In response to Wu S., Zhu W., Wang Z., Wang M. & Lan Y. (2007) Relationship between burnout and occupational stress among nurses in China. Journal of Advanced Nursing59(3), 233–239.


  • Ilona Palfi RN MSc,

    1. PhD Candidate, Senior Lecturer, Institute of Nursing and Clinical Sciences, Faculty of Health Sciences, University of Pécs, Hungary
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  • Imre Boncz MD MSc PhD,

    1. Honorary Professor, Department of Health Management and Policy, Faculty of Health Sciences, University of Pécs, Hungary
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  • András Oláh RN MNS,

    1. PhD Candidate, Senior Lecturer, Institute of Nursing and Clinical Sciences, Faculty of Health Sciences, University of Pécs, Hungary
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  • József Betlehem RN MNS MEdu PhD

    1. Principal Lecturer and Vice-Dean, Institute of Nursing and Clinical Sciences, Faculty of Health Sciences, University of Pécs, Hungary
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With great interest we read the paper concerning the relationship between burnout and occupational stress among Chinese nurses, recently published in JAN (Wu et al. 2007). As described, burnout and occupational stress can be reduced by job redesign and modification of the shift work system, and by offering occupational health education.

Caring for patients can be stressful and arduous work (Scott et al. 2006). Too much stress may cause physical or mental illness and impair judgement, making it impossible for nurses to overcome the stressors (Elfering et al. 2006). Stressors include work overload, lack of control at work, lack of support for staff, limited promotion, unclear roles, the suffering and death of patients, shift work, routine and underpaid work (McGrath et al. 1989, Palfi 2003, Gelsema et al. 2006, Pearson 2006).

In a study that we undertook during 2004 to 2005 we hypothesized that social and demographic factors (i.e. age, sex, education, scope of work, time spent in health care, second job, leaving a job) influence the development of burnout among nurses; and that certain institutional factors (i.e. type of care, types of hospital units, salary) contribute to burnout. Using the Burnout Questionnaire (Freudenberger & Richelson 1980) and the Burnout Symptomatic Questionnaire (Appelbaum 1980) we measured the presence of burnout among Hungarian hospital nurses (n = 805) and its relation to other work environmental factors. The Statistical Package for the Social Sciences 11.0 (SPSS Inc., Chicago, IL, USA) was used for testing linear regression.

Using the above mentioned tools, the total scores were not correlated with age, nursing position or work relationships. The results from the socio-demographic factors could not support the first hypothesis. On the other hand, having a second job and the prospect of leaving the job have an effect on burnout. Over 90% of the participants indicated that they had a second job, because of their low income. They have to work on their free days, or they have to do a second shift of work elsewhere (e.g. cleaning, in commerce or as salesperson). We assessed the significance of ‘job leaving’ separately from the significance of attendance records and second job. This showed that leaving one’s job is closely connected with burnout.

The percentile data for each burnout stage, as assessed on the BOQ, show that nurses who need to be treated for burnout syndrome in intensive care units accounted for 1·3% (5) of the sample, with another 9·4% [35 experiencing burnout. In long-term care units the ates was 2·9% (2), with the rate being even lower at 0·6% (1)] in active wards (an acute ward).

Burnout is twice as high among nurses working in intensive care units (10·7%) compared with nurses working in long-term care units (3·6%), and was least common among nurses working in active wards (0·6%). It is probable that nurses working in intensive care units cannot solve all the difficult day-to-day demands, and to manage this stress needs a lot of energy or else causes anxiety.

Low salaries may be considered as a major problem in some healthcare systems and, in our own country, this fact forces nurses to take on a second job. Tired nurses cannot fulfil expectations: therefore, they are frustrated and may make mistakes.

Nurses waste their qualification on leaving their job, or those nurses who persist in their posts pay a high price in terms of their well-being and health. Employers lose devoted staff and get poor performance from their employees. Last but not least, patients do not receive high quality nursing.

In finding out about the preventive factors of burnout syndrome we reached conclusions that were very similar to the results reported in JAN by Wu et al. (2007). In the first place, better work schedules and sharing responsibility in work teams were ranked highest among the scores. Better working conditions, autonomy, professional development and promotion for nurses may play an important role in reducing work stress and burnout. As a new aspect of improving health at work we identified support from family and in the workplace as a significant factor. In shaping healthier work places and better quality of life, time for rest, recreation, relaxation and regular fitness exercises were indicated as necessary activities. Some of the nurses suggested Bálint groups and regular supervision as being valuable for diminishing stress. Balint training supports team members of exploring the dynamics of patient care; with regular meeting it helps caregivers to gain insight into their own reactions to patients and to meet the biopsychosocial needs of their patients. In addition, Balint group has been proposed as a method to teach professionalism through improvement in listening skills with both patients and caregivers, encouraging integrative, creative and divergent thinking, encouraging empathy, improving observation skills and encouraging self-reaction and self-evaluation (Novack et al. 1997).

We want to highlight that unclear and complicated situations may mean that heavy workloads are demanded from nurses. Nurses are aware of these difficulties, especially if effecting change is out with their own control. Such events lead to crises. Arguably, burnout can be prevented if we pay attention to the people who pursue nursing as a profession. Today they nurse our loved ones, but tomorrow we will be the patients.