis C, Garcia I, Canadas GR, De la Fuente EI. Risk factors and prevalence of burnout syndrome in the nursing profession. Int J Nurs Stud. 2015;52(1):240–9.

Bagheri Hosseinabadi M, Ebrahimi MH, Khanjani N, Biganeh J, Mohammadi S, Abdolahfard M. The effects of amplitude and stability of circadian rhythm and occupational stress on burnout syndrome and job dissatisfaction among irregular shift working nurses. J Clin Nurs. 2019;28(9-10):1868–78.

Khamisa N, Peltzer K, Ilic D, Oldenburg B. Work related stress, burnout, job satisfaction and general health of nurses: a follow-up study. Int J Nurs Pract. 2016;22(6):538–45.

Dall’Ora C, Griffiths P, Ball J, Simon M, Aiken LH. Association of 12 h shifts and nurses’ job satisfaction, burnout and intention to leave: findings from a cross-sectional study of 12 European countries. BMJ Open. 2015;5(9):e008331.

Stimpfel AW, Sloane DM, Aiken LH. The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. Health Aff (Millwood). 2012;31(11):2501–9.

Poncet MC, Toullic P, Papazian L, Kentish-Barnes N, Timsit JF, Pochard F, et al. Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med. 2007;175(7):698–704.

Stone PW, Du Y, Gershon RR. Organizational climate and occupational health outcomes in hospital nurses. J Occup Environ Med. 2007;49(1):50–8.

Bourbonnais R, Comeau M, Vezina M, Dion G. Job strain, psychological distress, and burnout in nurses. Am J Ind Med. 1998;34(1):20–8.

Basinska BA, Wilczek-Ruzyczka E. The role of rewards and demands in burnout among surgical nurses. Int J Occup Med Environ Health. 2013;26(4):593–604.

Garcia-Sierra R, Fernandez-Castro J, Martinez-Zaragoza F. Relationship between job demand and burnout in nurses: does it depend on work engagement? J Nurs Manag. 2016;24(6):780–8.

Laeeque SH, Bilal A, Babar S, Khan Z, Rahman SU. How patient-perpetrated workplace violence leads to turnover intention among nurses: the mediating mechanism of occupational stress and burnout. J Aggress Maltreat Trauma. 2018;27(1):96–118.

Laschinger HKS, Shamian J, Thomson D. Impact of magnet hospital characteristics on nurses’ perceptions of trust, burnout, quality of care, and work satisfaction. Nurs Econ. 2001;19(5):209–19.

Li B, Bruyneel L, Sermeus W, Van den Heede K, Matawie K, Aiken L, et al. Group-level impact of work environment dimensions on burnout experiences among nurses: a multivariate multilevel probit model. Int J Nurs Stud. 2013;50(2):281–91.

Van Bogaert P, Meulemans H, Clarke S, Vermeyen K, Van de Heyning P. Hospital nurse practice environment, burnout, job outcomes and quality of care: test of a structural equation model. J Adv Nurs. 2009;65(10):2175–85.

Laschinger HKS, Leiter MP. The impact of nursing work environments on patient safety outcomes - the mediating role of burnout/engagement. J Nurs Adm. 2006;36(5):259–67.

Garrett DK, McDaniel AM. A new look at nurse burnout: the effects of environmental uncertainty and social climate. J Nurs Adm. 2001;31(2):91–6.

Bobbio A, Bellan M, Manganelli AM. Empowering leadership, perceived organizational support, trust, and job burnout for nurses: a study in an Italian general hospital. Health Care Manag Rev. 2012;37(1):77–87.

Spence Laschinger HK, Wong CA, Grau AL. The influence of authentic leadership on newly graduated nurses’ experiences of workplace bullying, burnout and retention outcomes: a cross-sectional study. Int J Nurs Stud. 2012;49(10):1266–76.

Lee HF, Chiang HY, Kuo HT. Relationship between authentic leadership and nurses’ intent to leave: the mediating role of work environment and burnout. J Nurs Manag. 2019;27(1):52–65.

Kanste O, Kyngas H, Nikkila J. The relationship between multidimensional leadership and burnout among nursing staff. J Nurs Manag. 2007;15(7):731–9.

Lake ET. Development of the practice environment scale of the Nursing Work Index. Res Nurs Health. 2002;25(3):176–88.

Nantsupawat A, Kunaviktikul W, Nantsupawat R, Wichaikhum OA, Thienthong H, Poghosyan L. Effects of nurse work environment on job dissatisfaction, burnout, intention to leave. Int Nurs Rev. 2017;64(1):91–8.

Vahey DC, Aiken LH, Sloane DM, Clarke SP, Vargas D. Nurse burnout and patient satisfaction. Med Care. 2004;42(2 Suppl):II57–66.

Klopper HC, Coetzee SK, Pretorius R, Bester P. Practice environment, job satisfaction and burnout of critical care nurses in South Africa. J Nurs Manag. 2012;20(5):685–95.

Zhang LF, You LM, Liu K, Zheng J, Fang JB, Lu MM, et al. The association of Chinese hospital work environment with nurse burnout, job satisfaction, and intention to leave. Nurs Outlook. 2014;62(2):128–37.

Liu Y, Aungsuroch Y. Factors influencing nurse-assessed quality nursing care: a cross-sectional study in hospitals. J Adv Nurs. 2018;74(4):935–45.

Marques-Pinto A, Jesus EH, Mendes A, Fronteira I, Roberto MS. Nurses’ intention to leave the organization: a mediation study of professional burnout and engagement. Span J Psychol. 2018;21:E32.

Aiken LH, Sloane DM. Effects of organizational innovations in AIDS care on burnout among urban hospital nurses. Work Occup. 1997;24(4):453–77.

Spence Laschinger HK, Leiter M, Day A, Gilin D. Workplace empowerment, incivility, and burnout: impact on staff nurse recruitment and retention outcomes. J Nurs Manag. 2009;17(3):302–11.

Dutra HS, Cimiotti JP, Guirardello EB. Nurse work environment and job-related outcomes in Brazilian hospitals. Appl Nurs Res. 2018;41:68–72.

Laschinger HK. Job and career satisfaction and turnover intentions of newly graduated nurses. J Nurs Manag. 2012;20(4):472–84.

Estryn-Behar M, Van der Heijden BI, Oginska H, Camerino D, Le Nezet O, Conway PM, et al. The impact of social work environment, teamwork characteristics, burnout, and personal factors upon intent to leave among European nurses. Med Care. 2007;45(10):939–50.

Basar U, Basim N. A cross-sectional survey on consequences of nurses’ burnout: moderating role of organizational politics. J Adv Nurs. 2016;72(8):1838–50.

Van Bogaert P, Timmermans O, Weeks SM, van Heusden D, Wouters K, Franck E. Nursing unit teams matter: impact of unit-level nurse practice environment, nurse work characteristics, and burnout on nurse reported job outcomes, and quality of care, and patient adverse events--a cross-sectional survey. Int J Nurs Stud. 2014;51(8):1123–34.

Firth H, Britton P. Burnout, absence and turnover amongst British nursing staff. J Occup Psychol. 1989;62(1):55–9.

Giorgi F, Mattei A, Notarnicola I, Petrucci C, Lancia L. Can sleep quality and burnout affect the job performance of shift-work nurses? A hospital cross-sectional study. J Adv Nurs. 2018;74(3):698–708.

Tourigny L, Baba VV, Wang XY. Burnout and depression among nurses in Japan and China: the moderating effects of job satisfaction and absence. Int J Hum Resour Manag. 2010;21(15):2741–61.

Johnson J, Louch G, Dunning A, Johnson O, Grange A, Reynolds C, et al. Burnout mediates the association between depression and patient safety perceptions: a cross-sectional study in hospital nurses. J Adv Nurs. 2017;73(7):1667–80.

Nantsupawat A, Nantsupawat R, Kunaviktikul W, Turale S, Poghosyan L. Nurse burnout, nurse-reported quality of care, and patient outcomes in Thai hospitals. J Nurs Scholarsh. 2016;48(1):83–90.

Poghosyan L, Clarke SP, Finlayson M, Aiken LH. Nurse burnout and quality of care: cross-national investigation in six countries. Res Nurs Health. 2010;33(4):288–98.

Zarei E, Khakzad N, Reniers G, Akbari R. On the relationship between safety climate and occupational burnout in healthcare organizations. Saf Sci. 2016;89:1–10.

Halbesleben JR, Wakefield BJ, Wakefield DS, Cooper LB. Nurse burnout and patient safety outcomes: nurse safety perception versus reporting behavior. West J Nurs Res. 2008;30(5):560–77.

Teng CI, Shyu YI, Chiou WK, Fan HC, Lam SM. Interactive effects of nurse-experienced time pressure and burnout on patient safety: a cross-sectional survey. Int J Nurs Stud. 2010;47(11):1442–50.

Cimiotti JP, Aiken LH, Sloane DM, Wu ES. Nurse staffing, burnout, and health care-associated infection. Am J Infect Control. 2012;40(6):486–90.

Antonakis J, Bendahan S, Jacquart P, Lalive R. On making causal claims: a review and recommendations. Leadersh Q. 2010;21(6):1086–120.

Maben J, Latter S, Clark JM. The sustainability of ideals, values and the nursing mandate: evidence from a longitudinal qualitative study. Nurs Inq. 2007;14(2):99–113.

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Studies’ settings, sample sizes, burnout and correlates measurement, and appraisal of quality.

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Interventions to reduce burnout among clinical nurses: systematic review and meta-analysis

• Miran Lee   ORCID: orcid.org/0000-0002-6920-9537 1 &
• Chiyoung Cha   ORCID: orcid.org/0000-0003-0115-1348 2  

Scientific Reports volume  13 , Article number:  10971 ( 2023 ) Cite this article

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Sporadic evidence exists for burnout interventions in terms of types, dosage, duration, and assessment of burnout among clinical nurses. This study aimed to evaluate burnout interventions for clinical nurses. Seven English databases and two Korean databases were searched to retrieve intervention studies on burnout and its dimensions between 2011 and 2020.check Thirty articles were included in the systematic review, 24 of them for meta-analysis. Face-to-face mindfulness group intervention was the most common intervention approach. When burnout was measured as a single concept, interventions were found to alleviate burnout when measured by the ProQoL (n = 8, standardized mean difference [SMD] = − 0.654, confidence interval [CI] =  − 1.584, 0.277, p < 0.01, I 2  = 94.8%) and the MBI (n = 5, SMD = − 0.707, CI = − 1.829, 0.414, p < 0.01, I 2  = 87.5%). The meta-analysis of 11 articles that viewed burnout as three dimensions revealed that interventions could reduce emotional exhaustion (SMD = − 0.752, CI = − 1.044, − 0.460, p < 0.01, I 2  = 68.3%) and depersonalization (SMD = − 0.822, CI = − 1.088, − 0.557, p < 0.01, I 2  = 60.0%) but could not improve low personal accomplishment. Clinical nurses' burnout can be alleviated through interventions. Evidence supported reducing emotional exhaustion and depersonalization but did not support low personal accomplishment.

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Introduction.

Burnout, first described by Freudenberger 1 , is a negative condition characterized by the gradual depletion of physical, emotional, and mental energy due to excessive work 2 . Maslach (1976) later conceptualized burnout as a multidimensional syndrome characterized by emotional exhaustion, depersonalization, and diminished personal commitment 3 . Burnout occurs during the maintenance of interpersonal relationships and is most prevalent in the fields of nursing, medicine, and education, which deal directly with many people 3 .

Nursing is an occupation that experiences one of the highest rates of burnout 4 . Nurse burnout is defined as a physical, psychological, emotional, and socially exhausted status caused by unsuccessfully managed job stress and limited social support 5 . The globally pooled prevalence of nurse burnout is 11.2% 6 . However, in other studies classifying burnout symptoms, nurse burnout was as high as 40.0% 7 , 8 . Moreover, nurse burnout in the post-COVID-19 pandemic era has worsened. In a recent study, nurse burnout was as high as 68.0% 9 .

The factors that contribute to burnout are diverse and intricate. Occupational stress is the most influential factor 10 . The causes of nurse burnout were excessive workload; lack of staffing; role conflict; low autonomy; time pressure; interpersonal conflict between patients, guardians, and medical staff; and absence of leadership support 11 . Burnout can have a significant impact on the group and the organization, so prevention and action are required 2 . The impact of nurse burnout is significant in that it not only negatively influences nurses but also patients and healthcare organizations 5 . Nurse burnout is associated with low-quality care, a threat to patient safety 12 , medication error 13 , and an extended patient hospital stay 14 . Nurses who experience burnout have physical symptoms, such as headache, fatigue, hypertension, and musculoskeletal problems 5 , and psychological symptoms, such as depression, sleep disorders, and difficulty concentrating 15 . Exhausted nurses may also experience behavioral disorders that negatively affect their health, such as smoking and drinking alcohol 5 . Nurse burnout might lead to the turnover 16 and a subsequent burden to healthcare organizations 11 .

Nurse burnout has been a frequently investigated topic owing to its high prevalence and detrimental impact. However, systematic reviews and meta-analysis studies were focused on the description of the nurse burnout phenomenon such as the prevalence of nurse burnout 7 , burnout level and risk factors 17 , and burnout-related factors in nurses 18 . Previous systematic reviews or meta-analysis studies that evaluated the effects of burnout programs were limited to mindfulness training 19 and coping strategies 20 . However, various programs, such as yoga, communication skills, stress management, mindfulness, meditation, and cognitive behavioral therapy, were implemented independently or in combination, and the level of evidence varied 21 , 22 . Nurse burnout interventions should be evaluated inclusively to understand their current effectiveness in reducing burnout among nurses. Previously conducted systematic reviews and meta-analyses on burnout interventions inclusively evaluated health professionals, which included nurses and medical doctors as participants 22 , 23 . However, nurses and medical doctors have different job descriptions 24 and different patterns of burnout 25 . Accordingly, to retrieve evidence for nurse burnout programs, the analysis should be refined to interventions specifically designed and implemented for nurses.

Furthermore, burnout has been measured in many ways. Burnout could be measured as a single concept 26 , 27 , 28 , though it is often measured as three dimensions based on the International Classification of Disease-11 (ICD-11). The most frequently used measure is the Maslach Burnout Inventory (MBI), which lists three areas of burnout: emotional exhaustion, depersonalization, and low personal accomplishment 23 , 29 . Some studies used the total score of the MBI and others used the three areas of burnout with some variations 30 , 31 . To be inclusive, burnout interventions should be evaluated by including studies that used burnout as a single concept and as three dimensions. Per this understanding, we aimed to analyze burnout interventions for clinical nurses.

This study is a systematic review and meta-analysis study on the effects of burnout reduction programs for clinical nurses. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline 32 .

Eligibility criteria

We used the PICO-SD (Population, Interventions, Comparison, Outcome—Study Design) framework to organize our research question: What is the effect of an intervention on reducing burnout among clinical nurses? Detailed information regarding the eligibility criteria is described in Table 1 . We selected articles published between 2011 and 2020 to yield results that reflected the reality of burnout intervention effects.

Search strategies

Nine search engines were utilized: seven global search engines in English (PubMed, CINAHL, PsycINFO, Scopus, ProQuest Dissertations & Theses (PQDT) Global, EBSCO, and Cochrane Library) and two domestic search engines in Korean (RISS, KISS). The search terms were “nurse*” and “burnout” and a combination of (Nurses OR nurse* OR registered nurse* OR healthcare provider* OR nursing staff OR healthcare worker* OR health care provider* OR health care worker* OR health personnel* OR health professional*) AND (burnout OR burn-out OR burn out) AND (treatment* OR intervention* OR program* OR therapy OR training OR exercise* OR practice* OR mindfulness OR meditation OR massage OR yoga).

Study selection and data extraction

Endnote 20.0 was used to manage retrieved studies and screen the redundant ones. After retrieval of the studies, titles and abstracts were reviewed to remove irrelevant studies. A full-text review of the studies was conducted afterward. Throughout the process, we worked independently and met weekly to discuss the process and select the studies.

Risk-of-bias assessment

To evaluate the risk of bias, we used the Cochrane’s Risk of Bias 2.0 (RoB 2.0) for the randomized controlled trials and Risk of Bias in Non-randomized Studies of Interventions (RoBINS-I) for the quasi-experimental studies. Discrepancies were resolved through discussion. In addition, a funnel plot was utilized to evaluate the possibility of publication bias.

Data synthesis and meta-analysis

For the systematic review, tables were used to classify article contents for descriptive analyses. For the meta-analysis, the R-4.1.1 program for Windows was used. In 16 articles, burnout was measured as a single concept using various instruments, while in 11 articles, burnout was measured as three dimensions: emotional exhaustion, depersonalization, and low personal accomplishment. Meta-analysis was conducted with the fixed effect model and the random effect model with 95% confidence interval, pooled mean differences, and weight of each article for each meta-analysis. The heterogeneity of the articles was calculated using the I 2 index. This research was exempted after review by the institutional review board at the institution of the principal investigator.

Study selection

We retrieved 5271 articles from the initial search. After reviewing the title and abstract, 5188 were excluded (duplicates, no intervention study, no comparison group, not target population). During the full-text review, 59 articles were excluded (no full-text, duplicates, no intervention study, no comparison group, not target population). Through reference check, six articles were included. Finally, 30 articles were included in our final analysis (Fig.  1 ).

Study selection.

Study characteristics

The characteristics of studies and interventions are described in Table 2 . Of the 30 articles, 12 were randomized controlled trials 26 , 28 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 and 18 were quasi-experimental studies 27 , 30 , 31 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 . Nineteen studies were conducted in Asia (Korea = 14, China = 3, India = 1, and Japan = 1). The types of publication were journals (n = 26) and thesis (n = 4). Participants were mostly women, with the female gender ranging from 71.9 to 100%. The age range of the participants was 24–46 years. There were between 21 and 296 participants, for a total of 1935, with 975 in the experimental group and 960 in the control group.

The most common interventions provided for burnout reduction were mindfulness-based stress reduction programs (n = 5) and face-to-face group format (n = 24). The duration of the intervention varied from one day to eight months. In most studies, control groups involved the waitlist group (n = 12) rather than an active control group. MBI (n = 19), ProQoL (n = 8) and others (n = 3) were the instruments used to measure burnout. Burnout was most often measured twice, before the intervention and immediately post-intervention. In three studies 37 , 38 , 44 , burnout was measured at baseline and follow-up only, not immediately post-intervention.

Risk-of-bias

Risk-of-bias is described in Table 2 . In general, the level of risk of bias for 12 randomized controlled trials was “some concern.” The level of risk of bias for the 18 quasi-experimental studies was “low risk of bias” for 15 studies, “moderate risk of bias” for two studies, and non-assessable due to limited information for one study.

The risk of publication bias was evaluated using a funnel plot (Fig.  2 ). The plot is symmetrical when publication bias is at minimum 58 . Studies with a small sample size were on the lower side, while those with a large sample size were on the opposite side. The small number of articles used in our study was a risk factor because it could affect the precision of the results. Among 30 articles, three articles 37 , 38 , 44 that did not conduct a post-test were excluded for meta-analysis. Sixteen articles measured burnout as a single concept 26 , 27 , 28 , 31 , 34 , 35 , 40 , 45 , 46 , 47 , 49 , 50 , 51 , 52 , 54 , 56 and 11 measured burnout as three dimensions: emotional exhaustion, depersonalization, and low personal accomplishment 30 , 33 , 36 , 39 , 41 , 42 , 43 , 48 , 53 , 55 , 57 . There was one outlier among articles that measured burnout as a single concept.

Funnel plots.

Meta-analysis

Instruments that measured burnout as a single concept were ProQoL (n = 8), MBI (n = 5), burnout questionnaire (n = 2), and OLBI (n = 1). Meta-analysis of articles that used ProQoL and MBI are described in Fig.  3 . For the articles that used ProQoL, the pooled analysis showed that intervention could statistically alleviate burnout (SMD = − 0.654, CI = − 1.584, 0.277, p < 0.01, I 2  = 94.8%). For the articles that used the MBI, the pooled analysis showed that intervention could statistically alleviate burnout (SMD = − 0.707, CI = − 1.829, 0.414, p < 0.01, I 2  = 87.5%).

Forest plots: Effect of interventions on burnout measured by ProQoL and MBI.

The meta-analysis of burnout interventions as three dimensions (n = 11) is described in Fig.  4 . The pooled analysis showed that interventions could statistically significantly reduce emotional exhaustion (SMD = − 0.752, CI = − 1.044, − 0.460, p < 0.01, I 2  = 68.3%) and depersonalization (SMD = − 0.822, CI = − 1.085, − 0.560, p < 0.01, I 2  = 60.0%). For improving low personal accomplishment, the pooled analysis result was not statistically significant.

Forest plots: effect of intervention on emotional exhaustion and depersonalization.

In this systematic review and meta-analysis, we analyzed 30 and 24 articles, respectively. Among 30 articles, more than half (n = 19) were published in Asia. Although nurse burnout is a global phenomenon, the prevalence of nurse burnout studies conducted in Asia might indicate the significance of the issue of nurse burnout in Asian countries. This notion is supported by a recent meta-analysis study on the global prevalence of nurse burnout, which reported that Southeast Asia and the Pacific region had a significantly higher prevalence of nurse burnout among si× global regions 6 . In Asia, nurses encounter poor working conditions such as low nurse patient ratios 59 and a rapidly aging population. High prevalence of nurse burnout in Asian countries might have drawn the nurse administrators and nursing scholars to research on nurse burnout interventions.

Our systematic review revealed that a mindfulness-based program was the most frequently used intervention for nurse burnout. Meta-analysis studies 19 have shown that mindfulness-based programs are effective in reducing nurse burnout. However, burnout refers to a state of physical, mental, and social exhaustion that may require various interventions. A systematic review of health professional burnout programs revealed that a vast array of interventions have been adopted alone or in combination 24 . Although mindfulness-based programs are helpful in lowering burnout level, their role might be limited to managing burnout rather than preventing or managing situations for burnout 60 . In many cases, the causes of burnout are multifaceted, which include but are not limited to issues with limited manpower, working longer shifts, not having schedule flexibility, and responding to high work and psychological demands 11 . Systematic support to improve work environments and tailored programs to train nurses to prevent repeated situations are needed.

All articles were appraised for risk of bias. The most concerning realm for risk of bias in both the randomized controlled trials and quasi-experimental studies was bias in the measurement of outcomes that were appraised as “some concern” or “moderate risk of bias.” As burnout is a subjective concept, all the interventions used a self-reported survey to measure the outcome, leading to a moderate risk of bias. To overcome this, biological indicators for burnout could be utilized. However, we would like to note that people are experts in their own feelings and psychological health. In measuring psychological concepts such as burnout, the concept of risk of bias should be re-assessed.

In our meta-analysis of articles that measured burnout as a single concept with ProQoL and MBI, the results favored intervention. Similarly, results of previous meta-analyses of various burnout interventions provided to health professionals reported that burnout could be reduced 23 . In this study, the authors argued that various factors, such as coping strategies, emotional regulation skills, and resilience, were enhanced through diverse burnout interventions and bridged health professionals’ burnout to wellness. Likewise, various programs could be utilized solitarily or in combination to reduce nurse burnout.

When burnout was measured as three dimensions, emotional exhaustion and depersonalization were lowered, leaving no evidence for increasing low personal accomplishment. In contrast, a recent meta-analysis study on burnout intervention for primary healthcare professionals reported that interventions had beneficial effects on all three dimensions of burnout, including low personal accomplishment 61 . In the previous meta-analysis study, 78.5% of the participants were physicians, while only 20.1% were nurses. This was one of the most significant differences between the studies. The nature of the profession in achieving personal accomplishment may explain the differences in intervention effect on low personal accomplishment. Personal accomplishment for nurses may be more closely tied to a workplace system. For instance, a study that measured personal accomplishment found that it was positively correlated with aspects of the workplace such as control, community, fairness, and values 62 . In accordance with this argument, a meta-analysis that examined the long-term effect of burnout intervention on nurses found that improvement in low personal accomplishment lasted only six months, whereas improvement in emotional exhaustion and depersonalization lasted a year 20 . The authors of this study also explained that low personal accomplishment is difficult to change in the long term because it is reliant on the work environment. Another possible reason for the burnout intervention not favoring low personal accomplishment might be owing to the contents of the intervention focusing on problem-solving skills, such as stress reduction, coping with the problem, and empowering the participants, which are helpful for emotional exhaustion and depersonalization.

Implications for future research are suggested as follows. This study revealed that the majority of burnout interventions for clinical nurses were delivered as face-to-face group programs, which could be challenging to implement during a pandemic such as COVID-19. Combining online and offline burnout programs may be an option for reducing the risk of infection. Despite the fact that clinical nurses benefit from burnout programs, they may require consistent support and feedback to continue the program 63 . Continual active feedback may be necessary for the implementation and maintenance of the burnout program for clinical nurses. A number of scholars view burnout as three dimensions in line with the ICD-11 definition of burnout and meta-analysis studies on the prevalence and risk factors for burnout explained burnout as three dimensions 6 , 64 , meaning there is ample evidence on the dimensions of burnout. However, when examining the effect of burnout interventions, burnout is often measured as a single concept. Burnout interventions should be designed to target all three areas. Additionally, more time and effort might be needed to promote personal accomplishment.

Limitations

In this study, we focused on nurses providing direct care in hospitals, excluding those who worked in outpatient clinics. Thus, our findings are limited to clinical nurses. The articles’ language was limited to English and Korean, half of which were in Korean. In addition, we limited our search to the past 10 years to reflect the reality of the burnout intervention effect, which may have caused selection bias. When the risk of bias was appraised, we identified some concerns, including moderate concerns. In addition, articles analyzed in this study used different instruments to measure burnout. We acknowledge the heterogeneity of the data, which is assumed by meta-analysis study. Thus, readers of this article should be aware of the risk of bias in the results and heterogeneity of the articles in instruments. The protocol of this systematic review and meta-analysis was not registered.

Conclusions

Thirty articles were included in the systematic review and 24 in the meta-analysis. Most of the evidence for nurse burnout was based on face-to-face group programs, which could be transformed into a virtual space in the post-COVID-19 era. Pooled analysis suggested that interventions could reduce burnout when measured as a single concept and reduce the emotional exhaustion and depersonalization dimensions of burnout. However, we could not find evidence for burnout interventions effectively promoting personal accomplishment.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to the IRB restriction but are available from the corresponding author on reasonable request.

Abbreviations

Confidence interval

International Classification of Disease-11

Maslach Burnout Inventory

Not available

Oldenburg Burnout Inventory

Professional Quality of Life Scale

Randomized controlled trial

Standardized mean difference

Freudenberger, H. J. Staff burn-out. J. Soc. Issues 30 (1), 159–165 (1974).

Article   Google Scholar  

Stamm, B. H. The Concise ProQOL Manual . In Pocatello: ProQOL.org (2010).

Maslach, C. Burned-out. Hum. Behav. 5 (9), 16–22 (1976).

Google Scholar  

Kim, S. H. & Yang, Y. S. A Meta analysis of variables related to Burnout of nurse in Korea. J. Dig. Converg. 13 (8), 387–400 (2015).

Nabizadeh-Gharghozar, Z., Adib-Hajbaghery, M. & Bolandianbafghi, S. Nurses’ job burnout: A hybrid concept analysis. J. Caring Sci. 9 (3), 154–161 (2020).

Article   PubMed   PubMed Central   Google Scholar  

Woo, T., Ho, R., Tang, A. & Tam, W. Global prevalence of burnout symptoms among nurses: A systematic review and meta-analysis. J. Psychiatr. Res. 123 , 9–20 (2020).

Article   PubMed   Google Scholar  

Pradas-Hernández, L. et al. Prevalence of burnout in paediatric nurses: A systematic review and meta-analysis. PLoS ONE 13 (4), e0195039 (2018).

Ramirez-Baena, L. et al. A multicentre study of burnout prevalence and related psychological variables in medical area hospital nurses. J. Clin. Med. 8 (1), 92 (2019).

Bruyneel, A., Smith, P., Tack, J. & Pirson, M. Prevalence of burnout risk and factors associated with burnout risk among ICU nurses during the COVID-19 outbreak in French speaking Belgium. Intensive Crit. Care Nurs. 65 , 103059 (2021).

Morgantini, L. A. et al. Factors contributing to healthcare professional burnout during the COVID-19 pandemic: A rapid turnaround global survey. PLoS ONE 15 (9), e0238217 (2020).

Article   CAS   PubMed   PubMed Central   Google Scholar  

Dall’Ora, C., Ball, J., Reinius, M. & Griffiths, P. Burnout in nursing: A theoretical review. Hum. Resour. Health 18 (1), 41 (2020).

Salyers, M. P. et al. The relationship between professional burnout and quality and safety in healthcare: A meta-analysis. J. Gen. Intern. Med. 32 (4), 475–482 (2017).

Montgomery, A. P. et al. Nurse burnout predicts self-reported medication administration errors in acute care hospitals. J. Healthc. Qual. 43 (1), 13–23 (2021).

Nantsupawat, A., Nantsupawat, R., Kunaviktikul, W., Turale, S. & Poghosyan, L. Nurse burnout, nurse-reported quality of care, and patient outcomes in Thai hospitals. J. Nurs. Scholarsh. 48 (1), 83–90 (2016).

Rudman, A., Arborelius, L., Dahlgren, A., Finnes, A. & Gustavsson, P. Consequences of early career nurse burnout: A prospective long-term follow-up on cognitive functions, depressive symptoms, and insomnia. EClinical Med. 27 , 100565 (2020).

Ashrafi, Z., Ebrahimi, H., Khosravi, A., Navidian, A. & Ghajar, A. The relationship between quality of work life and burnout: A linear regression structural-equation modeling. Health Scope 7 (1), e68266 (2018).

Molina-Praena, J. et al. Levels of burnout and risk factors in medical area nurses: A meta-analytic study. Int. J. Environ. Res. Public Health 15 (12), 2800 (2018).

Deldar, K., Froutan, R., Dalvand, S., Gheshlagh, R. G. & Mazloum, S. R. The relationship between resiliency and burnout in Iranian nurses: A systematic review and meta-analysis. Open Access Maced J. Med. Sci. 6 (11), 2250–2256 (2018).

Suleiman-Martos, N. et al. The effect of mindfulness training on burnout syndrome in nursing: A systematic review and meta-analysis. J. Adv. Nurs. 76 (5), 1124–1140 (2020).

Lee, H. F., Kuo, C. C., Chien, T. W. & Wang, Y. R. A meta-analysis of the effects of coping strategies on reducing nurse burnout. Appl. Nurs. Res. 31 , 100–110 (2016).

de-Oliveira, S. M., de-Alcantara-Sousa, L. V., Vieira-Gadelha, M. D. S. & do-Nascimento, V. B. Prevention actions of burnout syndrome in nurses: An integrating literature review. Clin. Pract. Epidemiol. Ment. Health 15 , 64–73 (2019).

Aryankhesal, A. et al. Interventions on reducing burnout in physicians and nurses: A systematic review. Med. J. Islam Repub. Iran 33 , 77 (2019).

PubMed   PubMed Central   Google Scholar  

Zhang, X. J., Song, Y., Jiang, T., Ding, N. & Shi, T. Y. Interventions to reduce burnout of physicians and nurses: An overview of systematic reviews and meta-analyses. Medicine 99 (26), e20992 (2020).

O’Leary, K. J., Sehgal, N. L., Terrell, G., Williams, M. V., High Performance Teams and the Hospital of the Future Project Tea. Interdisciplinary teamwork in hospitals: A review and practical recommendations for improvement. J. Hosp. Med. 7 (1), 48–54 (2012).

Dubale, B. W. et al. Systematic review of burnout among healthcare providers in sub-Saharan Africa. BMC Public Health 19 (1), 1–20 (2019).

Dincer, B. & Inangil, D. The effect of emotional freedom techniques on nurses’ stress, anxiety, and burnout levels during the COVID-19 pandemic: A randomized controlled trial. Explore. 17 (2), 109–114 (2021).

Kim, H. R. & Yoon, S. H. Effects of group rational emotive behavior therapy on the nurses’ job stress, burnout, job satisfaction, organizational commitment and turnover intention. J. Korean Acad. Nurs. 48 (4), 432–442 (2018).

Rajeswari, H., Sreelekha, B. K., Nappinai, S., Subrahmanyam, U. & Rajeswari, V. Impact of accelerated recovery program on compassion fatigue among nurses in South India. Iran. J. Nurs. Midwifery Res. 25 (3), 249 (2020).

Maslach, C., Jackson, S. E. & Leiter, M. P. Maslach Burnout Inventory, Manual 3rd edn. (Consulting Psychologists Press, 1996).

Bagheri, T., Fatemi, M. J., Payandan, H., Skandari, A. & Momeni, M. The effects of stress-coping strategies and group cognitive-behavioral therapy on nurse burnout. Ann. Burns Fire Disasters 32 (3), 184 (2019).

CAS   PubMed   PubMed Central   Google Scholar  

Jang, O. J., Ryu, U. J. & Song, H. J. The effects of a group art therapy on job stress and burnout among clinical nurses in oncology units. J. Korean Clin. Nurs. Res. 21 (3), 366–376 (2015).

Page, M. J. et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. Int. J. Surg. 88 , 105906 (2021).

Alexander, G. K., Rollins, K., Walker, D., Wong, L. & Pennings, J. Yoga for self-care and burnout prevention among nurses. Workplace Health Saf. 63 (10), 462–470 (2015).

Berger, R. & Gelkopf, M. An intervention for reducing secondary traumatization and improving professional self-efficacy in well baby clinic nurses following war and terror: A random control group trial. Int. J. Nurs. Stud. 48 (5), 601–610 (2011).

Kharatzadeh, H., Alavi, M., Mohammadi, A., Visentin, D. & Cleary, M. Emotional regulation training for intensive and critical care nurses. Nurs. Health Sci. 22 (2), 445–453 (2020).

Kil, K. H. & Song, Y. S. Effects on psychological health of nurses in tertiary hospitals by applying a self-cosmetology training program. J. Korean Soc. Cosm. 22 (6), 1444–1453 (2016).

Kubota, Y. et al. Effectiveness of a psycho-oncology training program for oncology nurses: A randomized controlled trial. Psychooncology 25 (6), 712–718 (2016).

Özbaş, A. A. & Tel, H. The effect of a psychological empowerment program based on psychodrama on empowerment perception and burnout levels in oncology nurses: Psychological empowerment in oncology nurses. Palliat Support Care 14 (4), 393–401 (2016).

Redhead, K., Bradshaw, T., Braynion, P. & Doyle, M. An evaluation of the outcomes of psychosocial intervention training for qualified and unqualified nursing staff working in a low-secure mental health unit. J. Psychiatr. Ment. Health Nurs. 18 (1), 59–66 (2011).

Article   CAS   PubMed   Google Scholar  

Shin, Y. K., Lee, S. Y., Lee, J. M., Kang, P. & Seol, G. H. Effects of short-term inhalation of patchouli oil on professional quality of life and stress levels in emergency nurses: A randomized controlled trial. J. Altern. Complement Med. 26 (11), 1032–1038 (2020).

Wei, R., Ji, H., Li, J. & Zhang, L. Active intervention can decrease burnout in ED nurses. J. Emerg. Nurs. 43 (2), 145–149 (2017).

Xie, C. et al. Educational intervention versus mindfulness-based intervention for ICU nurses with occupational burnout: A parallel, controlled trial. Complement Ther. Med. 52 , 102485 (2020).

Ahn, M. N. The effect of mindfulness-based stress reduction program on nurse's stress, burnout, sleep and happiness. Master’s thesis, Eulji University (Daejeon, 2017).

Alenezi, A., McAndrew, S. & Fallon, P. Burning out physical and emotional fatigue: Evaluating the effects of a programme aimed at reducing burnout among mental health nurses. Int. J. Ment. Health Nurs. 28 (5), 1045–1055 (2019).

Bae, H. J. & Eun, Y. Effects of mindfulness-based stress reduction program for small and medium sized hospital nurses. Korean J. Stress Res. 27 (4), 455–463 (2019).

Choi, K. H., Kwon, S. & Hong, M. The effect of an empowerment program for advanced beginner hospital nurses. J. Korean Data Anal. Soc. 18 (2), 1079–1092 (2016).

Duarte, J. & Pinto-Gouveia, J. Effectiveness of a mindfulness-based intervention on oncology nurses’ burnout and compassion fatigue symptoms: A non-randomized study. Int. J. Nurs. Stud. 64 , 98–107 (2016).

Felker, A. J. An Examination of yoga as a stress reduction intervention for nurses. Doctoral dissertation, Walden University (Minnesota, 2013).

Jang, Y. M. Development and evaluation of nurse's workplace mutual respect program, Doctoral dissertation, Eulji University (Daejeon, 2019).

Kang, H. J. & Bang, K. S. Development and evaluation of a self-reflection program for intensive care unit nurses who have experienced the death of pediatric patients. J. Korean Acad. Nurs. 47 (3), 392–405 (2017).

Kim, Y. A. & Park, J. S. Development and application of an overcoming compassion fatigue program for emergency nurses. J. Korean Acad. Nurs. 46 (2), 260–270 (2016).

Lee, S. M. & Sung, K. M. The effects of violence coping program based on middle-range theory of resilience on emergency room nurses’ resilience, violence coping, nursing competency and burnout. J. Korean Acad. Nurs. 47 (3), 332–344 (2017).

Luo, Y. H. et al. An evaluation of a positive psychological intervention to reduce burnout among nurses. Arch. Psychiatr. Nurs. 33 (6), 186–191 (2019).

Rhee, J. S., Kim, S. H., Lee, W. K. & Shin, J. G. The effects of MBSR(Mindfulness based stress reduction) program on burnout of psychiatric nurses: Pilot study. J. Korean Assoc. Soc. Psychiatry 17 (1), 25–31 (2012).

Sabancıogullari, S. & Dogan, S. Effects of the professional identity development programme on the professional identity, job satisfaction and burnout levels of nurses: A pilot study. Int. J. Nurs. Pract. 21 (6), 847–857 (2015).

Yoo, D. Effect of an expressive writing program on professional quality of life and resilience of intensive care unit nurses. In Master’s thesis, Cha University (Gyeonggi, 2017).

Yoon, H. S. Effects of the happy arts therapy program to psychological well-being and emotional exhaust in nurse practitioners. Off. J. Korean Soc. Dance Sci. 29 (29), 53–74 (2013).

Field, A. P. & Gillett, R. How to do a meta-analysis. Br. J. Math. Stat. Psychol. 63 (3), 665–694 (2010).

Article   MathSciNet   PubMed   Google Scholar  

Drennan, V. M. & Ross, F. Global nurse shortages: The facts, the impact and action for change. Br. Med. Bull. 130 (1), 25–37 (2019).

Green, A. A. & Kinchen, E. V. The effects of mindfulness meditation on stress and burnout in nurses. J. Holist. Nurs. 39 (4), 356–368 (2021).

Salvado, M., Marques, D. L., Pires, I. M. & Silva, N. M. Mindfulness-based interventions to reduce burnout in primary healthcare professionals: A systematic review and meta-analysis. Healthcare (Basel, Switzerl.) 9 (10), 1342 (2021).

Whittington, K. D., Shaw, T., McKinnies, R. C. & Collins, S. K. Promoting personal accomplishment to decrease nurse burnout. Nurse Lead. 19 (4), 416–420 (2021).

Wu, X., Hayter, M., Lee, A. J. & Zhang, Y. Nurses’ experiences of the effects of mindfulness training: A narrative review and qualitative meta-synthesis. Nurse Educ. Today 100 , 104830 (2021).

Galanis, P., Vraka, I., Fragkou, D., Bilali, A. & Kaitelidou, D. Nurses’ burnout and associated risk factors during the COVID-19 pandemic: A systematic review and meta-analysis. J. Adv. Nurs. 77 (8), 3286–3302 (2021).

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This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (No. 2021R1A2C2008166).

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C.C. envisioned the systematic review and drafted the manuscript. C.C. and M.L. are involved in data search and assessing articles for eligibility and the risk of bias. C.C. and M.L. read and approved the final version of the manuscript. C.C. and M.L. wrote the manuscript together (M.L. was mainly in charge of the background and discussion and C.C. was mainly involved in the method and discussion). All authors reviewed and revised the manuscript.

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Lee, M., Cha, C. Interventions to reduce burnout among clinical nurses: systematic review and meta-analysis. Sci Rep 13 , 10971 (2023). https://doi.org/10.1038/s41598-023-38169-8

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DOI : https://doi.org/10.1038/s41598-023-38169-8

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The Impact of Resiliency on Nurse Burnout: An Integrative Literature Review

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In this literature review, the correlation between resiliency and nurse burnout is analyzed, and strategies to increase resiliency are identified. By identifying contributing factors associated with burnout and high-risk work environments, healthcare leaders can implement strategies to build resiliency and prevent burnout.

To develop programs that support nurses with needed resources and tools to overcome adversity, nurse leaders should understand the challenges nurses face and how they respond to these challenges. The goal of this integrative review is to identify causes of nurse burnout, characteristics of nurses with high resiliency, and strategies to increase resiliency in nurses.

The following questions were used to guide the review:

* What factors contribute to nurse burnout?

* Is there a relationship between nurse burnout and resiliency?

* What characteristics are present in nurses with high resiliency?

* What strategies can nurses implement to increase their resiliency?

* What strategies and programs can organizational leaders implement to increase resiliency among nurses?

Estimates suggest the nursing shortage will reach 260,000-400,000 by 2025 (Lowe, 2013). Nursing turnover has contributed substantially to the current shortage, with nursing schools unable to meet the demand of the healthcare market (Cochran, 2017). Recent research has investigated why nurses leave the profession and what qualities are present in nurses who continue to work in high-intensity settings (Foureur, Besley, Burton, Yu, & Crisp, 2013; Kutluturkan, Sozeri, Uysal, & Bay, 2016; McDonald, Jackson, Wilkes, & Vickers, 2013; Mealer et al., 2014; Mealer, Jones, & Meek, 2017; Mroz, 2015; Potter et al., 2013; Rushton, Batcheller, Schroeder, & Donohue, 2015). Information gained from these studies can guide leaders to identify strategies to maintain a productive, healthy nursing workforce.

Burnout occurs when a person can no longer manage the effects of stress (Kutluturkan et al., 2016). Nurses are leaving the profession in part because of burnout, worsening the nursing shortage. Nurse burnout also contributes to poor patient satisfaction scores and increased infection rates (Steinberg, Klatt, & Duchemin, 2017). Coping strategies, which are determined by nurses' level of resiliency, are important for nurses to use in overcoming a stressful environment.

Lee and colleagues (2015) defined resiliency as an individual's ability to overcome an adverse situation with optimism and self-control. Rushton and co-authors (2015) identified it as the ability to overcome...

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A narrative review of burnout syndrome in medical personnel.

1. Introduction

2. risk factors for burnout, 3. instruments used for evaluating burnout, 4. biomarkers monitoring burnout, 5. protectors against burnout, 6. repercussions of burnout, 7. discussion, 8. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

• Rotenstein, L.S.; Torre, M.; Ramos, M.A.; Rosales, R.C.; Guille, C.; Sen, S.; Mata, D.A. Prevalence of Burnout among Physicians: A Systematic Review. JAMA 2018 , 320 , 1131–1150. [ Google Scholar ] [ CrossRef ]
• Freudenberger, H.J. Staff Burn-Out. J. Soc. Issues 1974 , 30 , 159–165. [ Google Scholar ] [ CrossRef ]
• Maslach, C.; Jackson, S.E.; Leiter, M.P. (Eds.) Maslach Burnout Inventory Manual ; Consulting Psychologists Press: Mountain View, CA, USA, 1996; pp. 1–10. [ Google Scholar ]
• Maslach, C.; Jackson, S.E.; Leiter, M.P. (Eds.) Maslach Burnout Inventory Manual , 4th ed.; Publisher Mind Garden, Inc.: Menlo Park, CA, USA, 2016; Available online: www.mindgarden.com (accessed on 8 May 2024).
• Demerouti, E.; Bakker, A.B.; Nachreiner, F.; Schaufeli, W.B. The job demands-resources model of burnout. J. Appl. Psychol. 2001 , 86 , 499–512. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Borritz, M.; Rugulies, R.; Bjorner, J.B.; Villadsen, E.; Mikkelsen, O.A.; Kristensen, T.S. Burnout among employees in human service work: Design and baseline findings of the PUMA study. Scand. J. Public Health 2006 , 34 , 49–58. [ Google Scholar ] [ CrossRef ]
• Shanafelt, T.D.; Boone, S.; Tan, L.; Dyrbye, L.N.; Sotile, W.; Satele, D.; West, C.P.; Sloan, J.; Oreskovich, M.R. Burnout and Satisfaction with Work-Life Balance among US Physicians Relative to the General US Population. Arch. Intern. Med. 2012 , 172 , 1377–1385. [ Google Scholar ] [ CrossRef ]
• Shanafelt, T.D.; West, C.P.; Sinsky, C.; Trockel, M.; Tutty, M.; Satele, D.V.; Carlasare, L.E.; Dyrbye, L.N. Changes in Burnout and Satisfaction with Work-Life Integration in Physicians and the General US Working Population between 2011 and 2017. Mayo Clin. Proc. 2019 , 94 , 1681–1694. [ Google Scholar ] [ CrossRef ]
• De Hert, S. Burnout in Healthcare Workers: Prevalence, Impact and Preventative Strategies. Local Reg. Anesth. 2020 , 13 , 171–183. [ Google Scholar ] [ CrossRef ]
• Arnetz, B.B. Psychosocial challenges facing physicians of today. Soc. Sci. Med. 2000 , 52 , 203–213. [ Google Scholar ] [ CrossRef ]
• Suksatan, W.; Jasim, S.A.; Widjaja, G.; Jalil, A.T.; Chupradit, S.; Ansari, M.J.; Mustafa, Y.F.; Hammoodi, H.A.; Mohammadi, M.J. Assessment effects and risk of nosocomial infection and needle sticks injuries among patents and health care worker. Toxicol. Rep. 2022 , 9 , 284–292. [ Google Scholar ] [ CrossRef ]
• Triassi, M.; Pennino, F. Infectious risk for healthcare workers: Evaluation and prevention. Ann. Ig. 2018 , 30 , 48–51. [ Google Scholar ] [ CrossRef ]
• Saadeh, R.; Khairallah, K.; Abozeid, H.; Al Rashdan, L.; Alfaqih, M.; Alkhatatbeh, O. Needle Stick and Sharp Injuries among Healthcare Workers: A Retrospective Six-Year Study. Sultan Qaboos Univ. Med. J. 2020 , 20 , 54–62. [ Google Scholar ] [ CrossRef ]
• Merlo, G.; Rippe, J. Physician Burnout: A Lifestyle Medicine Perspective. Am. J. Lifestyle Med. 2021 , 15 , 148–157. [ Google Scholar ] [ CrossRef ]
• Salari, N.; Khazaie, H.; Hosseinian-Far, A.; Khaledi-Paveh, B.; Kazeminia, M.; Mohammadi, M.; Shohaimi, S.; Daneshkhah, A.; Eskandari, S. The prevalence of stress, anxiety and depression within front-line healthcare workers caring for COVID-19 patients: A systematic review and meta-regression. Hum. Resour. Health 2020 , 18 , 100. [ Google Scholar ] [ CrossRef ]
• Majumder, J.; Minko, T. Recent Developments on Therapeutic and Diagnostic Approaches for COVID-19. AAPS J. 2021 , 23 , 14. [ Google Scholar ] [ CrossRef ]
• Carlsten, C.; Gulati, M.; Hines, S.; Rose, C.; Scott, K.; Tarlo, S.M.; Torén, K.; Sood, A.; de la Hoz, R.E. COVID-19 as an occupational disease. Am. J. Ind. Med. 2021 , 64 , 227–237. [ Google Scholar ] [ CrossRef ]
• Molina-Praena, J.; Ramirez-Baena, L.; Gómez-Urquiza, J.L.; Cañadas, G.R.; De la Fuente, E.I.; Cañadas-De la Fuente, G.A. Levels of Burnout and Risk Factors in Medical Area Nurses: A Meta-Analytic Study. Int. J. Environ. Res. Public Health 2018 , 15 , 2800. [ Google Scholar ] [ CrossRef ]
• Burri, S.D.; Smyrk, K.M.; Melegy, M.S.; Kessler, M.M.; Hussein, N.I.; Tuttle, B.D.; Clewley, D.J. Risk factors associated with physical therapist burnout: A systematic review. Physiotherapy 2022 , 116 , 9–24. [ Google Scholar ] [ CrossRef ]
• Dugani, S.; Afari, H.; Hirschhorn, L.R.; Ratcliffe, H.; Veillard, J.; Martin, G.; Lagomarsino, G.; Basu, L.; Bitton, A. Prevalence and factors associated with burnout among frontline primary health care providers in low- and middle-income countries: A systematic review. Gates Open Res. 2018 , 2 , 4. [ Google Scholar ] [ CrossRef ]
• Montgomery, A.P.; Azuero, A.; Patrician, P.A. Psychometric properties of Copenhagen Burnout Inventory among nurses. Res. Nurs. Health 2021 , 44 , 308–318. [ Google Scholar ] [ CrossRef ]
• Suleiman-Martos, N.; Albendín-García, L.; Gómez-Urquiza, J.L.; Vargas-Román, K.; Ramirez-Baena, L.; Ortega-Campos, E.; De La Fuente-Solana, E.I. Prevalence and Predictors of Burnout in Midwives: A Systematic Review and Meta-Analysis. Int. J. Environ. Res. Public Health 2020 , 17 , 641. [ Google Scholar ] [ CrossRef ]
• Block, R.I.; Bair, H.L.; Carillo, J.F. Is Exhaustion More Sensitive Than Disengagement to Burnout in Academic Anesthesia? A Study Using the Oldenburg Burnout Inventory. Psychol. Rep. 2020 , 123 , 1282–1296. [ Google Scholar ] [ CrossRef ]
• Demerouti, E.; Bakker, A.B.; Vardakou, I.; Kantas, A. The convergent validity of two burnout instruments: A multitrait-multimethod analysis. Eur. J. Psychol. Assess. 2003 , 19 , 12–23. [ Google Scholar ] [ CrossRef ]
• Widerszal-Bazyl, M.; Cieślak, M. Monitoring Psychosocial Stress at Work: Development of the Psychosocial Working Conditions Questionnaire. Int. J. Occup. Saf. Ergon. 2000 , 6 , 59–70. [ Google Scholar ] [ CrossRef ]
• Schaufeli, W.B.; Desart, S.; De Witte, H. Burnout Assessment Tool (BAT)—Development, Validity, and Reliability. Int. J. Environ. Res. Public Health 2020 , 17 , 9495. [ Google Scholar ] [ CrossRef ]
• Abeltina, M.; Stokenberga, I.; Skudra, J.; Rascevska, M.; Kolesovs, A. Burnout Clinical Subtypes Questionnaire (BCSQ-36): Reliability and validity study in Latvia. Psychol. Health Med. 2020 , 25 (Suppl. S1), 1–12. [ Google Scholar ] [ CrossRef ]
• Guerrero-Barona, E.; Guerrero-Molina, M.; García-Gómez, A.; Moreno-Manso, J.M.; García-Baamonde, M.E. Quality of Working Life, Psychosocial Factors, Burnout Syndrome and Emotional Intelligence. Int. J. Environ. Res. Public Health 2020 , 17 , 9550. [ Google Scholar ] [ CrossRef ]
• Pérez-Fuentes, M.D.C.; Molero Jurado, M.D.M.; Martos Martínez, Á.; Gázquez Linares, J.J. New Burnout Evaluation Model Based on the Brief Burnout Questionnaire: Psychometric Properties for Nursing. Int. J. Environ. Res. Public Health 2018 , 15 , 2718. [ Google Scholar ] [ CrossRef ]
• Gerber, M.; Colledge, F.; Mücke, M.; Schilling, R.; Brand, S.; Ludyga, S. Psychometric properties of the Shirom-Melamed Burnout Measure (SMBM) among adolescents: Results from three cross-sectional studies. BMC Psychiatry 2018 , 18 , 266. [ Google Scholar ] [ CrossRef ]
• Hadzibajramovic, E.; Ahlborg, G., Jr.; Grimby-Ekman, A.; Lundgren-Nilsson, Å. Internal construct validity of the stress-energy questionnaire in a working population, a cohort study. BMC Public Health 2015 , 15 , 180. [ Google Scholar ] [ CrossRef ]
• Salmela-Aro, K.; Kiuru, N.; Nurmi, J.E. The role of educational track in adolescents’ school burnout: A longitudinal study. Br. J. Educ. Psychol. 2008 , 78 Pt 4 , 663–689. [ Google Scholar ] [ CrossRef ]
• Carmona-Halty, M.; Mena-Chamorro, P.; Sepúlveda-Páez, G.; Ferrer-Urbina, R. School Burnout Inventory: Factorial Validity, Reliability, and Measurement Invariance in a Chilean Sample of High School Students. Front. Psychol. 2022 , 12 , 774703. [ Google Scholar ] [ CrossRef ]
• May, R.W.; Rivera, P.M.; Rogge, R.D.; Fincham, F.D. School Burnout Inventory: Latent Profile and Item Response Theory Analyses in Undergraduate Samples. Front. Psychol. 2020 , 11 , 188. [ Google Scholar ] [ CrossRef ]
• Roskam, I.; Brianda, M.-E.; Mikolajczak, M. A Step Forward in the Conceptualization and Measurement of Parental Burnout: The Parental Burnout Assessment (PBA). Front. Psychol. 2018 , 9 , 758. [ Google Scholar ] [ CrossRef ]
• Zhao, W.; Liao, X.; Li, Q.; Jiang, W.; Ding, W. The Relationship between Teacher Job Stress and Burnout: A Moderated Mediation Model. Front. Psychol. 2022 , 12 , 784243. [ Google Scholar ] [ CrossRef ]
• Raedeke, T.D.; Smith, A.L. Development and Preliminary Validation of an Athlete Burnout Measure. J. Sport Exerc. Psychol. 2001 , 23 , 281–306. [ Google Scholar ] [ CrossRef ]
• Jonsdottir, I.H.; Dahlman, A.S. Mechanisms in endocrinology: Endocrine and immunological aspects of burnout: A narrative review. Eur. J. Endocrinol. 2019 , 180 , R147–R158. [ Google Scholar ] [ CrossRef ]
• Guseva Canu, I.; Marca, S.C.; Dell’Oro, F.; Balázs, Á.; Bergamaschi, E.; Besse, C.; Bianchi, R.; Bislimovska, J.; Koscec Bjelajac, A.; Bugge, M.; et al. Harmonized definition of occupational burnout: A systematic review, semantic analysis, and Delphi consensus in 29 countries. Scand. J. Work. Environ. Health 2020 , 47 , 95–107. [ Google Scholar ] [ CrossRef ]
• Demarzo, M.; García-Campayo, J.; Martínez-Rubio, D.; Pérez-Aranda, A.; Miraglia, J.L.; Hirayama, M.S.; de Salvo, V.M.A.; Cicuto, K.; Favarato, M.L.; Terra, V.; et al. Frenetic, under-Challenged, and Worn-out Burnout Subtypes among Brazilian Primary Care Personnel: Validation of the Brazilian “Burnout Clinical Subtype Questionnaire” (BCSQ-36/BCSQ-12). Int. J. Environ. Res. Public Health 2020 , 17 , 1081. [ Google Scholar ] [ CrossRef ]
• Montero-Marin, J.; Zubiaga, F.; Cereceda, M.; Demarzo, M.M.P.; Trenc, P.; Garcia-Campayo, J. Burnout Subtypes and Absence of Self-Compassion in Primary Healthcare Professionals: A Cross-Sectional Study. PLoS ONE 2016 , 11 , e0157499, Erratum in PLoS ONE 2020 , 15 , e0231370. [ Google Scholar ] [ CrossRef ]
• Montero-Marín, J.; García-Campayo, J.; Mera, D.M.; del Hoyo, Y.L. A new definition of burnout syndrome based on Farber’s proposal. J. Occup. Med. Toxicol. 2009 , 4 , 31. [ Google Scholar ] [ CrossRef ]
• Noushad, S.; Ahmed, S.; Ansari, B.; Mustafa, U.H.; Saleem, Y.; Hazrat, H. Physiological biomarkers of chronic stress: A systematic review. Int. J. Health Sci. 2021 , 15 , 46–59. [ Google Scholar ]
• Danhof-Pont, M.B.; van Veen, T.; Zitman, F.G. Biomarkers in burnout: A systematic review. J. Psychosom. Res. 2011 , 70 , 505–524. [ Google Scholar ] [ CrossRef ]
• Illnerová, H.; Buresová, M.; Presl, J. Melatonin rhythm in human milk. J. Clin. Endocrinol. Metab. 1993 , 77 , 838–841. [ Google Scholar ] [ CrossRef ]
• Dubbels, R.; Reiter, R.; Klenke, E.; Goebel, A.; Schnakenberg, E.; Ehlers, C.; Schiwara, H.; Schloot, W. Melatonin in edible plants identified by radioimmunoassay and by high performance liquid chromatography-mass spectrometry. J. Pineal Res. 1995 , 18 , 28–31. [ Google Scholar ] [ CrossRef ]
• Zisapel, N. New perspectives on the role of melatonin in human sleep, circadian rhythms and their regulation. Br. J. Pharmacol. 2018 , 175 , 3190–3199. [ Google Scholar ] [ CrossRef ]
• Back, K. Melatonin metabolism, signaling and possible roles in plants. Plant J. 2020 , 105 , 376–391. [ Google Scholar ] [ CrossRef ]
• Claustrat, B.; Leston, J. Melatonin: Physiological effects in humans. Neurochirurgie 2015 , 61 , 77–84. [ Google Scholar ] [ CrossRef ]
• Reiter, R.J.; Mayo, J.C.; Tan, D.; Sainz, R.M.; Alatorre-Jimenez, M.; Qin, L. Melatonin as an antioxidant: Under promises but over delivers. J. Pineal Res. 2016 , 61 , 253–278. [ Google Scholar ] [ CrossRef ]
• Rothe, N.; Steffen, J.; Penz, M.; Kirschbaum, C.; Walther, A. Examination of peripheral basal and reactive cortisol levels in major depressive disorder and the burnout syndrome: A systematic review. Neurosci. Biobehav. Rev. 2020 , 114 , 232–270. [ Google Scholar ] [ CrossRef ]
• He, S.-C.; Wu, S.; Du, X.-D.; Jia, Q.; Wang, C.; Wu, F.; Ning, Y.; Wang, D.; Wang, L.; Zhang, X.Y. Interactive effects of corticotropin-releasing hormone receptor 1 gene and work stress on burnout in medical professionals in a Chinese Han population. J. Affect. Disord. 2019 , 252 , 1–8. [ Google Scholar ] [ CrossRef ]
• Wolfram, M.; Bellingrath, S.; Feuerhahn, N.; Kudielka, B.M. Emotional exhaustion and overcommitment to work are differentially associated with hypothalamus–pituitary–adrenal (HPA) axis responses to a low-dose ACTH 1–24 (Synacthen) and dexamethasone–CRH test in healthy school teachers. Stress 2012 , 16 , 54–64. [ Google Scholar ] [ CrossRef ]
• Lennartsson, A.-K.; Theorell, T.; Kushnir, M.M.; Jonsdottir, I.H. Low Levels of Dehydroepiandrosterone Sulfate in Younger Burnout Patients. PLoS ONE 2015 , 10 , e0140054, Erratum in PLoS ONE 2015 , 10 , e0143192. [ Google Scholar ] [ CrossRef ]
• Gao, W.; Penz, M.; Wekenborg, M.; Walther, A.; Kirschbaum, C. Determination of thyroid hormones in human hair with online SPE LC–MS/MS: Analytical protocol and application in study of burnout. Psychoneuroendocrinology 2019 , 106 , 129–137. [ Google Scholar ] [ CrossRef ]
• Lennartsson, A.-K.; Billig, H.; Jonsdottir, I.H. Burnout is associated with elevated prolactin levels in men but not in women. J. Psychosom. Res. 2014 , 76 , 380–383. [ Google Scholar ] [ CrossRef ]
• Gulen, B.; Serinken, M.; Eken, C.; Karcıoglu, Ö.; Kucukdagli, O.T.; Kilic, E.; Akpinar, G.; Nogay, S.; Kuh, M. Serum S100B as a Surrogate Biomarker in the Diagnoses of Burnout and Depression in Emergency Medicine Residents. Acad. Emerg. Med. 2016 , 23 , 786–789. [ Google Scholar ] [ CrossRef ]
• Sertoz, O.O.; Binbay, I.T.; Koylu, E.; Noyan, A.; Yıldırım, E.; Mete, H.E. The role of BDNF and HPA axis in the neurobiology of burnout syndrome. Prog. Neuro-Psychopharmacol. Biol. Psychiatry 2008 , 32 , 1459–1465. [ Google Scholar ] [ CrossRef ]
• Dahlman, A.S.; Blennow, K.; Zetterberg, H.; Glise, K.; Jonsdottir, I.H. Growth factors and neurotrophins in patients with stress-related exhaustion disorder. Psychoneuroendocrinology 2019 , 109 , 104415. [ Google Scholar ] [ CrossRef ]
• Bärtl, C.; Henze, G.-I.; Giglberger, M.; Peter, H.L.; Konzok, J.; Wallner, S.; Kreuzpointner, L.; Wüst, S.; Kudielka, B.M. Higher allostatic load in work-related burnout: The Regensburg Burnout Project. Psychoneuroendocrinology 2022 , 143 , 105853. [ Google Scholar ] [ CrossRef ]
• Socaciu, A.I.; Ionuţ, R.; Socaciu, M.A.; Ungur, A.P.; Bârsan, M.; Chiorean, A.; Socaciu, C.; Râjnoveanu, A.G. Melatonin, an ubiquitous metabolic regulator: Functions, mechanisms and effects on circadian disruption and degenerative diseases. Rev. Endocr. Metab. Disord. 2020 , 21 , 465–478. [ Google Scholar ] [ CrossRef ]
• Alonso-González, C.; González, A.; Martínez-Campa, C.; Gómez-Arozamena, J.; Cos, S. Melatonin sensitizes human breast cancer cells to ionizing radiation by downregulating proteins involved in double-strand DNA break repair. J. Pineal Res. 2015 , 58 , 189–197. [ Google Scholar ] [ CrossRef ]
• Minich, D.M.; Henning, M.; Darley, C.; Fahoum, M.; Schuler, C.B.; Frame, J. Is Melatonin the “Next Vitamin D”?: A Review of Emerging Science, Clinical Uses, Safety, and Dietary Supplements. Nutrients 2022 , 14 , 3934. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Blask, D.E.; Dauchy, R.T.; Sauer, L.A. Putting cancer to sleep at night: The neuroendocrine/circadian melatonin signal. Endocrine 2005 , 27 , 179–188. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Metlaine, A.; Sauvet, F.; Gomez-Merino, D.; Elbaz, M.; Delafosse, J.Y.; Leger, D.; Chennaoui, M. Association between insomnia symptoms, job strain and burnout syndrome: A cross-sectional survey of 1300 financial workers. BMJ Open 2017 , 7 , e012816. [ Google Scholar ] [ CrossRef ]
• Li, Y.; Xue, T.; Jin, J.; Wu, H.E.; Dong, Y.; Zhen, S.; He, S.-C.; Zhang, X.Y. Interaction between the BDNF gene rs16917237 polymorphism and job stress on job burnout of Chinese university teachers. J. Affect. Disord. 2022 , 309 , 282–288. [ Google Scholar ] [ CrossRef ]
• Olivé, V.; Navinés, R.; Macías, L.; López, J.; Ariz, J.; Quesada, S.; Barroso, S.; Filella, X.; Langohr, K.; Martin-Santos, R. Psychosocial and biological predictors of resident physician burnout. Gen. Hosp. Psychiatry 2022 , 78 , 68–71. [ Google Scholar ] [ CrossRef ]
• Del Giudice, M.; Gangestad, S.W. Rethinking IL-6 and CRP: Why they are more than inflammatory biomarkers, and why it matters. Brain Behav. Immun. 2018 , 70 , 61–75. [ Google Scholar ] [ CrossRef ]
• Dam, A.; Perera, T.; Jones, M.; Haughy, M.; Gaeta, T. The Relationship between Grit, Burnout, and Well-Being in Emergency Medicine Residents. AEM Educ. Train. 2018 , 3 , 14–19. [ Google Scholar ] [ CrossRef ]
• Salvagioni, D.A.J.; Melanda, F.N.; Mesas, A.E.; González, A.D.; Gabani, F.L.; De Andrade, S.M. Physical, psychological and occupational consequences of job burnout: A systematic review of prospective studies. PLoS ONE 2017 , 12 , e0185781. [ Google Scholar ] [ CrossRef ]
• Salles, A.; Lin, D.; Liebert, C.; Esquivel, M.; Lau, J.N.; Greco, R.S.; Mueller, C. Grit as a predictor of risk of attrition in surgical residency. Am. J. Surg. 2017 , 213 , 288–291. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Nie, Z.; Jin, Y.; He, L.; Chen, Y.; Ren, X.; Yu, J.; Yao, Y. Correlation of burnout with social support in hospital nurses. Int. J. Clin. Exp Med. 2015 , 8 , 19144–19149. [ Google Scholar ]
• Molero Jurado, M.D.M.; Pérez-Fuentes, M.D.C.; Gázquez Linares, J.J.G.; Simón Márquez, M.D.M.; Martos Martínez, Á. Burnout Risk and Protection Factors in Certified Nursing Aides. Int. J. Environ. Res. Public Health 2018 , 15 , 1116. [ Google Scholar ] [ CrossRef ]
• Nightingale, S.; Spiby, H.; Sheen, K.; Slade, P. The impact of emotional intelligence in health care professionals on caring behaviour towards patients in clinical and long-term care settings: Findings from an integrative review. Int. J. Nurs. Stud. 2018 , 80 , 106–117. [ Google Scholar ] [ CrossRef ]
• Dutheil, F.; Parreira, L.M.; Eismann, J.; Lesage, F.-X.; Balayssac, D.; Lambert, C.; Clinchamps, M.; Pezet, D.; Pereira, B.; Le Roy, B. Burnout in French General Practitioners: A Nationwide Prospective Study. Int. J. Environ. Res. Public Health 2021 , 18 , 12044. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Duijts, S.F.A.; Kant, I.; Swaen, G.M.H.; van den Brandt, P.A.; Zeegers, M.P.A. A meta-analysis of observational studies identifies predictors of sickness absence. J. Clin. Epidemiol. 2007 , 60 , 1105–1115. [ Google Scholar ] [ CrossRef ]
• Paiva, B.S.R.; Mingardi, M.; Valentino, T.C.d.O.; de Oliveira, M.A.; Paiva, C.E. Prevalence of burnout and predictive factors among oncology nursing professionals: A cross-sectional study. Sao Paulo Med. J. 2021 , 139 , 341–350. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Cañadas-De-La Fuente, G.A.; Ortega, E.; Ramirez-Baena, L.; De La Fuente-Solana, E.I.; Vargas, C.; Gómez-Urquiza, J.L. Gender, Marital Status, and Children as Risk Factors for Burnout in Nurses: A Meta-Analytic Study. Int. J. Environ. Res. Public Health 2018 , 15 , 2102. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Mincarone, P.; Bodini, A.; Tumolo, M.R.; Sabina, S.; Colella, R.; Mannini, L.; Sabato, E.; Leo, C.G. Association Between Physical Activity and the Risk of Burnout in Health Care Workers: Systematic Review. JMIR Public Health Surveill. 2024 , 10 , e49772. [ Google Scholar ] [ CrossRef ]
• Rosales-Ricardo, Y.; Ferreira, J.P. Effects of Physical Exercise on Burnout Syndrome in University Students. MEDICC Rev. 2022 , 24 , 36–39. [ Google Scholar ] [ CrossRef ]
• Restrepo, J.; Lemos, M. Addressing psychosocial work-related stress interventions: A systematic review. Work 2021 , 70 , 53–62. [ Google Scholar ] [ CrossRef ]
• Oreskovich, M.R.; Kaups, K.L.; Balch, C.M.; Hanks, J.B.; Satele, D.; Sloan, J.; Meredith, C.; Buhl, A.; Dyrbye, L.N.; Shanafelt, T.D. Prevalence of alcohol use disorders among American surgeons. Arch. Surg. 2012 , 147 , 168–174. [ Google Scholar ] [ CrossRef ]
• Gundersen, L. Physician Burnout. Ann. Intern. Med. 2001 , 135 , 145–148. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Bianchi, R.; Schonfeld, I.S.; Laurent, E. Burnout–depression overlap: A review. Clin. Psychol. Rev. 2015 , 36 , 28–41. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Shanafelt, T.D.; Balch, C.M.; Dyrbye, L.; Bechamps, G.; Russell, T.; Satele, D.; Rummans, T.; Swartz, K.; Novotny, P.J.; Sloan, J.; et al. Special report: Suicidal ideation among American surgeons. Arch. Surg. 2011 , 146 , 54–62. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Wurm, W.; Vogel, K.; Holl, A.; Ebner, C.; Bayer, D.; Mörkl, S.; Szilagyi, I.-S.; Hotter, E.; Kapfhammer, H.-P.; Hofmann, P. Depression-Burnout Overlap in Physicians. PLoS ONE 2016 , 11 , e0149913. [ Google Scholar ] [ CrossRef ]
• Guan, S.; Xiaerfuding, X.; Ning, L.; Lian, Y.; Jiang, Y.; Liu, J.; Ng, T.B. Effect of Job Strain on Job Burnout, Mental Fatigue and Chronic Diseases among Civil Servants in the Xinjiang Uygur Autonomous Region of China. Int. J. Environ. Res. Public Health 2017 , 14 , 872. [ Google Scholar ] [ CrossRef ]
• Available online: https://www.medscape.com/slideshow/2022-lifestyle-happiness-6014665 (accessed on 8 May 2024).
• Wirtz, P.H.; von Känel, R. Psychological Stress, Inflammation, and Coronary Heart Disease. Curr. Cardiol. Rep. 2017 , 19 , 111. [ Google Scholar ] [ CrossRef ]
• Melamed, S.; Kushnir, T.; Shirom, A. Burnout and risk factors for cardiovascular diseases. Behav. Med. 1992 , 18 , 53–60. [ Google Scholar ] [ CrossRef ]
• Bellani, M.L.; Furlani, F.; Gnecchi, M.; Pezzotta, P.; Trotti, E.M.; Bellotti, G.G. Burnout and related factors among HIV/AIDS health care workers. AIDS Care 1996 , 8 , 207–222. [ Google Scholar ] [ CrossRef ]
• Eaton, L. Health workforce burn-out. Bull. World Health Organ. 2019 , 97 , 585–586, Erratum in Bull World Health Organ. 2019 , 97 , 728. [ Google Scholar ] [ CrossRef ]
• Maslach, C.; Schaufeli, W.B.; Leiter, M.P. Job Burnout. Annu. Rev. Psychol. 2001 , 52 , 397–422. [ Google Scholar ] [ CrossRef ]
• Linn, L.S.; Brook, R.H.; Clark, V.A.; Davies, A.R.; Fink, A.; Kosecoff, J. Physician and Patient Satisfaction as Factors Related to the Organization of Internal Medicine Group Practices. Med. Care 1985 , 23 , 1171–1178. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Haas, J.S.; Cook, E.F.; Puopolo, A.L.; Burstin, H.R.; Cleary, P.D.; Brennan, T.A. Is the professional satisfaction of general internists associated with patient satisfaction? J. Gen. Intern. Med. 2000 , 15 , 122–128. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• DiMatteo, M.R.; Sherbourne, C.D.; Hays, R.D.; Ordway, L.; Kravitz, R.L.; McGlynn, E.A.; Kaplan, S.; Rogers, W.H. Physicians’ characteristics influence patients’ adherence to medical treatment: Results from the Medical Outcomes Study. Health Psychol. 1993 , 12 , 93–102. [ Google Scholar ] [ CrossRef ]
• Sun, X.; Zhang, M.; Lu, Z.; Zhang, Z.; Zheng, J.C.; Cheng, L.; Zeng, L.; Qian, Y.; Huang, L. Turnover intention and related factors among resident physicians in China under the standardised residency training programme: A cross-sectional survey. BMJ Open 2022 , 12 , e061922. [ Google Scholar ] [ CrossRef ]
• Davey, M.M.; Cummings, G.; Newburn-Cook, C.V.; Lo, E.A. Predictors of nurse absenteeism in hospitals: A systematic review. J. Nurs. Manag. 2009 , 17 , 312–330. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Pei, P.; Lin, G.; Li, G.; Zhu, Y.; Xi, X. The association between doctors’ presenteeism and job burnout: A cross-sectional survey study in China. BMC Health Serv. Res. 2020 , 20 , 715. [ Google Scholar ] [ CrossRef ]
• Velando-Soriano, A.; Ortega-Campos, E.; Gómez-Urquiza, J.L.; Ramírez-Baena, L.; De La Fuente, E.I.; Cañadas-De La Fuente, G.A. Impact of social support in preventing burnout syndrome in nurses: A systematic review. Jpn. J. Nurs. Sci. 2019 , 17 , e12269. [ Google Scholar ] [ CrossRef ]
• Dall’ora, C.; Ejebu, O.-Z.; Ball, J.; Griffiths, P. Shift work characteristics and burnout among nurses: Cross-sectional survey. Occup. Med. 2023 , 73 , 199–204. [ Google Scholar ] [ CrossRef ]
• Poza, J.J.; Pujol, M.; Ortega-Albás, J.J.; Romero, O.; Insomnia Study Group of the Spanish Sleep Society (SES). Melatonin in sleep disorders. Neurol. (Engl. Ed.) 2022 , 37 , 575–585. [ Google Scholar ] [ CrossRef ]
• Ślusarz, R.; Cwiekala-Lewis, K.; Wysokiński, M.; Filipska-Blejder, K.; Fidecki, W.; Biercewicz, M. Characteristics of Occupational Burnout among Nurses of Various Specialties and in the Time of the COVID-19 Pandemic—Review. Int. J. Environ. Res. Public Health 2022 , 19 , 13775. [ Google Scholar ] [ CrossRef ]
• Crudden, G.; Margiotta, F.; Doherty, A.M. Physician burnout and symptom of anxiety and depression: Burnout in Consultant Doctors in Ireland Study (BICDIS). PLoS ONE 2023 , 18 , e0276027. [ Google Scholar ] [ CrossRef ]
• O’Higgins, M.; Rojas, L.A.; Echeverria, I.; Roselló-Jiménez, L.; Benito, A.; Haro, G. Burnout, psychopathology and purpose in life in healthcare workers during COVID-19 pandemic. Front. Public Health 2022 , 10 , 926328. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Briciu, V.; Leucuta, D.-C.; Tőkés, G.E.; Colcear, D. Burnout, Depression, and Job Stress Factors in Healthcare Workers of a Romanian COVID-19 Dedicated Hospital, after Two Pandemic Years. Int. J. Environ. Res. Public Health 2023 , 20 , 4118. [ Google Scholar ] [ CrossRef ]
• Taylor, C.E.; Scott, E.J.; Owen, K. Physical activity, burnout and quality of life in medical students: A systematic review. Clin. Teach. 2022 , 19 , e13525. [ Google Scholar ] [ CrossRef ]
• Schneider-Matyka, D.; Świątoniowska-Lonc, N.; Polański, J.; Szkup, M.; Grochans, E.; Jankowska-Polańska, B. Assessment of The Effect of Stress, Sociodemographic Variables and Work-Related Factors on Rationing of Nursing Care. Int. J. Environ. Res. Public Health 2023 , 20 , 2414. [ Google Scholar ] [ CrossRef ]
• Wood, E.A.; Egan, S.C.; Ange, B.; Garduno, H.; Williams, D.R.; Wyatt, T.R. Association of Self-Reported Burnout and Protective Factors in Single Institution Resident Physicians. J. Grad. Med. Educ. 2020 , 12 , 284–290. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Reiter, R.J.; Paredes, S.D.; Manchester, L.C.; Tan, D.-X. Reducing oxidative/nitrosative stress: A newly-discovered genre for melatonin. Crit. Rev. Biochem. Mol. Biol. 2009 , 44 , 175–200. [ Google Scholar ] [ CrossRef ] [ PubMed ]

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Ungur, A.-P.; Bârsan, M.; Socaciu, A.-I.; Râjnoveanu, A.G.; Ionuț, R.; Goia, L.; Procopciuc, L.M. A Narrative Review of Burnout Syndrome in Medical Personnel. Diagnostics 2024 , 14 , 1971. https://doi.org/10.3390/diagnostics14171971

Ungur A-P, Bârsan M, Socaciu A-I, Râjnoveanu AG, Ionuț R, Goia L, Procopciuc LM. A Narrative Review of Burnout Syndrome in Medical Personnel. Diagnostics . 2024; 14(17):1971. https://doi.org/10.3390/diagnostics14171971

Ungur, Andreea-Petra, Maria Bârsan, Andreea-Iulia Socaciu, Armand Gabriel Râjnoveanu, Răzvan Ionuț, Letiția Goia, and Lucia Maria Procopciuc. 2024. "A Narrative Review of Burnout Syndrome in Medical Personnel" Diagnostics 14, no. 17: 1971. https://doi.org/10.3390/diagnostics14171971

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• Published: 11 September 2024

Effort–reward imbalance and well-being among psychiatric nurses: the mediating role of burnout and decent work

• Xiaoyan Zhang 1   na1 ,
• Liya Zhang 1   na1 ,
• Bowen Xue 1 ,
• Yanping Li 1 ,
• Mengmeng Yan 1 ,
• Hong Luo 1 &
• Xiaoyu Huang 1  

BMC Nursing volume  23 , Article number:  635 ( 2024 ) Cite this article

Metrics details

Psychiatric nurses face additional challenges due to negative perceptions, workplace violence, and a lack of respect, impacting their well-being and job satisfaction, which are crucial for improving psychiatric care and patient outcomes.

This study aims to examine the relationship between effort-reward imbalance, well-being, burnout, and decent work among psychiatric nurses.

This study used a cross-sectional design. Data were collected using a convenience sampling method in February 2024 from 397 psychiatric nurses at two psychiatric hospitals in Hangzhou and Huzhou, Zhejiang Province. The Effort-Reward Imbalance Scale, Decent Work Perception Scale, Maslach Burnout Inventory-General Survey, and General Well-Being Schedule Scale were used for data collection. Data analysis was conducted using SPSS 26.0 and the PROCESS macro.

The study found that effort-reward imbalance among psychiatric nurses was negatively correlated with decent work ( r = -0.564, p  < 0.001) and well-being ( r = -0.541, p  < 0.001), and positively correlated with burnout ( r  = 0.603, p  < 0.001). Burnout mediated the relationship between effort-reward imbalance and well-being (95% CI [-0.386, -0.257]), while decent work also served as a mediator (95% CI [-0.100, -0.012]). Additionally, burnout and decent work were found to mediate the relationship between effort-reward imbalance and well-being (95% CI [-0.050, -0.006]).

This study highlights the impact of effort-reward imbalance on well-being, confirming that burnout and decent work serve as mediators. Enhancing support, fair compensation, reasonable work schedules, and professional development can promote psychiatric nurses’ perception of decent work and improve their well-being.

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Introduction

While individuals may harbor dreams and ambitions for their work lives, factors such as economic constraints, social status, gender, religious beliefs, sexual orientation, or race may hinder their realization [ 1 ]. Stigma surrounding mental illness is also a significant factor. Over the past few decades, public perception of psychiatric hospitals has remained negative. The image of a “psychiatric hospital” often conjures up that of a large, custodial institution, typically located in the suburbs [ 2 ]. Psychiatric nurses, as mental health professionals, are also affected by stigmatization. Research has found widespread negative perceptions of psychiatry among members of other medical professions [ 3 ], reflecting the lower social status of psychiatric nurses and their lack of sufficient respect and recognition. Moreover, psychiatric nurses exposed to workplace violence and similar environments suffer significant harm to their physical and mental well-being [ 4 ]. Therefore, providing psychiatric nurses with sufficient incentives, ensuring their perception of decent work, and enhancing job satisfaction are crucial for improving the quality of psychiatric care, maintaining patient safety, and promoting patient recovery.

Employment is often a prerequisite for individuals to sustain income, and the rewards of work can impact their social status and economic strength. However, research reports indicate the presence of Effort-Reward Imbalance (ERI) among psychiatric nurses [ 5 ], characterized by an imbalance in the reciprocal relationship where individuals invest high effort and low reward reflects [ 6 ]. Particularly in psychiatric healthcare settings, challenges such as working with difficult patient populations, limited resources, uncompensated efforts, violence, and aggression can lead to this imbalance [ 7 ]. Past studies have shown that such imbalance can trigger anger, depression, and perceptions of unfairness, consequently resulting in physical ailments and mental disorders [ 8 ]. Therefore, for psychiatric nurses, maintaining a balance between effort and reward in their work is an urgent issue that needs to be addressed. We hypothesize that there is a negative correlation between effort-reward imbalance and decent work.

In recent years, the concept of decent work has garnered significant attention and is closely linked to a series of initiatives by the International Labour Organization (ILO) aimed at respecting workers’ rights. At the macro level, decent work refers to ensuring that workers can work under conditions of freedom, fairness, safety, and dignity by promoting employment, strengthening social protection, safeguarding workers’ basic rights, and engaging in tripartite dialogue among governments, employers, and workers’ organizations [ 9 ]. At the individual level, decent work is a composite concept encompassing five key aspects: physically and interpersonally safe working conditions, hours that permit free time and sufficient rest, organizational values aligned with family and social values, fair compensation, and access to adequate healthcare [ 10 ]. Ensuring nurses’ perception of decent work is beneficial for both individual nurses and organizations. On one hand, safeguarding nurses’ decent work reduces burnout and intention to resign, enhancing their enthusiasm and stability in their roles [ 11 ]. On the other hand, a decent work environment fosters nurses’ work immersion, thereby enhancing their professional competence and service quality [ 12 ]. Additionally, decent work inspires nurses’ grit, enabling them to demonstrate higher adaptability and resilience when facing work pressures and challenges [ 13 ]. Therefore, considering the profound impact of burnout on nurses and organizations, we hypothesize that nurses’ burnout is negatively correlated with their perception of decent work.

Burnout refers to a syndrome that develops under prolonged work stress, encompassing three dimensions: emotional exhaustion, depersonalization, and reduced personal accomplishment [ 14 ]. Emotional exhaustion reflects the state of emotional fatigue and the degree of loss of enthusiasm for work. Depersonalization reflects the extent to which an individual adopts a negative, detached, or indifferent attitude towards clients. Reduced personal accomplishment reflects the degree to which an individual negatively evaluates the significance and value of their work [ 15 ]. In May 2019, the World Health Organization(WHO) included “burnout” in the International Classification of Diseases(ICD), highlighting the prevalence and severity of burnout [ 16 ]. Existing research indicates that burnout negatively impacts both physical and psychological health. Physiologically, burnout is associated with continuous autonomic nervous system activation, dysfunction of the sympathoadrenal medullary axis, elevated cortisol levels, changes in brain structure and function, metabolic syndrome, cardiovascular diseases, musculoskeletal disorders, respiratory diseases, and health issues such as headaches and infections [ 17 , 18 ]. Psychologically, burnout is associated with anxiety and depression, and it affects an individual’s well-being [ 19 , 20 ]. Therefore, we hypothesize that burnout is negatively correlated with the well-being of psychiatric nurses.

The well-being of nurses in their profession has be defined as their positive evaluation of their contributions to nursing work and the nursing profession, enabling nurses to be in the best possible state at any given time, with the ability to adapt to and overcome adversity as much as possible [ 21 ]. Research has found a close correlation between nursing quality and performance and well-being [ 22 ]. Moreover, from a long-term perspective, workplace well-being is conducive to reducing nurses’ burnout and enhancing job efficiency and satisfaction [ 23 , 24 ]. Therefore, safeguarding the well-being of nurses is crucial for both nurses themselves and their patients. Another study suggests that when employees’ basic needs are met, their well-being also improves [ 24 ]. Hence, we hypothesize that nurses’ perception of decent work is positively correlated with well-being.

The Job Demands-Resources (JD-R) model provides theoretical support for understanding these variables. This model emphasizes the interaction between an individual’s demands and resources in the work environment and how these interactions affect job performance, attitudes, and well-being. In this model, job demands are defined as aspects of the job that require physical and psychological effort, such as workload, role conflict, and time pressure. Job resources are positive factors that help individuals achieve work goals, reduce the physiological and psychological costs of job demands, and promote personal growth and development, such as job autonomy, colleague support, and performance feedback [ 25 , 26 ]. Within the JD-R framework, we hypothesize that the effort-reward imbalance for psychiatric nurses’ influences well-being through two pathways. The Deterioration Pathway: In this pathway, effort-reward imbalance increases burnout, which in turn reduces well-being. The Enhancement Pathway: In this pathway, a strong perception of decent work, as a reflection of good job resources, can mitigate the impact of burnout and enhance nurses’ well-being. Hence, we hypothesize that effort-reward imbalance among psychiatric nurses’ influences well-being, with burnout and decent work mediating this relationship.

Previous studies have explored the relationships between certain variables, such as the positive correlation between effort-reward imbalance and burnout [ 27 ], the negative correlation between effort-reward imbalance, burnout, and well-being [ 20 , 28 ], and the impact of decent work on nurses’ burnout [ 11 ]. However, there is a lack of research examining the relationship between effort-reward imbalance, well-being, decent work, and burnout, particularly among psychiatric nurses. Therefore, this study aims to examine the relationship between effort-reward imbalance, well-being, burnout, and decent work among psychiatric nurses. It also provides theoretical support and practical guidance for improving the working environment, conditions, job satisfaction, and professional development of psychiatric nurses.

Study design

This study employed a quantitative cross-sectional survey design, rigorously adhering to the guidelines outlined in the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. The research was conducted in February 2024 at two psychiatric specialty hospitals in Hangzhou and Huzhou cities, located in Zhejiang Province, China. These hospitals shared similarities in healthcare standards and operational models.

Sample size calculation utilized the G-Power 3.196 linear multiple regression algorithm. With an effect size of 0.15, α value of 0.05, and regression coefficient of 0.05, at a significance level of 0.05, and an expected power (1 - β error probability) of 0.95. The study encompassed 23 variables, including 6 socio-demographic characteristics and 13 dimensions related to the scale. The calculation indicated a minimum sample size requirement of 234 nurses. Considering a potential 20% rate of invalid questionnaires, at least 257 nurses were needed to meet the minimum sample size.

The inclusion criteria for participants were as follows: (1) Registered nurses; (2) Minimum of one year of experience in psychiatric healthcare; (3) Informed consent and willingness to participate in the study. Exclusion criteria included: (1) Nurses on leave; (2) Interns or trainees; (3) Administrative or logistical nursing staff.

The study gathered a total of 410 questionnaires. After excluding 13 invalid responses, 397 questionnaires were ultimately included in the analysis, resulting in an effective rate of 96.8%.

Measurements

Demographic information.

Demographic characteristics encompass gender, age, educational background, experience in psychiatric work, professional title, marital status.

Effort-reward imbalance scale

In this study, the Chinese version of the Effort-Reward Imbalance (ERI) Scale was used to investigate the effort-reward situation among psychiatric nurses. Developed by Siegrist [ 29 ], this scale has been widely used in the Chinese occupational population with demonstrated reliability and validity [ 30 ]. The scale comprises 23 items, representing three dimensions: “Effort” (6 items, scores ranging from 6 to 30), “Reward” (11 items, scores ranging from 11 to 55), and “Overcommitment” (6 items, scores ranging from 6 to 24). We calculated the Effort-Reward Ratio (ERR) to assess the imbalance between effort and reward. The ERR is calculated as (Effort Score / Reward Score) × (11 / 6), where a higher ERR indicates a more severe imbalance. In this study, the Cronbach’s α coefficient for this scale was calculated as 0.939.

Decent work perception scale

The Decent Work Perception Scale (DWPS), developed by Chinese scholars [ 31 ], was employed in this study to assess the perception of decent work among psychiatric nurses. This scale has been previously utilized in the nursing population and demonstrates good reliability and validity [ 11 ]. It consists of 16 items organized into five dimensions: Work Rewards (4 items), Work Position (3 items), Work Atmosphere (3 items), Work Development (3 items), and Work Recognition (3 items). Responses were rated on a 5-point Likert scale ranging from “1” (strongly disagree) to “5” (strongly agree), with total scores ranging from 16 to 80. Higher scores indicate a stronger perception of decent work. In this study, the Cronbach’s α coefficient for DWPS was determined to be 0.949.

Maslach burnout inventory-general survey

This study used the Chinese version of the Maslach Burnout Inventory-General Survey (MBI-GS) to investigate burnout among psychiatric nurses. The scale was developed by Maslach and has been cross-culturally adapted by Chinese scholars Chaoping Li [ 32 ]. It has been widely used among nurse populations. The scale includes three dimensions: emotional exhaustion, depersonalization, and reduced personal accomplishment, with a total of 15 items. Each item is assessed using a 7-point Likert scale, with scores ranging from 0 (never) to 6 (everyday) based on the nurse’s personal experiences. The personal accomplishment dimension is scored in reverse. Higher MBI-GS scores indicate higher levels of burnout. In this study, the Cronbach’s α coefficient for the Maslach-GS was 0.923.

General well-being schedule scale

This study used the General Well-Being Schedule Scale(GWBSS), developed by the National Center for Health Statistics in the United States [ 33 ], to assess the well-being of psychiatric nurses. The scale has been adapted by Chinese scholars and extensively used in China, demonstrating robust reliability and validity [ 34 ]. Comprising 18 items, the scale evaluates six dimensions: health worry, energy level, satisfying interesting life, mood (depressive or cheerful), emotional–behavioral control, and relaxed versus tense–anxious. For scoring, items 2, 5, 6, and 7 are rated on a 5-point scale, items 15–18 on a 10-point scale, while the remaining items are scored using a 6-point system. Additionally, items 1, 3, 6, 7, 9, 11, 13, 15, and 16 are reverse-scored. A higher total score on the scale indicates higher subjective well-being. In this study, the Cronbach’s α coefficient for this scale was calculated as 0.791.

Data collection

This study used electronic questionnaires for the survey. Before implementation, researchers created electronic links containing the consent form, instructions, and questionnaire content. Nurses could proceed to the next step only after reading and agreeing to the informed consent form. The instructions emphasized the purpose of the questionnaire, the guiding principles for answering questions, and important notes and explanations. Researchers trained data collectors on questionnaire distribution, focusing on the methods for completing the questionnaire, the principles of informed consent, the study’s purpose and significance, the instructions for completing the questionnaire, and familiarity with the questionnaire items. Two research assistants, after unified training, were responsible for distributing the questionnaires, with one researcher dedicated to quality supervision during the data collection process. First, team members communicated with the heads of the nursing departments of the two hospitals via email and meetings. After obtaining permission to conduct the survey, the research assistants sent the electronic questionnaire links to the nurses. Before completing the questionnaire, nurses were informed about the purpose and significance of the study, all potential risks, and emergency contact information. Nurses could freely choose to participate or decline to participate in the study, and they could withdraw at any time during the study without any consequences. Upon completion, the data were stored in a secure electronic folder accessible only to the researchers and authorized personnel with the password.

Data analysis

The questionnaire responses were automatically generated in spreadsheet format to ensure consistency in answers. We conducted a search for data anomalies (e.g., 12121212, 11111111) and subsequently removed them. Data analysis was performed using SPSS 26.0 and the PROCESS Macro. Harman’s single-factor test was employed to check for common method bias. Descriptive statistics were utilized to analyze the demographic characteristics of the study participants and the mean scores of variables. The relationships between variables were examined through Pearson correlation analysis. PROCESS v4.0 was used to assess the mediating roles of nurses’ burnout and decent work in the relationship between effort-reward imbalance and well-being. Bootstrap resampling generated 5,000 samples for mediation analysis, and a 95% confidence interval was applied for significance assessment of path coefficients. A p-value of < 0.05 was considered statistically significant.

Common method bias test

This study used a questionnaire survey to collect data. Due to the substantial number of questionnaire items and the extended duration for completion, and in order to mitigate common method bias, the data were subjected to Harman’s single-factor test. The results of the unrotated principal component factor analysis indicated the presence of ten factors with eigenvalues greater than 1. The first factor accounted for 32.64% of the total variance, falling below the 40% critical threshold. Therefore, it can be inferred that this study is not significantly affected by common method bias.

Sociodemographic characteristics

Table  1 presents the characteristics of the participants. Among them, 366 were female nurses, while 31 were male nurses, with ages ranging from 22 to 55 years, averaging 36.18 ± 8.17 years. The majority of participants had 5–15 years of work experience, accounting for 41.8%. Additionally, 367 participants held a bachelor’s degree, comprising 92.4% of the sample. The predominant professional title was supervisor nurse, with 170 individuals, representing 42.8%. Furthermore, 73.0% of the participants were married.

Descriptive statistics of variables

In this study, psychiatric nurses scored an average of 0.92 ± 0.28 on effort-reward imbalance, 30.47 ± 13.46 on burnout, 55.68 ± 10.84 on decent work, and 84.12 ± 15.33 on well-being. The scores for each dimension are presented in Table  2 .

Pearson correlation analysis

In this study, Pearson correlation analysis was conducted to examine the relationships among effort-reward imbalance, burnout, decent work, and well-being among psychiatric nurses, as presented in Table  2 . The results revealed negative correlations between effort-reward imbalance scores and decent work ( r =-0.564, p  < 0.001), well-being ( r =-0.541, p  < 0.001). Additionally, a positive correlation was found between effort-reward imbalance and burnout ( r  = 0.603, p  < 0.001). A negative correlation was found between decent work and burnout ( r =-0.541, p  < 0.001). Furthermore, a positive correlation was observed between decent work and well-being ( r  = 0.511, p  < 0.001). Finally, burnout was negatively correlated with well-being ( r =-0.691, p  < 0.001).

Mediation effect analysis

Table  3 presents the results of the relationship analysis among various variables. Effort-reward imbalance demonstrates a direct negative impact on well-being (β=-0.141, p  = 0.003) and decent work (β=-0.373, p  < 0.001). Furthermore, it exerts direct positive effects on burnout (β = 0.603, p  < 0.001). Burnout exhibits a negative direct effect on decent work (β=-0.316, p  < 0.001) and well-being (β=-0.526, p  < 0.001). Additionally, decent work shows a positive direct effect on well-being (β = 0.147, p  = 0.001).

As Fig.  1 shows, the results of the mediation analysis indicate that burnout mediates the relationship between effort-reward imbalance and well-being (95% CI [-0.386, -0.257]). Similarly, decent work also serves as a mediator between effort-reward imbalance and well-being (95% CI [-0.100, -0.012]). Additionally, burnout and decent work served as chain mediators in the relationship between effort-reward imbalance and well-being (95% CI [-0.050, -0.006]) (See Table  4 ). The confidence intervals for all these mediation effects do not include 0, confirming the existence of sequential mediation effects. Furthermore, the mediated effect accounts for 73.94% of the total effect.

The mediation of burnout and decent work in the relationship between effort-reward imbalance and well-being

Discussions

This study conducted a survey among nurses from two psychiatric hospitals in Zhejiang Province to investigate the relationships among effort-reward imbalance, burnout, decent work, and well-being, aiming to further validate theories in JD-R model. The findings revealed a direct impact of effort-reward imbalance on nurses’ well-being. Additionally, burnout and decent work were found to mediate the relationship between effort-reward imbalance and well-being.

The results of this study indicate a positive correlation between the effort-reward imbalance and burnout among psychiatric nurses, aligning with our hypothesized outcomes. Similar conclusions have been drawn from previous research [ 35 ]. This finding holds significant practical implications as psychiatric nurses often encounter challenges such as collaborating with difficult patient populations, limited resources, violence, and aggression [ 7 ]. Nurses must focus not only on the physical symptoms of their patients but also on their mental state and behavior. The continuously high job demands deplete the physical and mental resources of psychiatric nurses, making them more susceptible to burnout. Therefore, hospital management should pay close attention to the work environment and resource allocation for psychiatric nurses, ensuring they have sufficient support and resources to cope with the challenges they face in their work.

Additionally, this study’s findings reveal a negative correlation between burnout and the perception of decent work among psychiatric nurses. Notably, another study has shown that decent work can influence burnout; specifically, decent work as a job resource can alleviate burnout [ 11 ]. This suggests a potential bidirectional relationship between decent work and burnout: on one hand, a good working environment and perception of decent work can reduce burnout; on the other hand, when nurses are in a state of burnout, their perception of decent work may be diminished, further exacerbating the negative effects of burnout. Therefore, managers should take a multi-faceted approach to actively prevent and intervene in the burnout of psychiatric nurses, to maintain their perception of decent work and overall job satisfaction.

Additionally, the study findings revealed a positive correlation between psychiatric nurses’ perception of decent work and their sense of well-being. This aligns with previous research, further emphasizing the significance of decent work in enhancing overall employee well-being [ 36 ]. Decent work entails establishing a secure, supportive, and conducive work environment for employees. In psychiatric settings, a safe and supportive work environment can mitigate the impact of work stressors such as violence and intimidation on nurses, thereby enhancing their well-being [ 37 ]. Moreover, decent work emphasizes fair compensation, including competitive wages, benefits, and opportunities for career advancement. Adequate financial remuneration acknowledges psychiatric nurses’ expertise, skills, and contributions, alleviating financial strain and enhancing overall well-being. Benefits such as health insurance, paid leave, and employee assistance programs further support nurses’ physical and mental health, fostering a sense of well-being. Therefore, psychiatric healthcare institutions should strive to create a decent work environment to ensure that psychiatric nurses can provide optimal patient care.

Finally, this study reveals that the imbalance between effort and reward for psychiatric nurses affects their well-being, with burnout and the perception of decent work serving as mediators in this relationship. These findings are consistent with the JD-R [ 26 ]. Specifically, psychiatric nurses often encounter emotionally demanding and complex work environments, where they not only handle numerous medical tasks but also manage patients’ emotional fluctuations and unpredictable behaviors. This high-pressure work environment can lead to feelings of effort-reward imbalance [ 38 ]. When psychiatric nurses perceive an imbalance between their effort and reward, they may experience frustration, disappointment, and excessive stress [ 27 ]. Over time, this continuous pressure leads to burnout, which further impacts their perception of decent work and reduces their overall well-being. This indicates a deterioration pathway where high job demands and low rewards deplete nurses’ physical and mental resources, lowering their well-being. Moreover, burnout not only reduces nurses’ work efficiency but also changes their perception of work [ 39 , 40 ]. They may feel that their work is undervalued, leading to a diminished sense of decent work. Conversely, a strong perception of decent work, as a reflection of good job resources, can mitigate the impact of burnout and enhance nurses’ well-being. Therefore, managers need to promote the perception of decent work among psychiatric nurses, alleviate the effects of effort-reward imbalance and burnout, and enhance their well-being.

Implication

This study holds significant practical implications for psychiatric nursing. Firstly, managers should prioritize achieving a balance between psychiatric nurses’ efforts and rewards to ensure they receive due recognition and compensation. This can be accomplished through the establishment of equitable salary structures, offering opportunities for career advancement, and implementing reward systems [ 41 ]. Secondly, both managers and healthcare institutions need to strengthen the support system for psychiatric nurses, fostering a more harmonious and supportive work environment. This includes providing psychological counseling and emotional support services, establishing support groups and in-house social platforms, and enhancing patient and family understanding and respect for nurses’ work [ 42 ]. Moreover, creating a decent work environment is crucial, whereby managers ensure psychiatric nurses have appropriate equipment, optimize workflow and compensation mechanisms, promote respect for nurses, and bolster various welfare benefits.

The study has several limitations. Firstly, its cross-sectional design precludes establishing causal relationships among variables. Therefore, future research could employ longitudinal designs to explore the causality between effort-reward imbalance and well-being. Secondly, although the electronic questionnaire emphasized anonymity and voluntariness, it still cannot entirely eliminate confounding factors such as nurses’ social expectations and recall biases. Future studies could employ qualitative research methods for further exploration. Lastly, the sample primarily consisted of psychiatric nurses, predominantly female with undergraduate degrees. Future studies could further investigate variations in variables among different genders and educational backgrounds.

The present study elucidates the impact of effort-reward imbalance on well-being and confirms the mediating roles of burnout and decent work. These findings provide a critical foundation for enhancing the work environment and welfare of psychiatric nurses. Psychiatric hospital management should focus on providing adequate support, fair compensation, reasonable work schedules, and professional development opportunities. By improving these key factors, the negative effects of effort-reward imbalance and burnout can be mitigated, creating a more supportive and well-being-oriented work environment for psychiatric nurses.

Data availability

The data that support the findings of this study are available from the corresponding author on reasonable request.

Abbreviations

Effort-reward imbalance

International labour organization

World Health Organization

Strengthening the reporting of observational studies in epidemiology

International classification of diseases

Job demands-resources

Nourafkan NJ, Tanova C. Employee perceptions of decent work: a systematic literature review of quantitative studies. Curr Psychol. 2023;42(34):29772–800.

Article   Google Scholar  

Sartorius N, Gaebel W, Cleveland HR, Stuart H, Akiyama T, Arboleda-Flórez J, Baumann AE, Gureje O, Jorge MR, Kastrup M, et al. WPA guidance on how to combat stigmatization of psychiatry and psychiatrists. World Psychiatry. 2010;9(3):131–44.

Article   PubMed   PubMed Central   Google Scholar  

Gaebel W, Zäske H, Zielasek J, Cleveland H-R, Samjeske K, Stuart H, Arboleda-Florez J, Akiyama T, Baumann AE, Gureje O, et al. Stigmatization of psychiatrists and general practitioners: results of an international survey. Eur Arch Psychiatry Clin NeuroSci. 2015;265(3):189–97.

Article   PubMed   Google Scholar  

Konttila J, Holopainen A, Kyngäs H, Pesonen H-M. Background characteristics and exposure to violence predict well-being at work among psychiatric outpatient nurses. Arch Psychiatr Nurs. 2021;35(2):223–31.

Schulz M, Damkröger A, Heins C, Wehlitz L, Löhr M, Driessen M, Behrens J, Wingenfeld K. Effort-reward imbalance and burnout among German nurses in medical compared with psychiatric hospital settings. J Psychiatr Ment Health Nurs. 2009;16(3):225–33.

Article   CAS   PubMed   Google Scholar  

Sperlich S, Peter R, Geyer S. Applying the effort-reward imbalance model to household and family work: a population-based study of German mothers. BMC Public Health. 2012;12(1):12.

Colindres CV, Bryce E, Coral-Rosero P, Ramos-Soto RM, Bonilla F, Yassi A. Effect of effort-reward imbalance and burnout on infection control among Ecuadorian nurses. Int Nurs Rev. 2018;65(2):190–9.

Jackson B, Kubzansky LD, Wright RJ. Linking perceived unfairness to physical health: the perceived unfairness model. Rev Gen Psychol. 2006;10(1):21–40.

Decent work. Report of the Director-General, International Labour Conference, 87th Session. Geneva. https://www.ilo.org/public/english/standards/relm/ilc/ilc87/rep-i.htm

Svicher A, Di Fabio A, Gori A. Decent work in Italy: a network analysis. Australian J Career Dev. 2022;31(1):42–56.

Xue B, Feng Y, Hu Z, Chen Y, Zhao Y, Li X, Yang Y, Zhang J, Zhang Y, Luo H. Assessing the mediation pathways: how decent work affects turnover intention through job satisfaction and burnout in nursing. Int Nurs Rev 2024.

Yu R, Gan Q, Bian J, Chen R, Sun X, Ling H. The mediating role of psychological empowerment in perceptions of decent work and work immersion among Chinese nurses: a cross-sectional study. Int Nurs Rev 2023.

El-Gazar E, A Zoromba H, Hassan Saad Elzohairy M. Effects of decent work on nurses’ grit and interprofessional teamness: a cross-sectional study during the COVID-19 pandemic. Egypt J Health Care. 2022;13(1):2091–104.

Maslach C, Leiter MP. Burnout. In: Stress: Concepts, Cognition, Emotion, and Behavior: Handbook of Stress. edn.; 2016: 351–357.

Homayooni A, Homayooni F, Homayooni S. The relationship between personality traits, basic psychological needs satisfaction, work-related psychological flexibility and job burnout. Iran Occup Health. 2020;16(6):27–39.

Google Scholar  

Adlakha D. Burned out: Workplace policies and practices can tackle Occupational Burnout. Workplace Health Saf. 2019;67(10):531–2.

Bayes A, Tavella G, Parker G. The biology of burnout: causes and consequences. World J Biol Psychiatry. 2021;22(9):686–98.

Lovell LP, Atherley AEN, Watson HR, King RD. An exploration of burnout and resilience among emergency physicians at three teaching hospitals in the English-speaking Caribbean: a cross-sectional survey. Lancet Reg Health Am. 2022;15:100357.

PubMed   PubMed Central   Google Scholar  

Koutsimani P, Montgomery A. A two-Wave Study on the associations of Burnout with Depression and anxiety: the mediating and moderating role of Perceived Family support. Psychol Rep. 2023;126(1):220–45.

Qu H-Y, Wang C-M. Study on the relationships between nurses’ job burnout and subjective well-being. Chin Nurs Res. 2015;2(2):61–6.

Patrician PA, Bakerjian D, Billings R, Chenot T, Hooper V, Johnson CS, Sables-Baus S. Nurse well-being: a concept analysis. Nurs Outlook. 2022;70(4):639–50.

Kim EJ, Kim SK. Nurses’ happiness: integrative literature review and meta-analysis. J Korean Acad Soc Home Health Care Nurs. 2021;28(3):243–55.

Tzeng ST, Su BY, Chen HM. Correlation among Workplace Burnout, Resilience, and well-being in nursing staff: a cross-sectional study in Taiwan. J Nurs Res 2023, 31(5).

Han S. Nurses’ job crafting, work engagement, and well-being: a path analysis. BMC Nurs. 2023;22(1):405.

Schaufeli WB, Bakker AB, Van Rhenen W. How changes in job demands and resources predict burnout, work engagement, and sickness absenteeism. J Organizational Behav. 2009;30(7):893–917.

Demerouti E, Bakker AB, Nachreiner F, Schaufeli WB. The job demands-resources model of burnout. J Appl Psychol. 2001;86(3):499.

Diekmann K, Böckelmann I, Karlsen HR, Lux A, Thielmann B. Effort-reward imbalance, Mental Health and Burnout in Occupational groups that Face Mental stress. J Occup Environ Med. 2020;62(10):847–52.

Van Vegchel N, De Jonge J, Meijer T, Hamers JPH. Different effort constructs and effort–reward imbalance: effects on employee well-being in ancillary health care workers. J Adv Nurs. 2001;34(1):128–36.

Siegrist J. Adverse health effects of high-effort/low-reward conditions. : Educational Publishing Foundation; 1996: 27–41.

Li J, Yang W, Cheng Y, Siegrist J, Cho S-I. Effort–reward imbalance at work and job dissatisfaction in Chinese healthcare workers: a validation study. Int Arch Occup Environ Health. 2005;78(3):198–204.

Mao G, Liu W, Song H. Perceived decent work: Scale Development and Validation. Stat Decis. 2014;30(14):86–9.

Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory: third edition. Evaluating stress: a book of resources. edn. Lanham, MD, US: Scarecrow Education; 1997. pp. 191–218.

Fazio A. A concurrent validation study of the NCHS General Well-Being Schedule.(Dept. of HEW Publ. No. HRA-78-1347). Hyattsville, MD: National Center for Health Statistics 1977.

Duan J. The application of General Well-being schedule in university students. Chin J Clin Psychol. 1996;4(1):56–7.

Yuan Z, Yu D, Zhao H, Wang Y, Jiang W, Chen D, Liu X, Li X. Burnout of healthcare workers based on the effort-reward imbalance model: a cross-sectional study in China. Int J Public Health. 2021;66:599831.

Duffy RD, Prieto CG, Kim HJ, Raque-Bogdan TL, Duffy NO. Decent work and physical health: a multi-wave investigation. J Vocat Behav. 2021;127:103544.

Jain A, Hassard J, Leka S, Di Tecco C, Iavicoli S. The Role of Occupational Health Services in Psychosocial Risk Management and the Promotion of Mental Health and Well-being at work. Int J Environ Res Public Health. 2021;18(7):3632.

Teles MAB, Barbosa MR, Vargas AMD, Gomes VE, e Ferreira EF, Martins AMEBL, Ferreira RC. Psychosocial work conditions and quality of life among primary health care employees: a cross sectional study. Health Qual Life Outcomes. 2014;12(1):72.

Wang QQ, Lv WJ, Qian RL, Zhang YH. Job burnout and quality of working life among Chinese nurses: a cross-sectional study. J Nurs Adm Manag. 2019;27(8):1835–44.

Ashipala DO, Nghole TM. Factors contributing to burnout among nurses at a district hospital in Namibia: a qualitative perspective of nurses. J Nurs Adm Manag. 2022;30(7):2982–91.

Zhang J, Wang Y, Xu J, You H, Li Y, Liang Y, Li S, Ma L, Lau JT-f, Hao Y, et al. Prevalence of mental health problems and associated factors among front-line public health workers during the COVID-19 pandemic in China: an effort–reward imbalance model-informed study. BMC Psychol. 2021;9(1):55.

Ogbe E, Harmon S, Van den Bergh R, Degomme O. A systematic review of intimate partner violence interventions focused on improving social support and/ mental health outcomes of survivors. PLoS ONE. 2020;15(6):e0235177.

Article   CAS   PubMed   PubMed Central   Google Scholar  

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Acknowledgements

We sincerely thank all the nurses who participated. Additionally, we extend our gratitude to Huzhou Third Municipal Hospital for their support in data collection.

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Xiaoyan Zhang and Liya Zhang contributed equally to this work and share first authorship.

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Affiliated Mental Health Center & Hangzhou Seventh People’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310007, Zhejiang, China

Xiaoyan Zhang, Liya Zhang, Bowen Xue, Yanping Li, Mengmeng Yan, Hong Luo & Xiaoyu Huang

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HL and XH conceived and designed the study. XZ, LZ, YL, and MY performed data collection, XZ and LZ drafted the paper, and reviewed the manuscript. BX performed the statistical analyses and editing and of the manuscript. All authors contributed to and approved the final manuscript.

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Correspondence to Hong Luo or Xiaoyu Huang .

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This study strictly adhered to the principles of the Helsinki Declaration. Ethical approval for the research was obtained from the Ethics Review Committee of the Affiliated Mental Health Center & Hangzhou Seventh People’s Hospital, Zhejiang University School of Medicine (Approval No. 2024-009). Informed consent was obtained from all participants in this study.

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Zhang, X., Zhang, L., Xue, B. et al. Effort–reward imbalance and well-being among psychiatric nurses: the mediating role of burnout and decent work. BMC Nurs 23 , 635 (2024). https://doi.org/10.1186/s12912-024-02301-4

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Received : 24 June 2024

Accepted : 28 August 2024

Published : 11 September 2024

DOI : https://doi.org/10.1186/s12912-024-02301-4

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Burnout in critical care nurses: a literature review

Affiliation.

• 1 Grey Nuns Community Hopsital, Edmonton, AB. [email protected]
• PMID: 23342935

Burnout and its development in critical care nurses is a concept that has received extensive study, yet remains a problem in Canada and around the world. Critical care nurses are particularly vulnerable to developing burnout due to the chronic occupational stressors they are exposed to, including high patient acuity, high levels of responsibility, working with advanced technology, caring for families in crisis, and involved in morally distressing situations, particularly prolonging life unnecessarily. The purpose of this article is to explore how the chronic stressors that critical care nurses are exposed to contribute to the development of burnout, and strategies for burnout prevention. A review of the literature between the years 2007 and 2012 was conducted and included the search terms burnout, moral distress, compassion fatigue, intensive care, critical care, and nursing. The search was limited to the adult population, English language, and Western cultures. The results revealed that nurse managers play a crucial role in preventing burnout by creating a supportive work environment for critical care nurses. Strategies for nurse managers to accomplish this include being accessible to critical care nurses, fostering collegial relationships among the different disciplines, and making a counsellor or grief team available to facilitate debriefing after stressful situations, such as a death. In addition, critical care nurses can help prevent burnout by being a support system for each other and implementing self-care strategies.

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Burnout: A Review of Theory and Measurement

Sergio edú-valsania.

1 Department of Social Sciences, Universidad Europea Miguel de Cervantes (UEMC), C/Padre Julio Chevalier, 2, 47012 Valladolid, Spain; se.cmeu@udes

Ana Laguía

2 Department of Social and Organizational Psychology, Faculty of Psychology, Universidad Nacional de Educación a Distancia (UNED), C/Juan del Rosal 10, 28040 Madrid, Spain; se.denu.isp@onairomaj

Juan A. Moriano

A growing body of empirical evidence shows that occupational health is now more relevant than ever due to the COVID-19 pandemic. This review focuses on burnout, an occupational phenomenon that results from chronic stress in the workplace. After analyzing how burnout occurs and its different dimensions, the following aspects are discussed: (1) Description of the factors that can trigger burnout and the individual factors that have been proposed to modulate it, (2) identification of the effects that burnout generates at both individual and organizational levels, (3) presentation of the main actions that can be used to prevent and/or reduce burnout, and (4) recapitulation of the main tools that have been developed so far to measure burnout, both from a generic perspective or applied to specific occupations. Furthermore, this review summarizes the main contributions of the papers that comprise the Special Issue on “Occupational Stress and Health: Psychological Burden and Burnout”, which represent an advance in the theoretical and practical understanding of burnout.

1. Introduction

When work and professional environments are not well organized and managed, they can have adverse consequences for workers that, far from dignifying them, exhaust them and consume their psychological resources. Burnout has become one of the most important psychosocial occupational hazards in today’s society, generating significant costs for both individuals and organizations [ 1 , 2 , 3 , 4 ]. Although burnout was initially considered to be specific to professionals working in the care of people [ 5 ], later evidence has shown that this syndrome can develop among all types of professions and occupational groups [ 6 , 7 ]. However, burnout prevalence estimates vary considerably according to the burnout definition applied. For instance, a national study of US general surgery residents found estimates varied from 3.2% to 91.4%, with 43.2% of respondents acknowledging weekly symptoms [ 8 ].

The enormous negative impact that burnout has on the work and personal lives of workers, also affecting the economy and public health of the most affected countries, has led the World Health Organization (WHO) to include this syndrome in the 11th Revision of the International Classification of Diseases (ICD-11) as a phenomenon exclusive to the occupational context. Likewise, the need to address burnout is also justified for legal reasons, such as compliance with the European Union Framework Directive on Health and Safety (89/391/EEC).

A growing body of empirical evidence shows that occupational health is now more relevant than ever due to the COVID-19 pandemic. Particularly, the pandemic has placed considerable psychological strain on healthcare workers. Since the COVID-19 outbreak, numerous studies related to burnout have been carried out with samples of frontline healthcare workers, physicians, nurses, or pharmacists across the world [ 9 , 10 , 11 , 12 ]. However, the lack of a baseline level of burnout before the pandemic makes it difficult to compare changes in prevalence for the same populations. Evidence from studies of the impact of past outbreaks (e.g., SARS, influenza, or Ebola epidemics) show long-term cognitive and mental health effects (e.g., emotional distress, post-traumatic stress disorder) [ 13 ]. This evidence can be useful to design interventions for healthcare workers. These are also hard times for workers in general. Teleworking full-time due to COVID-19 has received the attention of several empirical works, which analyze job exhaustion and burnout [ 14 , 15 , 16 , 17 ]. Teacher burnout is also the focus of an increasing number of studies [ 18 , 19 , 20 , 21 ]. Additionally, working parents may experience high levels of stress in the home environment during the COVID-19 pandemic, leading to parental burnout [ 22 , 23 ].

This review aims to understand what burnout is and its different components, how it occurs, to identify the factors that trigger burnout and the individual factors that modulate it, to identify the effects that burnout generates at both individual and organizational levels, to understand which are the main actions that can be used to prevent and/or reduce burnout, and to present the main tools that currently exist to measure burnout.

2. Burnout: Definition and Development of This Construct

Overall, burnout syndrome is an individual response to chronic work stress that develops progressively and can eventually become chronic, causing health alterations [ 24 ]. From a psychological point of view, this syndrome causes damage at a cognitive, emotional, and attitudinal level, which translates into negative behavior towards work, peers, users, and the professional role itself [ 25 ]. However, it is not a personal problem, but a consequence of certain characteristics of the work activity [ 26 ].

Historically, Graham Greene was the first author to use the term burnout in his novel “A Burnt-Out Case” when describing the story of an architect who found neither meaning in his profession nor pleasure in life. Later, the term was picked up and introduced in the psychological sphere by Freudenberger [ 27 ], where he described burnout as a state of exhaustion, fatigue, and frustration due to a professional activity that fails to produce the expected expectations. Initially, this author delimited it as something exclusively related to volunteer workers in a care center where all kinds of people with mental disorders and social problems attended. Because of their occupation, these workers experienced in crescendo a loss of energy to the point of exhaustion and demotivation, as well as aggressiveness towards the service users.

Shortly thereafter, Maslach [ 28 ] introduced burnout into the scientific literature and defined it as a gradual process of fatigue, cynicism, and reduced commitment among social care professionals. Years later and after several empirical studies, Maslach and Jackson [ 5 ] reformulated the concept and elaborated a more rigorous and operational definition of burnout as a psychological syndrome characterized by emotional exhaustion, depersonalization and a reduced sense of professional efficacy that can appear in caregivers ( Table 1 ). The turning point between the two definitions is the consideration of burnout as a syndrome, with a syndrome being understood as a picture or set of symptoms and signs that exist at the same time and clinically define a particular state distinct from others.

Burnout dimensions.

However, some authors have argued that these three dimensions are not completely independent. Thus, it is possible to find several explanations in the literature. The difference between them lies in which is the first dimension that appears in the face of job stress (emotional exhaustion or depersonalization). Although definitive evidence has not yet been obtained, longitudinal studies have shown that there is a causal order between the key dimensions of burnout. Thus, high levels of emotional exhaustion lead to high levels of cynicism or depersonalization [ 29 ]. Likewise, empirical studies indicate that exhaustion and depersonalization constitute the core or key dimensions of the syndrome of being burned out at work, while lack of professional fulfillment is considered as an antecedent of burnout or even a consequence [ 30 ].

Finally, although Maslach and Jackson’s [ 5 ] conceptualization of burnout remains the most widely accepted, other definitions or formulations are found in the scientific literature. For example, Salanova et al. [ 31 ] reformulate such approaches and propose an extended model of burnout composed of: (1) exhaustion (related to crises in the relationship between the person and work in general), (2) mental distance that includes both cynicism (distant attitudes towards work in general) and depersonalization (distant attitudes towards the people for and with whom one works) and (3) professional inefficacy (feeling of not doing tasks adequately and being incompetent at work).

2.1. Subtypes of Burnout

As an alternative to the unitary definition of burnout, Montero-Marín [ 24 ] proposes that this syndrome does not always develop in the same way and that, on the contrary, there can be three variations that depend on the dedication of workers to their work activity ( Figure 1 ). These subtypes could also be understood as stages in which there is a progressive deterioration in the levels of worker commitment to their job and have repercussions when choosing the intervention to be applied [ 32 ]. From this theoretical perspective, burnout is considered a developing condition, with a progressive reduction in levels of engagement, and evolves from enthusiasm to apathy [ 24 ]. Burnout is proposed to typically appear with the excessive involvement characteristic of the frenetic subtype. Since it is not easy to maintain this level of activity without becoming exhausted, the worker may adopt a certain protective distance. This distancing may relieve workers from overactivity, but at the cost of the frustration that emerges in the under-challenged subtype. In the long run, this leads to a reduced perception of efficacy, giving way to passive coping strategies, typically present in the worn-out subtype. The parallelism between the evolution of the syndrome and the different subtypes raises the possibility of implementing new lines of therapeutic intervention on burnout by understanding the subtypes as a succession of stages in the development of the syndrome [ 24 ]. Indeed, empirical studies suggest a progressive deterioration from the frenetic to the under-challenged and worn-out [ 33 ]. Nevertheless, more longitudinal studies are still needed to clarify the transition from one subtype to another and the evolution of the syndrome.

Profiles and subtypes of burnout.

The frenetic subtype is typical of work contexts with overload and workers who work intensely until exhaustion. It also tends to be more frequent in jobs with split shifts, temporary contracts and, in general, situations that force workers to be much more involved to keep the job. It is the subtype of burnout in which workers show greater dedication to work. At the motivational level, these workers show high involvement and need to obtain important achievements and it has been related to a coping style based on the attempt to solve problems actively, for which they use a high number of working hours per week or are involved in different jobs at the same time. For all these reasons, this profile is associated with high levels of burnout and a feeling of abandonment of personal life and health at work.

The under-challenged subtype is typical of monotonous and unstimulating professions, with repetitive, mechanical, and routine tasks that do not provide the necessary satisfaction to workers, who state that the work is not rewarding and is monotonous. Consequently, workers show indifference, boredom, and lack of personal development along with a desire to change jobs. This subtype of burnout is related to high levels of cynicism, due to a lack of identification with work tasks, and is associated with an escapist coping style, based on distraction or cognitive avoidance.

The worn-out subtype is characterized mainly by feelings of hopelessness and a sense of lack of control over the results of their work and recognition of the efforts invested, so that they finally opt for neglect and abandonment as a response to any difficulty. It is, therefore, the profile in which the worker shows less dedication. Thus, this type of profile is strongly associated with the perception of inefficiency and a passive style of coping with stress, based mainly on behavioral disconnection, which generates a strong sense of incompetence and makes them experience feelings of guilt.

2.2. Why Does Burnout Appear and How Does It Develop?

Since the appearance of the term in the scientific literature, several approaches have emerged that have attempted to answer the question of why burnout appears and how it develops. In this section, we will focus on detailing the most current and empirically supported explanatory theories of burnout considering that, instead of being antagonistic to each other, they are complementary and provide a more global view of this syndrome. Specifically, the following theories are summarized: (1) social cognitive theory; (2) social exchange theory; (3) organizational theory; (4) structural theory; (5) job demands–resources theory; (6) emotional contagion theory.

2.2.1. Social Cognitive Theory

This approach is characterized by giving a central role to individual variables such as self-efficacy, self-confidence and self-concept in the development and evolution of burnout [ 34 , 35 ]. So, this syndrome is triggered when the worker harbors doubts about their own effectiveness, or that of their group, in achieving professional goals [ 36 , 37 ]. These approaches were corroborated in a study conducted in a Spanish context with 274 secondary school teachers showing that burnout occurred after the emergence of professional efficacy crises [ 36 ].

The circumstances facilitate the development of inefficacy expectations or efficacy crises are the following [ 38 ]: (1) negative experiences of failure in the past, (2) lack of reference models who have gone through a similar experience and have overcome it, (3) lack of external reinforcement for the work, (4) lack of feedback on the work completed or excessive negative criticism, and (5) difficulties at work. In this way, crises of effectiveness would lead to low professional fulfillment which, if maintained over time, would generate emotional exhaustion and then cynicism/depersonalization as a way of coping with stress ( Figure 2 ).

Development of burnout according to the socio-cognitive theory of the self-efficacy.

2.2.2. Social Exchange Theory

This theory considers that burnout occurs when the worker perceives a lack of equity between the efforts and contributions made and the results obtained in their work [ 39 ]. This lack of reciprocity, which can occur with service users, colleagues, supervisors, and organizations, consumes the emotional resources of professionals, generating an emotional exhaustion that becomes chronic. From this approach, burnout can be triggered by the significant interpersonal demands involved in dealing with clients/users that become emotionally consuming. Thus, to avoid contact with the original source of discomfort, depersonalization or cynicism is used as a stress coping strategy, which ultimately leads to low personal fulfillment ( Figure 3 ).

Development of burnout according to social exchange theory.

2.2.3. Organizational Theory

This approach considers that burnout is a consequence of organizational and work stressors (see Section 3.1 ) combined with inadequate individual coping strategies [ 40 , 41 ]. Within this theory, there are two alternative models to explain the relationships between the dimensions of burnout. According to Golembiewski et al. [ 41 ], burnout starts because of the existence of organizational stressors or risk factors, such as work overload or role ambiguity, and before which some individuals show as a coping strategy a decrease in their organizational commitment, which is very similar to cynicism and depersonalization. Subsequently, the person will experience low personal fulfillment at work and emotional exhaustion, which triggers burnout syndrome. Thus, depersonalization would be the first phase of burnout, followed by a feeling of low self-fulfillment and, finally, emotional exhaustion. The alternative proposal is that put forward by Cox et al. [ 40 ]. For these authors, the emotional exhaustion caused by enduring work stressors is the initial dimension of this syndrome. Depersonalization is considered a coping strategy in the face of emotional exhaustion and low personal fulfillment is the result.

2.2.4. Demands–Resources Theory

This approach postulates that burnout occurs when there is an imbalance between the demands and resources derived from work [ 42 ]. Job demands are those job factors that require sustained physical or mental effort and are associated with certain physiological costs due to activation of the hypothalamic–pituitary–adrenal axis and psychological costs (e.g., subjective fatigue, reduced focus of attention, and redefinition of task requirements). Common work demands include work overload, emotional labor, time pressure, or interpersonal conflicts. When recovery in the face of such demands is insufficient or inadequate, a state of physical and mental exhaustion is triggered.

Work resources, on the other hand, refer to the physical, psychological, organizational, or social aspects of work that can reduce the demands of work and the associated physiological and psychological costs and that can be decisive in achieving work objectives. Resources at work can be organizational in nature, but also personal ( Table 2 ). When demands exceed resources, fatigue occurs; if this imbalance is maintained over time, fatigue becomes chronic and, finally, burnout appears. Therefore, job demands have a direct and positive relationship with burnout, especially emotional exhaustion, while the existence of job resources inversely influences depersonalization by minimizing or reducing its use as a coping strategy.

Summary of main demands and job resources.

2.2.5. Structural Theory

This approach maintains that burnout is a response to chronic job stress that appears when the coping strategies employed by the individual to manage job stressors fail. Initially, work stress will elicit a series of coping strategies. When the coping strategies initially employed are not successful, they lead to professional failure and to the development of feelings of low personal fulfillment at work and emotional exhaustion. Faced with these feelings, the subject develops depersonalization attitudes as a new form of coping. (The sequence is illustrated in Figure 4 .) In turn, burnout will have adverse consequences both for the health of individuals and for organizations. This model has been empirically contrasted with different professional groups such as teachers or nurses [ 43 ].

Development of burnout according to structural theory.

2.2.6. Theory of Emotional Contagion

Emotional contagion refers to the tendency to automatically imitate and synchronize facial expressions, vocalizations, postures, and movements with those of other people and, consequently, to converge emotionally with them [ 44 ]. When people work together, it is common for them to share situations and experience collective emotions, such as sadness, fear, or exhaustion. Therefore, from this theory it is considered that burnout occurs in work groups, since there are shared beliefs and emotions that are developed throughout social interaction [ 38 ]. This burnout contagion has been evidenced especially in teaching and health personnel [ 45 ], as well as between spouses (outside work). Thus, emotional contagion influences the development of burnout both inside and outside the workplace [ 26 , 46 ].

3. What Circumstances Trigger Burnout?

The antecedents are those aspects that are going to propitiate, trigger, and/or maintain people suffering from burnout syndrome. In general, these aspects can be classified into two broad categories: (1) organizational factors such as, for example, the workload or the emotional demands involved, and (2) individual factors such as, for example, the worker’s personality or coping strategies. It is important to emphasize that this syndrome is primarily a consequence of exposure to certain working conditions and not an individual characteristic such as a personality trait. Strictly speaking, therefore, the triggers of burnout would be factors related to the work (be it content, structure or relationships with users, clients, bosses, and/or colleagues). However, it is considered that, although organizational factors are capable per se of generating burnout, certain individual factors would act as moderating variables. Thus, personal aspects such as, for example, a lack of self-confidence or the use of stress-avoidance coping mechanisms could play a role in enhancing situational factors. On the other hand, other individual characteristics, such as optimism or active coping, can lessen or even slow down the negative effect of organizational factors on burnout and its consequences.

3.1. Organizational Factors

Regarding situational factors, reviews of the scientific literature [ 47 ] show that, in general, both the type of tasks, the way they are organized and the relationships between colleagues, bosses, and/or clients are potential burnout triggers or risk factors.

3.1.1. Work Overload

Workload, both quantitative and qualitative, when excessive, requires sustained effort, generating physiological and psychological costs. Such symptoms can trigger the experience of burnout and psychological distancing from work as a self-defense mechanism [ 48 ].

3.1.2. Emotional Labor

Emotional labor is understood as the psychological process necessary to self-regulate one’s emotions and show those emotions desired by the organization. It involves controlling or hiding negative emotions such as anger, irritation or discomfort to comply with the rules or requirements of the organization and objectives of the job, as well as the display of emotions not felt, such as sympathy towards customers or users, although the opposite is really felt, or tranquility in situations in which what is really felt is fear. Emotional labor will therefore involve a greater workload. In this sense, several studies have shown positive relationships between emotional labor and burnout in different professions, such as teachers [ 49 ] and HR department workers [ 50 ].

3.1.3. Lack of Autonomy and Influence at Work

Lack of freedom at work when performing tasks, as well as the inability to influence decisions that affect work has been positively associated with higher levels of burnout. Conversely, when workers experience autonomy and control over their work, there are lower rates of burnout and higher rates of professional fulfillment [ 48 ]. In this line, several investigations have found negative relationships between burnout and empowerment, so that the greater the empowerment perceived by workers, the lower the levels of burnout experienced [ 51 , 52 ].

3.1.4. Ambiguity and Role Conflict

When the worker does not know what is expected of them and/or does not have enough information about their mission (role ambiguity) or in their case the different tasks and demands to be fulfilled are incongruent or incompatible with each other (role conflict), burnout levels are increased [ 53 ].

3.1.5. Inadequate Supervision and Perception of Injustice

The perception of inadequate supervision (e.g., excessively directive, and unfair by only focusing on the negative aspects without valuing achievements and efforts, or at the other extreme not at all directive or non-existent) increases the risk of developing burnout. On the contrary, a fair treatment with employees favors the increase in available resources, exerting a negative effect on emotional exhaustion in such a way that workers are less likely to develop burnout symptomatology [ 54 ].

3.1.6. Lack of Perceived Social Support

Lack of social support at work, either from co-workers or supervisors, as well as internal conflicts between co-workers are considered important triggers of burnout. On the contrary, social support has been found to act as a brake on this syndrome [ 55 ].

3.1.7. Poor Working Hours

The working hours conditions that make it difficult to reconcile family and professional life are another important trigger of burnout. For instance, shift work, high rotations, night work, long working hours, or a large amount of overtime are powerful triggers of burnout. Additionally, such hourly characteristics are positively related to sleep disorders, heart problems, health complaints, job dissatisfaction, decreased attention and performance, as well as an increased risk of accidents [ 48 ].

3.2. Individual Factors Modulating Burnout

Regarding individual factors, both personality traits and sociodemographic variables and coping strategies have been analyzed as predisposing or facilitating the development of burnout in the case of the presence of some of the organizational factors explained above. Table 3 summarizes these factors and their modulating effect on burnout: positive (they amplify the effect of social factors) or negative (they reduce the effect of social factors).

Individual burnout modulators.

Personality influences how people perceive their work environment and, therefore, how they manage and cope with work demands and resources. Several studies [ 56 , 57 , 58 ] conclude that the personality traits posited in the Big Five model (extraversion, neuroticism, agreeableness, conscientiousness, and openness to experience; [ 59 ]) are significantly but differentially associated with burnout. Thus, it has been found that there is a negative correlation between extraversion and the components of burnout. Thus, extraversion will be a protective factor against burnout. As for neuroticism or emotional instability, positive correlations have been found with burnout. Therefore, people with less emotional stability will be more likely to suffer from burnout. Agreeableness is another personality factor that has shown a protective effect on burnout, so that more-agreeable workers tend to experience less burnout than their less-agreeable colleagues. Likewise, conscientiousness, or the tendency to behave responsibly and persistently, reduces the likelihood of burnout. Finally, openness to experience that represents aspects related to breadth of interests and creativity also has protective effects on burnout as it is positively associated with professional efficacy and negatively associated with depersonalization.

Other individual characteristics that influence the development of burnout are the external locus of control, the type A behavior pattern and having high expectations. Locus of control [ 60 ] refers to the degree to which people believe they have control over events and their lives (internal locus of control) and the degree to which they believe that events occur due to external causes such as chance or the decisions of others (external locus of control). The greater the external locus of control, the greater the probability of developing burnout, especially in ambiguous or novel situations, in which the persons believe they have little or no possibility of controllability. Type A behavior pattern is characterized by competitiveness, impulsivity, impatience, and aggressiveness, and has been widely implicated as a health risk factor. This behavior pattern is positively related to the emotional exhaustion and depersonalization factors of burnout. Finally, the expectations that employees have regarding their work are related to the level of burnout, such that higher expectations and higher goal setting lead to greater efforts and thus higher levels of emotional exhaustion and depersonalization [ 47 , 48 ]. The person’s level of involvement also seems to be important. Specifically, over-involvement has also been proposed as a potent trigger, especially when it may be impossible to achieve goals. This mismatch between expectations and realities can lead to frustration and burnout in workers.

In terms of sociodemographic variables, reviews of studies [ 47 , 48 ] point to an inverse relationship between age and burnout, such that people will experience lower levels of burnout as their age increases. However, the results are not always so consistent. A systematic review of the determinants of burnout [ 61 ] found a significant relationship between increasing age and increased risk of depersonalization, although on the other hand there is also a greater sense of personal accomplishment. Regarding gender, most studies indicate that emotional exhaustion and low professional fulfillment tend to be more common among women while depersonalization is more frequent in men. In relation to marital status, workers who are single (especially men) seem to be more exposed to burnout compared to those who live with a partner. However, such findings seem to be more appropriate in men, as in the case of working women, it constitutes an additional risk factor since working women are usually responsible for household chores and, therefore, this may pose a difficulty in reconciling personal and professional life.

Coping strategies are another variable that play an important role in the development of burnout [ 62 , 63 ]. Although there are several classifications of coping strategies, the most established one is the distinction between problem-focused coping and emotion-focused coping [ 64 ]. Problem-focused coping represents an attempt to act directly on the stressful situation, whereas emotion-focused coping focuses on modifying negative emotional responses to stressful events, avoiding intervening on them. Empirical evidence suggests that, in general, avoidance and emotion-focused coping are positively related to burnout, that is, they favor it, whereas active and problem-focused coping are negatively related to burnout, that is, they reduce it. However, not all emotion-focused coping strategies increase burnout, as social support-seeking, reappraisal, and religious support, in some cases, have protective effects on burnout [ 55 ]. On the other hand, it has also been proposed that the effectiveness of problem-focused coping may depend on the control that individuals can exert over potential stressors in the work environment. Specifically, the use of problem-focused active coping strategies when there is little possibility of controlling and/or changing environmental stressors may exacerbate the undesirable effects of work stress; in such situations it is more advisable to employ coping strategies to facilitate adaptation to the situation. Therefore, one cannot be blunt in concluding that emotion-focused coping strategies are always negative since problem-focused coping only seems adaptive in controllable situations, while avoidance-oriented coping is adaptive in situations that are difficult to control [ 65 ].

3.3. Future Research

This section has focused on summarizing the main triggers of burnout. However, since burnout symptoms develop and evolve differently depending on individual characteristics (e.g., personality or coping strategies) and the work environment (e.g., job demands or leadership styles), it is necessary to continue advancing the knowledge of which are the personal factors that in combination with certain contextual triggers produce greater or lesser symptomatology. For example, when faced with the same stressor, do all personality types experience the same symptoms and consequences? Which personalities are more vulnerable to developing burnout when faced with specific triggers? Which are the most potentially harmful combinations of individual characteristics and contextual triggers? And which are the least? From a temporal perspective, it would also be necessary to carry out more longitudinal studies to study the evolution of symptomatology.

Finally, and because of the increase in home working during the COVID-19 pandemic, it would also be interesting to examine whether teleworking may cause a greater or lesser occurrence of this symptomatology, compared to face-to-face work, as well as to examine possible differences depending on the sector of activity.

4. Consequences of Burnout

Burnout results in a series of adverse consequences both for the individuals who suffer from it and for the organizations in which these professionals work. These consequences are initially of a psychological nature, but maintained over time, they translate into adverse effects on the physical/biological health and behaviors of workers, which in turn will have undesirable organizational consequences [ 66 ].

4.1. Psychological Consequences

The psychological alterations generated by the syndrome of being burned out at work occur at both cognitive and emotional levels. Different studies have associated this syndrome with concentration and memory problems, difficulty in making decisions, reduced coping capacity, anxiety, depression, dissatisfaction with life, low self-esteem, insomnia, irritability and increased alcohol and tobacco consumption [ 66 , 67 ]. Other researchers have also shown that this syndrome can pose a significant risk of suicide [ 68 ].

4.2. Health Consequences

Several reviews of studies conclude that employees with higher levels of burnout are more likely to suffer from a variety of physical health problems such as musculoskeletal pain, gastric alterations, cardiovascular disorders, headaches, increased vulnerability to infections, as well as insomnia and chronic fatigue [ 69 ]. Burnout has also been found to dangerously increase blood cortisol levels [ 70 ] and constitutes an independent risk factor for type 2 diabetes [ 71 ]. Now, the way these symptoms manifest themselves is not the same in all individuals, nor do they all have to occur.

4.3. Behavioral Consequences

In addition to physical and psychological health problems, in general, burnout is also directly related to job dissatisfaction [ 72 ], low organizational commitment [ 66 ], increased absenteeism [ 73 ], turnover intention [ 74 ], and reductions in performance [ 47 ]. On the other hand, some employees with burnout syndrome may justifiably leave their job; however, others decide to remain working [ 75 ]. This may lead to work presenteeism (i.e., individuals go to work, although they do not really fulfill their responsibilities due to health issues). In addition, burnout can lead to deviant and counterproductive behaviors in workers, aggressiveness among colleagues and towards users, alcohol and psychotropic drug use, misuse of corporate material, or even theft [ 68 , 69 , 75 , 76 ].

However, the form and evolution of these individual consequences (psychological, health, and behavioral) is not the same in all cases. In this sense, and although it is not always easy to delimit them, four levels of burnout syndrome have been described [ 77 ]:

• Mild: those affected have mild, unspecific physical symptoms (headaches, back pain, low back pain), show some fatigue, and become less operative.
• Moderate: insomnia, attention and concentration deficits appear. At this level, detachment, irritability, cynicism, fatigue, boredom, progressive loss of motivation, making the individual emotionally exhausted with feelings of frustration, incompetence, guilt, and negative self-esteem.
• Severe: increased absenteeism, task aversion and depersonalization, as well as alcohol and psychotropic drug abuse.
• Extreme: extreme behaviors of isolation, aggressiveness, existential crisis, chronic depression, and suicide attempts.

4.4. Organizational Consequences

The negative consequences experienced at the individual level by workers with burnout translate into low motivation and performance that can extend to the work unit and the organization, causing a reduction in the quality of services [ 78 ]. Likewise, employees suffering from burnout influence the rest of the organization, causing greater conflicts or interrupting work tasks, thus reducing production and increasing production times [ 67 ]. Therefore, as indicated in the emotional contagion theory, burnout can cause a “contagion effect”, generating a bad working environment [ 45 ]. This syndrome also usually generates significant economic losses as a consequence of absenteeism, loss of efficiency and counterproductive behaviors [ 76 ].

4.5. Future Research

It would be interesting to examine in depth the relationships between the psychological alterations caused by burnout and the effects on workers’ health, safety, and performance. For example, how psychological damage caused by burnout influences workers’ attitudes and behavior, and exploration of the possible modulating role of individual factors and certain organizational characteristics (i.e., leadership, organizational climate, cohesion among workers). In addition, longitudinal studies would be necessary to analyze the possible relationship between the different consequences of burnout and productivity.

5. Prevention Strategies

Now we have established what burnout is and what circumstances trigger it, in this section we will focus on how to act both to avoid and to reverse its occurrence and consequences. First, the most appropriate type of preventive intervention should be selected. Primary prevention is aimed at all workers and its purpose is to reduce or eliminate organizational risk factors to prevent the occurrence of burnout. Primary prevention is the most consistent with the principles of an occupational risk prevention management system by providing workers with adequate support, job adaptations, information, and adequate training to deal with this psychosocial risk.

Secondary prevention, on the other hand, is carried out once the first symptoms of burnout have appeared, so it is not aimed at all workers, but only at those who are already affected and its purpose in general is that such symptoms do not evolve further, improving the way in which the person responds to these stressors. These interventions are aimed more at individuals than at the organization, bringing about changes in attitudes and improving their coping resources, which does not imply that there are no organizational interventions as well. Finally, tertiary prevention focuses on employees who are already burned out at work. The aim of this type of prevention is to reduce the most severe harms (e.g., serious health problems and/or poor job performance). Since this type of intervention is aimed at trying to resolve the damage to the worker’s physical and/or psychological health, it is considered reactive and not strictly speaking prevention, but treatment.

From another perspective, we will classify the interventions considering the promoter of the intervention, that is, who organizes, decides and, if necessary, finances the actions to be carried out. In this sense, interventions can be classified as follows: (1) promoted by the organization, which in turn could be subdivided into actions directed at the organizational and job structure and actions directed at employees, and (2) promoted by individuals, which could also be subdivided into interventions directed at oneself as an individual and interventions directed at improving one’s interaction with the organization and with aspects of the job ( Table 4 ).

Summary of burnout interventions.

5.1. Organizational Interventions Aimed at Work Structure

The following is a description of interventions that generally focus on reducing work stressors and increasing the organizational resources available to workers [ 79 , 80 ].

• (1) Work redesign. This measure aims to partially change the objectives and tasks of the job while improving the quality of work by eliminating structural and/or procedural elements that interfere and generate stress [ 81 ]. It could also be considered job redesign the enrichment of jobs through the incorporation of new and more stimulating tasks that make the job more motivating and rewarding.
• (2) Modification of exposure times to potential stressors. This can be completed by reducing the time in which the worker is exposed to the most stressful elements of the job (such as, for example, attention to users or patients) through job rotation, or, if necessary, by performing other tasks or activities [ 82 , 83 ].
• Humanization of schedules and implementation of work–life balance plans. This intervention involves organizing and making work schedules and shifts more flexible to allow for the reconciliation of personal and professional life [ 84 ]. In this sense, variable work shifts and long working hours exceeding 8 h should be eliminated.
• Managers’ leadership development. Supervisor support and leadership is considered an important work resource capable of reducing burnout levels in employees. However, not all supervisors employ an adequate leadership style. In this sense, several studies have shown that authentic [ 54 ], transformational [ 85 ], and servant [ 86 ] leadership styles are related to decreased burnout and have positive effects on employees’ psychological resources [ 87 ]. For this reason, these are the leadership styles that should be developed and trained to avoid the occurrence of this syndrome. Additionally, the performance of leaders and specifically leadership behaviors should also be regularly evaluated by the individuals working with them to identify potentially adverse aspects that could trigger burnout.
• Use of rewards and incentives that are not only financial. Employees can be motivated by rewards that do not always need to be of a financial nature. Recognizing work well done is a very efficient way to increase workers’ motivation levels and prevent burnout [ 48 ]. As indicated previously, one of the factors causing efficiency crises, which in turn were triggers of burnout, was the lack of reinforcement and appraisal by supervisors. In addition to recognition of accomplishment, other types of rewards such as greater time flexibility (which can facilitate work–life balance) or protected time to achieve personally meaningful work goals can enhance well-being. In contrast, employing simple financial rewards may be less effective by encouraging overwork and pressure to achieve goals, which promote burnout.
• Development of welcoming programs. Since role conflicts and ambiguities are potential triggers of burnout, it is advisable for organizations to develop welcoming processes for new workers, where the mission of the position, tasks, and objectives to be fulfilled are explained with absolute clarity and they are progressively introduced to the most stressful elements of the job, always offering support from the supervisor or other colleagues [ 88 ].
• Burnout monitoring and design of customized plans. This consists of periodically conducting surveys and measurements of workers to “monitor” the organization’s burnout levels and compare the scores of workers according to units, location, position, supervisor, etc. (e.g., [ 89 ]). The aim is basically to identify the appearance of the first symptoms, thus preventing the syndrome from becoming chronic. It is important that, in addition to the levels of burnout, the organization identifies as precisely as possible the risk factors in the work environment that may be present to eliminate or minimize them. Additionally, since the specific way in which symptoms manifest themselves and which dimension is dominant varies in each work unit, to be effective it will be necessary to design interventions specific to the causes and consequences/symptoms identified.
• (1) Delivery of psychoeducational workshops on stress and burnout that can be scheduled in the same organization or by outsourcing the service.
• (2) Counseling services for workers with work-related problems. This action can be carried out within the organization or by outsourcing the service by referring the employee to a counseling specialist.
• (3) Referral to specialized health promotion services such as psychologists and medical specialists.

5.2. Interventions Promoted by the Organization Aimed at Employees

This type of intervention basically aims to increase the personal resources of employees to manage stressors at work, which in turn helps to reduce burnout levels.

Examples of training actions promoted by organizations to prevent burnout.

Generic phases of strengths-based interventions.

• Coaching and guidance. These are non-directive methods that encourage employees to regain control of their emotional state and well-being on their own, so the coach/counselor will not “prescribe” any treatment. Instead, the coach/counselor will guide the employee to come up with (or with some assistance) coping strategies on their own [ 93 ]. This type of intervention is usually typical of secondary prevention, in the early stages of the syndrome, when it is assumed that the person still has the capacity to redirect it.
• Creation of support groups. Peer and team support has always been critical in helping professionals cope with the difficulties and challenges of day-to-day life. This support encompasses a wide range of activities, including the celebration of achievements or the creation of formal support groups. In this sense, organizations should incorporate activities into work processes that are conducive to such a sense of community as dedicating time to share ideas and knowledge about how to act and deal with day-to-day professional challenges [ 88 ]. Support groups refer to any group of coworkers, whether formal (expressly created by the organization) or informal (not created by the organization but arising spontaneously) that meet regularly to exchange information, give each other emotional support and/or solve work problems. What these groups have in common is that they offer recognition for work completed (even if objectives have not been achieved), comfort, help, and companionship. The primary objective of the support groups is to reduce the professionals’ feelings of loneliness and emotional exhaustion, as well as the exchange of knowledge to develop effective ways of dealing with problems. This intervention (e.g., two hours every two weeks) is one of the most widely employed interventions for intervening on burnout and its benefits have been repeatedly demonstrated [ 73 ]. While the creation of support groups is an individual focus intervention, in many cases it is encouraged by the organization, or should be.

5.3. Individual-Focused Interventions Promoted by the Individual

These types of actions are initiated and determined by the workers themselves and are aimed at improving their emotional and physical state completely outside the work environment, including physical exercise, mindfulness, self-assessment and, where appropriate, psychotherapy.

• Physical exercise. Several studies have shown the positive effect of physical activity as a moderating variable of the effects of burnout on the health of workers [ 94 , 95 ]. Physical exercise can be used in primary, secondary and, where appropriate, tertiary prevention.
• Mindfulness training. A systematic review [ 96 ] of various specialized databases published between 2008 and 2017 concluded that mindfulness practice is effective in reducing burnout syndrome, both in its total values and in those corresponding to its dimensions, mitigating the negative psychosomatic and emotional effects of the syndrome, and increasing other positive ones such as empathy or concentration.
• Self-assessment. This intervention involves the self-observation of possible signs that could point to burnout. The way to do this is, for example, by keeping a diary of stress symptoms and related events such as specific symptoms, thoughts, feelings, and ways of coping with them. On the other hand, in addition to this type of diary, it is also important to measure the degree of burnout with a properly validated test, such as those indicated in the following section, and to compare one’s own score with that of a reference group or with oneself over time.
• (1) Cognitive techniques: these are aimed at the individual reevaluating and restructuring their appreciation and vision of stressful or problematic situations, so that they can deal with these situations more effectively. This type of technique is useful because people perceive situations subjectively and individually and, therefore, in a biased way. Cognitive techniques are aimed at identifying and modifying errors in the perception of reality to influence the emotions they provoke and the behavior they trigger.
• (2) Physiological deactivation techniques: the aim of this type of technique is to teach the person mechanisms to control, through relaxation, the increased physiological activation and anxiety caused by stressful stimuli.
• (3) Training in healthy lifestyle habits: physical exercise, a balanced diet, and restful sleep can help to reduce the symptoms of burnout.

5.4. Individually Driven, Work-Focused Interventions

These interventions are also initiated and determined by workers, but in this case, they are aimed at improving the work environment.

• Time management. Employees who are at risk of burnout often feel that they lack the time to fulfill all their responsibilities or that they work long hours with no time for personal use and rest. Self-management of time consists of correctly planning one’s time by making efficient use of the time available, organizing tasks realistically, and delegating them when appropriate, as well as dedicating daily time for personal activities and recreation [ 79 , 80 ]. Although this intervention is promoted by each worker, to facilitate proper time management, organizations as indicated above can or should provide training and coaching actions to their workers [ 97 ].

Types of adjustments made with job crafting.

5.5. Future Research

Evaluation research on the success or failure of intervention strategies aimed at preventing or containing burnout is stilled needed. The interventions presented in this section offer a general and broad view of how to deal with burnout. However, since this syndrome depends on and develops idiosyncratically according to personal factors as well as working conditions, future lines of research should focus on analyzing which are the most efficient interventions according to individual characteristics and situational triggers. In addition, it would be optimal to establish comparisons between different interventions aimed at both the individual and the organization level. Furthermore, it is necessary to analyze the possible interaction between interventions and whether the combination of several of them is potentiating, inhibiting, or redundant. Finally, it would also be interesting to establish longitudinal studies to detect which of these interventions are more effective in the long term.

6. Assessment and Measurement

When it comes to assessing burnout, several tools (scales and questionnaires) have been developed and validated in different countries. These tools can be classified into two broad categories: (1) generic instruments (i.e., instruments aimed at assessing the syndrome, without differentiating by professional occupations; the main difference between these instruments is the burnout theoretical model they consider and what other aspects, if any, they evaluate), and (2) specific instruments aimed at evaluating burnout in specific occupations (e.g., nurses, psychologists, physicians) or even out of job (e.g., sports, school and parental relationships). Table 8 shows the main instruments currently available for assessing burnout.

Instruments for assessing burnout.

6.1. Generic Instruments

Maslach Burnout Inventory (MBI; [ 5 ]). The most widely used and validated tool for measuring burnout. At first, this tool was designed exclusively to measure burnout in personnel in the care sector and was called the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). However, research and epidemiological studies showed that burnout can occur in any occupation and sector of activity, and for these reasons Schaufeli et al. [ 99 ] developed the definitive tool, the MBI-GS (Maslach Burnout Inventory-General Survey), based on the previous one and applicable to all occupations and jobs. This instrument has 16 items distributed in three dimensions: emotional exhaustion, cynicism, and reduced professional fulfillment. Thus, high scores on these dimensions would be indicative of burnout. This tool has subsequently been validated in different cultural and work contexts, such as Spanish [ 6 ], Italian [ 100 ], French [ 101 ], Chinese [ 102 ], and Arabic [ 103 ], among others.

Questionnaire for the Evaluation of Burnout Syndrome (CESQT; [ 104 ]). The CESQT consists of twenty items that are grouped into four dimensions: (1) enthusiasm for work: this is defined as the individual’s desire to achieve work goals because it is a source of personal pleasure. Low scores in this dimension indicate high levels of burnout; (2) psychic burnout: this is defined as the occurrence of emotional and physical exhaustion because of work; (3) indolence or the presence of negative attitudes of indifference and cynicism towards the organization’s customers; and (4) guilt: this is defined as the appearance of feelings of guilt for the behavior and negative attitudes developed at work, especially towards people with whom work relationships are established. This instrument has two different versions: the main version (CESQT), which is applied to workers who work with people (e.g., psychologists, teachers, or doctors) and the “Professional Disenchantment” version (CESQTDP), which is administered to those workers who do not work in direct contact with people. Although this tool was originally designed in a Spanish context, throughout these years the CESQT has also had a great reception and a wide development in different countries. It has been translated, adapted and validated in Germany [ 105 ], France [ 106 ], Italy [ 107 ], Portugal [ 108 ], and Poland [ 109 ]. In Anglo-Saxon literature, the use of the CESQT is regularly cited as the Spanish Burnout Inventory (SBI; e.g., [ 110 , 111 ]), and alludes to the theoretical model from which it starts, highlighting that among its strengths is the fact of collecting a broader vision of burnout than other instruments by including the dimension of guilt [ 67 ]. The wide dissemination of the instrument and its quality as a psychological assessment tool has favored the American Psychological Association (APA) to include it in its database of psychological tests.

Copenhagen Burnout Inventory (CBI; [ 112 ]). This scale allows the assessment of context-free burnout. It is composed of three main factors: (1) personal burnout, (2) work-related burnout, and (3) client-related burnout.

Oldenburg Burnout Inventory [ 113 ]. This inventory was developed to measure burnout across various occupational groups and measures two dimensions of burnout: (1) exhaustion, which is the primary symptom of burnout, and (2) disengagement from work.

Burnout Clinical Subtypes Questionnaire (BCSQ; [ 114 , 115 ]). The questionnaire consists of 36 items and measures the different properties of each clinical subtype. Each subtype consists of several facets: involvement, ambition, and overload of the frenetic type; indifference, lack of development, and boredom of the under-challenged type; and finally, neglect, lack of acknowledgement, and lack of control of the worn-out type. This questionnaire was originally developed in Spain, but recently it has been validated for other cultures such as Latvia [ 116 ] and Germany [ 117 ]. In its short version (BCSQ-12), consisting of 12 items, only one subscale of each subtype is analyzed (i.e., overload, lack of development, and neglect).

Burnout Assessment Tool (BAT; [ 118 ]). This tool is based on an alternative, comprehensive conceptualization of burnout, and includes all relevant elements that are associated with burnout. The questionnaire contains 33 items and consists of the BAT-C and BAT-S. The BAT-C assesses the four core dimensions: (1) exhaustion, (2) cognitive, (3) emotional impairment, and (4) mental distance). The BAT-S assesses two atypical secondary dimensions that often co-occur with the core symptoms: (1) psychological complaints, and (2) psychosomatic complaints.

Shirom–Melamed Burnout Questionnaire (SMBQ; [ 119 ]). The instrument comprises 22 items which consists of the following sub-scales: (1) emotional exhaustion, (2) physical fatigue, (3) cognitive weariness, (4) tension, and (5) listlessness. Later development of the instrument resulted in the Shirom–Melamed Burnout Measure (SMBM; [ 120 ]), which included 14 item divided in three subscales; (1) physical fatigue, (2) emotional exhaustion, and (3) cognitive weariness.

6.2. Specific Instruments

Maslach Burnout Inventory-Human Services Survey (MBI-HSS; [ 5 ]). This is a 22-item survey, applicable to human services jobs, for instance, clergy, police, therapists, social workers, medical professionals. The MBI-HSS (MP), adapted for medical personnel, and MBI-Educators Survey (MBI-ES), adapted for educators, are available online at https://www.mindgarden.com/117-maslach-burnout-inventory-mbi (accessed on 26 December 2022).

Brief Burnout Questionnaire Revised for nursing staff [ 121 ]. This instrument is an alternative tool to the MBI-HSS (MP). The questionnaire comprises 21 items that evaluate not only the syndrome itself, but also its antecedents and consequences. These items are gathered into four factors: (1) job dissatisfaction, comprising four items; (2) social climate, made up of three items; (3) personal impact, made up of four items, and (4) motivational exhaustion, comprising four items.

Physician Burnout Questionnaire-PhBQ [ 122 ]. This is another alternative instrument to the MBI-HSS (MP). The PhBQ contains 17 items and includes four subscales: burnout syndrome (PhBSS), antecedents (PhBAS), consequences (PhBCS), and personal resources (PPRS).

Teacher Burnout Questionnaire [ 123 ]. This questionnaire examines the burnout of teachers and is based on Maslach, Jackson and Leiter’s original instrument ([ 28 ]). The questionnaire comprises 14 items.

Psychologist’s Burnout Inventory—PBI [ 124 ]. This instrument measures four factors related to burnout among psychologist: control (three items assessing control over work activities, schedule, and decisions), overinvolvement (three items assessing feelings of responsibility for and spending time thinking about or dealing with clients), support (three items assessing emotional and instrumental support from colleagues), and negative client behaviors (six items assessing the experience of aggressive, dangerous, or threatening client behaviors). A revision of this instrument (PBI-R) was developed by Rupert et al. [ 125 ].

Athlete Burnout Questionnaire [ 126 , 127 ]. This tool is adapted to sport environments, and it is composed of 15 items organized in three dimensions: emotional/physical exhaustion, reduced sense of accomplishment and devaluation.

School Burnout Inventory-SBI [ 128 ]. This inventory comprises nine items grouped in three dimensions: (a) exhaustion at school, (b) cynicism toward the meaning of school, and (c) sense of inadequacy at school.

Parental Burnout Inventory [ 129 ]. This instrument assesses parental burnout syndrome, including exhaustion, distancing, and inefficacy.

6.3. Future Research

The main objection that could be made to the questionnaires presented above is that they are self-reported measures that focus especially on quantifying the burnout factors (emotional exhaustion, cynicism, and professional efficacy). However, since the burnout phenomenon is complex, more tools should be designed that consider both the antecedents and the physical and psychological consequences of burnout, thus offering a more global vision of this syndrome. As noted by Shirom [ 130 ], burnout measures should be analyzed within the framework of theoretical models that also consider causes and effects of burnout, as well as correlates. This type of instrument would, in turn, allow the development of more individualized and personalized interventions and treatments.

Moreover, different theoretical conceptualizations of burnout have led to the proliferation of a wide range of measurement instruments, usually comprising several dimensions. To what extent these instruments overlap or encompass different constructs remains to be seen. As a consequence, the burnout definition applied translates into considerably different burnout prevalence estimates in the literature. Furthermore, while some researchers use a unidimensional measure of burnout, others focus on one or more dimensions. Additionally, most instruments also lack a clinically validated threshold or cutoff values for burnout diagnosis.

Future lines of research could focus on examining the relationships between self-report measures of burnout and objective biological markers (i.e., salivary cortisol) to identify which questionnaires have the highest predictive capacity for these biomarkers. In addition, adaptation and validation of the main measurement instruments to different cultural contexts is still an ongoing need.

7. Special Issue on “Occupational Stress and Health: Psychological Burden and Burnout”

This Special Issue includes 21 papers which bring together recent developments and studies in this field. It aims to provide a comprehensive approach to occupational health from a broad range of perspectives. The results are of use for both researchers and practitioners. Undoubtedly, the COVID-19 pandemic has impacted organizational contexts increasing the risk of stress and burnout. Burnout and stress are analyzed from different perspectives with a focus on specific occupational groups in diverse countries from several continents. Post-Traumatic Stress Disorder (PTSD) in the Military Police of Rio de Janeiro (Brazil) is investigated as well as its correlations with socio-demographic and occupational variables [ 131 ]. Gender and age differences in personal discrimination experience, burnout, and job stress among physiotherapists and occupational therapists are examined in South Korea [ 132 ]. Nurses in South Korea are further studied with respect to emotional labor, burnout, turnover intention, and medical error levels within the previous six months [ 133 ]. Healthcare workers are also the focus of another study in Japan [ 134 ], which concludes that the number of physical symptoms perceived are positively related to burnout scores. Moreover, job strain and work–family conflict are associated with an increased risk of burnout, while being married, being a parent, and job support are associated with a decreased risk of burnout. In Spain, the relationship between burnout, compassion fatigue, and psychological flexibility is analyzed in geriatric nurses [ 135 ] as well as the prevalence of emotional exhaustion, depersonalization, and possible non-psychotic psychiatric disorders in nurses during the COVID-19 pandemic [ 136 ]. In Germany [ 137 ], teachers and social workers are surveyed following a model derived from the Job Demands–Resources theory to predict effects of strains on burnout, job satisfaction, general state of health, and life satisfaction. While some professionals working in the educational sector are burned out, other develop resilience, and thus it is important to identify antecedents and profiles (e.g., support), as evidenced by another study carried out in Spain [ 138 ]. Burnout and job satisfaction are additionally examined in a sample of music therapists in Spain [ 139 ]; a higher risk of burnout is associated with working longer hours in a palliative care setting.

Although a variety of instruments have been developed and validated in different contexts, new reliable and more specific tools are timely and highly valuable to better operationalize and understand job burnout. In this line, a new scale to gauge the balance between risks and resources ( Balance ) is developed in three French-speaking countries and then longitudinally tested in several English-speaking countries [ 140 ]. Another instrument is developed to evaluate job resources and further explore the relationship between resources and psychological detachment [ 141 ]. To assess the added value of a joint use of two tools, Leclercq et al. [ 142 ] compare the diagnostic accuracy of a structured interview guide and a self-reported questionnaire, finding differences in sensitivity and specificity with implications in diagnosis and treatment. A systematic review analyses both subjective and objective measurement methods to study fatigue, sleepiness, and sleep behavior in seafarers [ 143 ]. Related to new ways to measure and study stress, the “Study on Emergency physicians’ responses Evaluated by Karasek questionnaire” (SEEK) Protocol [ 144 ] presents the design of a study protocol to examine well-being in emergency healthcare workers in order to assess and determine Karasek scores in a large sample size of emergency healthcare workers and evaluate whether there is a change in work perception (both in the short and the long term). Additionally, this protocol will allow us to explore Karasek’s associations with some biomarkers of stress and protective factors.

The identification of mediators is another promising line of research. Mérida-López et al. [ 145 ] explore in a sample of pre-service teachers in Spain the mediator role of study engagement in the relationship between self- and other-focused emotion regulation abilities and occupational commitment. A moderated-mediation model is used in China to examine the effect of perceived overqualification on emotional exhaustion, the mediating role of emotional exhaustion in the relationship between perceived overqualification and creativity, and the moderating role of pay for performance in the perceived overqualification–emotional exhaustion relationship. Occupational stressors are studied in China as mediators in the psychological capital–family satisfaction link [ 146 ]. In Brazil, the moderating role of recovery from work stress is explored in the relationship between flexibility ideals and patterns of sustainable well-being at telework [ 147 ].

Last, a growing avenue of research is devoted to leadership. Leaders’ behaviors have important consequences for both employees and organizations. In this Special Issue, ethical leadership is investigated in South Korea with respect to emotional labor and emotional exhaustion [ 148 ]. Identity leadership, team identification, and employee burnout are examined in 28 countries within the Global Identity Leadership Development (GILD) project [ 149 ]. Security-providing leadership is proposed to be a job resource to prevent employee burnout [ 150 ].

8. Conclusions

In this review, we have analyzed what burnout is, what are its main dimensions, what models have been proposed for the description and explanation of this syndrome, what are its antecedents and consequences, what tools allow its evaluation and how it can be intervened both at the organizational and individual level. We also present our critical vision, indicating how each specific aspect should be studied today, the future lines of research on burnout, and what the future lines of intervention in organizations should be. The most recent research published in the Special Issue on “Occupational Stress and Health: Psychological Burden and Burnout”, 21 papers, is summarized according to main areas.

There is no doubt that burnout is currently a growing concern for individuals, organizations, and society. For example, among physicians, this syndrome has reached epidemic proportions around the world, accompanied by alarming levels of depression and suicidal ideation [ 151 ]. Thus, people suffering from burnout report feeling exhausted throughout the day, and not only during their working day. In fact, just thinking about work before getting up in the morning leaves them exhausted.

Work environments with excessive work schedules and high levels of demands, as well as the need to prove that one is worthy of a certain position, leave workers emotionally drained, cynical about work, and with a low sense of personal accomplishment. Moreover, the pressure does not end with the end of the workday; new technologies, mobile devices and the lack of boundaries prevent disconnection and the necessary recovery from work.

However, burnout is not an inevitable syndrome; it can be prevented before it appears and treated during its development. Nonetheless, interventions often focus on individuals rather than organizations, even though the main causes of this syndrome are organizational factors such as work overload or role ambiguity. As Shanafelt and Noseworthy [ 88 ] point out, organizations should regularly assess the well-being of their workers, both quantitatively and qualitatively, and consider it a key performance indicator. In fact, it is likely that the relationship between burnout and job performance is underestimated because burned-out workers adopt “performance protection” strategies to maintain priority tasks and neglect low-priority secondary tasks such as, for example, dealing kindly with customers, clients, or patients [ 152 ]. In this way, evidence of the syndrome is masked until critical points are reached.

Author Contributions

Conceptualization, S.E.-V. and J.A.M.; writing—original draft preparation, S.E.-V., J.A.M. and A.L.; writing—review and editing, A.L. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Conflicts of interest.

The authors declare no conflict of interest.

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