• burnout;
  • clinical nurses;
  • environment;
  • self-efficacy;
  • stressors


  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Study Limitations and Future Research
  8. Conclusion
  9. References

The aim of this study is to investigate the level of burnout of clinical nurses and to examine the influence of personal and environmental factors on nurse burnout. A total of 717 full-time nurses from six hospitals in Tianjin, China, completed five questionnaires: a demographic questionnaire, the Maslach Burnout Inventory, the General Self-Efficacy Scale, the Practice Environment Scale of the Nursing Work Index and the Nurse Job Stressor Scale. The participants had moderate levels of emotional exhaustion (mean score 23.95 ± 11.11) and depersonalization (mean score 7.90 ± 6.58) and a high level of reduced personal accomplishment (mean score 27.51 ± 10.96). Both personal and environmental factors were correlated with nurse burnout; however, personal factors played bigger roles in predicting personal accomplishment, whereas environmental factors played bigger roles in predicting emotional exhaustion and depersonalization. In order to reduce nurse job burnout effectively, administrators should pay more attention to the improvement of nurses' self-efficacy and professional nursing practice environment and the reduction of stressors.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Study Limitations and Future Research
  8. Conclusion
  9. References

The concept of burnout was initially identified by Freudenberg[1] (1974) in the 1970s. His description of burnout depicted idealistic young adults who worked hard and sacrificed their well-being for the benefit of society while receiving little recognition or reward.[2] Years later, Maslach and Jackson[3, 4] explained that burnout was a prolonged response to chronic emotional and interpersonal stress on the job, and was defined by the three dimensions of emotional exhaustion (feeling emotionally drained by one's contact with other people), depersonalization (negative feelings and cynical attitudes toward the recipients of one's service or care) and reduced personal accomplishment (the tendency to evaluate one's own work negatively).

Working environments in nursing involve specific job stressors such as exposure to pain and death, role stress, lack of support from supervisors, interpersonal conflicts and so on. Therefore, nursing has been considered as a risk profession for burnout.[5] Job burnout among nurses can result in mental fatigue, anxiety, lack of motivation and absence from work,[6, 7] which will undoubtedly increase nurse shortages and reduce patient safety outcomes.

Against the background of nurse shortages in their market areas, US scholars identified characteristics of some hospitals that made them ‘magnetic’. The results of their studies turned out to be quite fruitful. Inspired by the American experiences, some Chinese scholars have begun to study the attributes of ‘magnet hospitals’ in recent years. Some of the organizational attributes of magnet hospitals are decentralization of decision-making to the level of the nursing unit; recognition of professional nurse autonomy, accountability and responsibility for quality patient care; strong, effective and visible nursing leadership; and strong nurse–physician relationships—all of which can be recognized as characteristics of a good professional nursing practice environment (PNPE). Lake categorized them into five key attributes: nursing participation in hospital affairs; nursing foundations for quality of care; nurse manager ability, support and leadership; adequate staff and resources; and collaborative nurse–physician relationships.[8]

The characteristics of PNPEs described in the ‘magnet hospital’ research play important roles in the quality of nurses' work life and patient safety outcomes. The improvement of the nursing environment can result in greater nurse professionalism, empowerment, improved job satisfaction, higher nurse engagement, decreased burnout and higher retention rates,[9-11] as well as improved patient outcomes such as lower inpatient mortality and improved quality of care.[12, 13]

Empirical studies have confirmed that job burnout is related to many factors, such as efficacy beliefs, social support, coping strategy, workplace characteristics, and working environments and stress.[5, 14-18] Although many of the main factors contributing to the appearance of burnout are environmental factors (like stress and PNPE), it is necessary to consider personal factors (like self-efficacy) as well.

In China, many studies have also been done on nurse job burnout. For example, Xi et al. studied burnout in nurses from different nursing departments and found that nurses from the emergency department, medicine department and operating room had higher degrees of burnout.[19] In Wang's study, however, burnout in ICU nurses was the highest.[20] There have also been other studies on the influencing factors of nurse burnout, such as social support, job stress coping strategies, personality, professional self-concept and emotional intelligence,[21-25] but most of the research is about one single variable; multivariable studies are still scarce. What is more, research on PNPEs is also rare in China. Therefore, our study combined personal factors (self-efficacy, reason for working as a nurse, etc.) and environmental factors (job stress and PNPE) as independent variables to get a more comprehensive understanding of the influencing factors of nurse burnout.

The following research questions were posed:

  • What is the level of job burnout among clinical nurses in Tianjin, China?
  • Are demographics, self-efficacy, job stress and PNPE predictors of Chinese nurse burnout?


  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Study Limitations and Future Research
  8. Conclusion
  9. References

Research design

This study was a descriptive survey using a questionnaire with a cross-sectional correlation study design, focusing on the analysis of factors influencing clinical nurses' job burnout.

Research site and sample

Chinese hospitals are placed in three classes according to their different functions and their technical, quality and management levels. Six out of 29 tertiary first-class hospitals—the highest rank in the Chinese health-care system—in Tianjin were convenience-selected to conduct the study at. Each hospital has no less than 500 beds, and the usual nurse–patient ratio was 0.4:1. In this study, only registered nurses working in hospitals and having direct contact with patients were asked to participate, and their clinical areas were as follows: medicine, surgery, emergency department, operating room and ICU.

A total of 900 nurses eligible for inclusion were invited to participate, of whom 748 responded. Of the 748 surveys returned, 717 were useable for a response rate of 79.67%.

Research instruments

This study used five self-administered questionnaires. The demographic questionnaire was designed by the researcher, including demographic information such as gender, age, educational background, professional title, position tenure, administrative office, reason for working and so on. PNPE was measured with the Practice Environment Scale of the Nursing Work Index (PES-NWI), which was translated from English into Chinese for this study. Burnout, self-efficacy and job stress were measured with the Chinese version of the Maslach Burnout Inventory (MBI),[26] the General Self-Efficacy Scale (GSES)[27] and the Nurse Job Stressor Scale, respectively.[26]

The MBI was developed by Maslach and Jackson.[28] It comprises three subscales: emotional exhaustion, personal accomplishment and depersonalization. The three subscales have nine, eight and five items respectively, which are rated on a seven-point rating scale ranging from 0 (‘never’) to 6 (‘every day’). Scores for emotional exhaustion and depersonalization relate positively to the degree of these domains, which means higher scores indicate stronger burnout. In contrast, degree of burnout relates negatively to the personal accomplishment score. An emotional exhaustion score lying between 16 and 26 means moderate burnout; higher than 26 means a high degree of burnout. A depersonalization score lying between 6 and 9 means moderate burnout; higher than 9 means a high degree of burnout. A personal accomplishment score lying between 34 and 39 means moderate burnout; lower than 34 means a high degree of burnout. In our study, the overall Cronbach's α for the MBI was 0.83; α for each subscale ranged from 0.79 to 0.86, which indicated acceptable internal consistency.

The GSES, developed by Schwarzer and Aristi,[29] measures the self-efficacy of nurses, using 10 items that are rated on a four-point rating scale: 1, ‘completely incorrect’; 2, ‘incorrect’; 3, ‘correct’; 4, ‘completely correct’. The possible scores range between 10 and 40, and higher scores indicate greater self-efficacy. Three levels of self-efficacy can be recognized: low (10–20), moderate (21–30) and high (31–40). Cronbach's α for the scale was 0.88.

The PES-NWI[8] includes 31 items, divided into five subscales: nurse participation in hospital affairs (9 items); nursing foundations for quality of care (10 items); nurse manager ability, leadership and support of nurses (5 items); staffing and resource adequacy (4 items); and collegial nurse–physician relations (3 items). It uses a four-point rating scale: 1, ‘completely disagree’; 2, ‘disagree’; 3, ‘agree’; and 4, ‘completely agree’. Higher scores on the PES-NWI indicate higher levels of support in the PNPE. The English version of the questionnaire was translated into Chinese by one professional translator and two bilingual Chinese nurses. A back-translation was conducted to ensure equivalency. A group of four nursing experts reviewed the content and checked the validity and equivalence of the translation. A pilot test was conducted with 30 senior nursing students to ensure that the questionnaire was clear to respondents before it was used in the study. Cronbach's α for the PES-NWI across studies has ranged from 0.84 to 0.96. In our study, the overall Cronbach's α for the PES-NWI was 0.92; α for each subscale ranged from 0.62 to 0.82.

The Nurse Job Stressor Scale includes 35 items, divided into five subscales: stress from nursing practice and care (7 items), stress from workload and time allocation (5 items), stress from working environment and resources (3 items), stress from patient care (11 items) and stress from management and relationships (9 items). The items were rated on a five-point rating scale, with 1 indicating ‘none’ and 5 indicating ‘very much’. Higher scores signified higher levels of stress. In our study, the overall Cronbach's α for the scale was 0.96; α for each subscale ranged from 0.85 to 0.93.


The variables used in this research were the demographics, nurse job burnout, self-efficacy, PNPE and nurse job stress.

Ethical considerations

In all of the hospitals used for the gathering of data, all the ethical requirements for conducting research on human participants were met, as well as the ethical research requirements of the authors' university. Before the distribution of the questionnaires, the researcher contacted the nursing departments of the six hospitals and obtained consent from the nursing administrators. The participants were informed that involvement was completely voluntary and that they could withdraw at any time with no negative ramifications. At the same time, anonymity and confidentiality were assured.

Data collection procedure and analysis

The main study data collection was undertaken during October and December 2011. The participants were informed, both orally and in writing, of the study's purpose. Each of them was given an envelope containing a packet with the five questionnaires and a small gift by the researchers. The researchers went back to the hospitals to retrieve the sealed envelopes containing the completed questionnaires within 7 days after distribution.

The data analysis was conducted using SPSS 13.0 software (SPSS Inc., Chicago, IL, USA). Descriptive statistics was used to analyse the characteristics of the respondents and the study variables; the t-test was used to compare differences in burnout levels between other empirical studies and the current study; and correlation analysis and multiple stepwise regression analysis were used to analyse the predictors of nurse burnout.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Study Limitations and Future Research
  8. Conclusion
  9. References

Characteristics of the respondents

Out of the 717 nurses, 18 were male, 699 female. With regard to educational level, 10.9% of participants had a technical secondary school degree , 49.4% an associate degree and 39.7% a bachelor's degree. With regard to years worked, 12.1% had worked less than 1 year, 36.8% had worked 1–5 years, 19.7% had worked 6–10 years, 20.1% had worked 10–20 years and 11.3% more than 20 years. With regard to the departments where the nurses worked, 35.2% worked in medicine, 32.6% in surgery, 10.8% in the emergency department, 8.1% in the operating room and 13.3% in the ICU. With regard to Chinese professional ranks for clinical nurses, the sample consisted of 42.7% primary nurses, 34.3% junior nurses and 23.0% senior nurses, all of them having direct contact with patients. With regard to reason for working as a nurse, 16.3% of the participants liked the field of nursing, 6.7% worked to fulfil their parents' wish and 77% worked for a living.

Overall mean scores for job burnout, self-efficacy, PNPE and job stress

The overall mean job burnout score ( ± SD) was 59.58 ± 18.30. Mean scores on emotional exhaustion and depersonalization were 23.95 ± 11.11 and 7.90 ± 6.58, respectively, both of which were moderate levels. However, the level of personal accomplishment was lower, with a mean score of 27.51 ± 10.96.

The respondents (n = 717) had a moderate level of self-efficacy, with a mean score of 24.63 ± 5.65. The overall mean PNPE score was 80.87 ± 13.31; of the five PNPE dimensions, the three by which respondents were most easily affected were nursing foundations for quality of care, nurse participation in hospital affairs, and nurse manager ability, leadership and support of nurses. The overall mean score for job stress was 103.07 ± 22.93. Of the five dimensions, the top three stressors were patient care, management and relationships, and nursing practice and care.

Job burnout-related factors

The correlations between the variables of the present study are presented in Table 1. To understand which of the variables predicted nurse job burnout, multiple stepwise regression analysis was used (Table 2). In the regression analysis, 45.7% of the variance in emotional exhaustion was explained by a combination of total stress, reason for working and overall PNPE; 28.3% of personal accomplishment was explained by a combination of self-efficacy, nursing foundations for quality of care, stress from nursing practice and care, and reason for working. As the first factor entering the model, self-efficacy revealed to us the primary roles personal factors played in predicting personal accomplishment. In all, 30.9% of depersonalization was explained by stress from management and relationships, stress from patient care and overall PNPE, all of which were environmental factors.

Table 1. Spearman's correlation coefficients between dimensions of nurse job burnout, self-efficacy, professional nursing practice environment and job stress (n = 717)
  1. * P < 0.05; ** P < 0.01.

 1. Emotional exhaustion1             
 2. Personal accomplishment−0.1081
 3. Depersonalization0.691**−0.0621
 4. Self-efficacy−0.1300.385**−0.1051
 5. Stress from nursing practice and care0.463**−0.215**0.187**0.0051
 6. Stress from workload and time allocation0.493**−0.1000.285**−0.0620.727**1
 7. Stress from working environment and resources0.446**−0.1080.366**−0.0450.609**0.733**1
 8. Stress from patient care0.542**−0.1110.415**0.0150.663**0.680**0.653**1
 9. Stress from management and relationships0.512**−0.0540.460**−0.0250.436**0.478**0.467**0.670**1
10. Nurse participation in hospital affairs−0.175*0.195**−0.0760.260**−0.101−0.115−0.221**−0.115−0.0891
11. Nursing foundations for quality of care−0.0990.359**−0.172*0.345**0.0300.040−0.1310.013−0.0130.662**1
12. Nurse manager ability, leadership and support of nurses−0.165*0.300**−0.152*0.370**−0.094−0.070−0.127−0.095−0.190**0.698**0.549**1
13. Staffing and resource adequacy−0.137*0.114−0.0470.180**−0.073−0.154*−0.184**−0.059−0.0060.649**0.383**0.573**1
14. Collegial nurse–physician relations−0.164*0.233**−0.154*0.238**−0.126−0.149*−0.193**−0.144*−0.140*0.460**0.369**0.467**0.334**1
Table 2. Stepwise regression analysis of job burnout (n = 717)
Dependent variableIndependent variable (step)Standardized coefficient (β)ΔR2P value
  1. * P < 0.0; ** P < 0.01. PNPE, professional nursing practice environment.

Emotional exhaustionTotal stress0.603**0.4130.000
Reason for working as a nurse0.158*0.0310.012
Overall PNPE−0.129*0.0130.035
Total R20.457
Personal accomplishmentSelf-efficacy0.262**0.1650.001
Nursing foundations for quality of care0.258**0.0470.001
Stress from nursing practice and care−0.216**0.0570.003
Reason for working as a nurse−0.149*0.0140.048
Total R20.283
DepersonalizationStress from management and relationships0.376**0.2750.000
Stress from patient care0.210*0.0180.020
Overall PNPE−0.145*0.0160.031
Total R20.309


  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Study Limitations and Future Research
  8. Conclusion
  9. References

The purpose of this study was to examine job burnout and its related factors among nurses in 6 hospitals in Tianjin, China. Overall, nurses had different levels of burnout, and many factors appeared to contribute to their burnout.

Status of nurse burnout

The findings of the study revealed that the participants had moderate levels of emotional exhaustion and depersonalization and a very low level of personal accomplishment. Compared with the American norm,[30] there was a significant difference in each dimension (P < 0.05 or P < 0.01). The scores for emotional exhaustion (23.95 ± 11.11) and depersonalization (7.90 ± 6.5) in this study were higher, but the score of personal accomplishment (27.51 ± 10.96) was lower.

Compared with the domestic norm,[31] scores on emotional exhaustion and depersonalization were higher and personal accomplishment lower. Surprisingly, the difference in depersonalization was significant (P < 0.05). The nurses in Xie et al.'s study also showed less emotional exhaustion than those in the current study.[32] This might have some relation with the increasing shortage of nurses in recent years. Our results add to the current knowledge through comparison with the American and domestic norms. They might indicate that the burnout of Chinese nurses is getting worse in recent years. As the feeling of burnout can cause decline in the quality of work, change of job and even disturbances in physical and mental function, nurse burnout can increase the nurse shortage, causing a vicious circle; lead to poor patient care; and even harm nurses' family life. Therefore, it is important and urgent for nurse managers to pay close attention to nurses' sense of burnout.

Variables predicting nurse burnout

Variables predicting emotional exhaustion

In this study, environmental factors were the strongest predictors of emotional exhaustion. Job stress was the strongest of these; the more stressors in the work environment, the more emotional exhaustion would be caused. These results support past research that has shown a relationship between emotional exhaustion and job stress.[33, 34] Maslach et al. concluded that burnout is a ‘prolonged response to chronic job stress’.[35] The results of the study obviously manifest the fact that emotional exhaustion is the core component of burnout and belongs to the individual stress dimension of burnout.

Another environmental factor, PNPE, was also a predictor. The result of this study showed that better PNPE was associated with lower emotional exhaustion. This was quite consistent with the research of Laschinger et al., who reported that emotional exhaustion was significantly related to poor performance with regard to magnet hospital characteristics, such as nurse participation in hospital affairs, nursing foundations for quality of care and so on.[10] Slightly differently from that study, all the dimensions in our study, with the exception of nursing foundations for quality of care, were related to emotional exhaustion in the correlation analysis. Thus, we propose that all the dimensions together can have stronger influence on emotional exhaustion than any single factor. Employees' perceptions of the work environment can manifest themselves in terms of worrying about work conditions,[34] and burnout is viewed as a reaction to the work environment in terms of depletion of energy and coping resources,[36] which can cause emotional exhaustion.

Apart from those environmental factors, one personal factor, reason for working as a nurse, was also a significant predictor of emotional exhaustion in this study. As one's reason for working determines one's attitude toward one's job, it is obvious that nurses who love the nursing profession will have less sense of burnout than those who just work for a living. This has previously been demonstrated by Jourdain and Chenevert, who reported that not finding meaning in work was strongly associated with emotional exhaustion.[37] Similar findings have also been made in China. In Zhu et al.'s[38] and Wang et al.'s[11] research, reason for working was found to be significantly correlated with nurse job satisfaction and work engagement, and those who loved the job showed significantly higher satisfaction and engagement.

Variables predicting personal accomplishment

Empirical studies have identified lack of personal accomplishment as being correlated with many factors linked to career development.[5] In our correlation analysis, self-efficacy was significantly correlated with personal accomplishment; also, it was the first one entering the regression model. This result is supported by Zhou et al.[39] and Chen et al.,[40] who also identified significant correlations between self-efficacy and personal accomplishment. Psychologist Albert Bandura[41] has defined self-efficacy as the belief in one's capabilities to organize and execute the courses of action required to manage prospective situations. One's sense of self-efficacy can play a major role in how one approaches goals, tasks and challenges. At the same time, self-efficacy is the self-evaluation aspect of burnout. Nurses appear to be motivated if their work meets certain individual needs and values that are important to them;[42] thus, they can work more positively when these are met. The more clearly a nurse can formulate his/her own self-efficacy, the more easily he/she can find and strengthen the feeling of personal accomplishment. Therefore, nurse managers can encourage nurses to develop self-efficacy by empowering them or giving them other ways to meet the demands of their work.

Nursing foundations for quality of care was significantly correlated with personal accomplishment and was the second variable to enter the regression model. Whereas self-efficacy can be treated as a factor intrinsic to nurses, nursing foundations for quality of care might play an extrinsic motivational role because they fulfil basic needs for high quality of care. Different workplace characteristics influence the perceptions of quality of care provided at a hospital facility and the degree to which a nurse is either burned out or satisfied with his/her job.[16] If the workplace characteristics and working conditions meet the nurse's needs, he/she feels meaning in the work and personal responsibility for the outcomes.[42] Thus, it is easy to see that the nurse's personal accomplishment will be strengthened in a good environment.

Nurse shortage is very severe in China;[43] nurses can suffer a lot from practice and patient care because they need to do a lot more work than recommended and have more responsibilities. It has been found that it is probably not possible to determine ideal staffing systems or nurse–patient ratios if the quality of the working environment and workload are not considered.[44] Under the current staffing systems, nurses have experienced difficulty with the hierarchy of medicine, which has resulted in an impression that nurses' primary purpose is to follow the directions of physicians.[45] Thus, it is obvious that stress from nursing practice and care can also reduce nurses' personal accomplishment. In short, besides improving nurse self-efficacy, establishing a good environment is also an effective measure to increase nurse personal accomplishment.

Variables predicting depersonalization

Depersonalization is the interpersonal relationship aspect of burnout. In one empirical study, the researcher found that support from supervisors and recognition by physicians and patients were negatively related to depersonalization,[37] which was quite similar to the results of our study. In this study, all the dimensions entering the regression model were environmental factors, such as stress from management and relationships, stress from patient care and overall PNPE. Nurses are called ‘angels in white’ in China, which reflects their devotion to patients and selflessness. They are mainly motivated by the opportunity to help other people, and the subjective elements of nursing that make the job altruistic and interpersonal are viewed as the most important job motives.[46] Thus, the role of the managers might be very critical in regulating relationships among patients, physicians and nurses and reducing stress from patient care.

It has already been demonstrated that hospitals with poor care environments have a higher rate of work dissatisfaction and higher burnout levels.[17] Manojlovich and Laschinger's study also found that if nursing leadership ensured that components of supportive professional practice environments were in place, nurses would experience lower levels of burnout.[47] Thus, it is crucial for both the hospital and nurse managers to nurture a harmonious work environment for nurses.

Study Limitations and Future Research

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Study Limitations and Future Research
  8. Conclusion
  9. References

This study only used a convenience sample of the tertiary first-class hospitals, rendering the findings contextual and not necessarily representative. The study design is a cross-sectional type, which is not enough for getting a better understanding of the causal relationships. The study is also limited by the fact that all the questionnaires used were self-report, which carried the risk that the respondents would respond in a socially desirable manner. It is recommended that future studies be conducted among larger samples from hospitals of different levels and use randomized sampling to provide data that will be representative of the population of Chinese nurses. Longitudinal and interventional research methods are also recommended.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Study Limitations and Future Research
  8. Conclusion
  9. References

This study provides an integration of research on burnout, self-efficacy, PNPE and job stress at a cross-sectional level. The relations among self-efficacy, PNPE, job stress and burnout had not previously been the object of extensive research. The findings of this study suggest that nurses in Tianjin have moderate levels of emotional exhaustion and depersonalization and a high level of reduced personal accomplishment. Improvement of self-efficacy and PNPE as well as the reduction of job stressors will lead to reduction of job burnout. In order to reduce burnout effectively, the hospital administrators should reduce possible stressors, provide nurses with opportunities to participate in hospital affairs, provide enough human and material resources for nursing, build an effective management system, and employ a good nurse manager team. The nurse managers, for their part, should make every effort to help nurses out of all kinds of difficulties, encourage them to work confidently and build a harmonious environment in the nursing units.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Study Limitations and Future Research
  8. Conclusion
  9. References
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